In A Fee-for-service Payment Environment, What Incentives Do The Physicians Have?

OP-ED

Aligning Physician Incentives Doesn't Do It

Aug 6, 2013 •

My wife Mary and I recently got a series of early morning calls alerting us to the declining health of Mary's mom, who was in her 90s. She died later that week. We were stricken and so sad, but took comfort that she died with dignity and good care on her own terms, and at her home in San Francisco.

Ten years ago, we received a very different early morning call, about my father. An otherwise healthy and vigorous 72-year-old, Dad had fallen at home. Presuming he'd had a stroke, paramedics took him to a hospital with a neurosurgery speciality rather than to the university trauma center. That decision proved fatal.

A physician in Seattle at the time, I arrived the next day to find Dad in the intensive care unit on a ventilator. Dad's head CT revealed a massive intracranial hemorrhage. Dad also had a large, obvious contusion on his forehead.

The following day, the physicians asked to remove Dad from the ventilator. He died that night. We were profoundly devastated by his death and upset with the care he'd received.

Our family wasn't interested in blame or lawsuits. We did, however, want answers: Why hadn't Dad been treated for a traumatic injury from a fall? Shouldn't he have had timely surgery to relieve pressure from bleeding? What went wrong?

I've spent the last decade searching for answers, for myself and countless others, to questions about how to improve health care. I've had the honor of working with many people pushing health care toward high value, at the Robert Wood Johnson Foundation(RWJF) and elsewhere.

We've worked hard to find solutions. We all get it: The health care problem is a big, complex one without silver bullet answers. Still, we've made incredible progress with efforts like RWJF's Aligning Forces for Quality Initiative in which community alliances work to improve the value of their health care.

We're searching for ways to help us all make smarter health care decisions. We're helping health care professionals improve and patients and families be more proactive. We're exploring the price and cost of care, and ways to automate health care information with technology.

And importantly, we're working to align the incentives that health care professionals need to support and deliver great care. We strongly believe that unless we reward great results, we won't get them. That means payment reform, with a focus on financial incentives for those who hunt for waste, resolve safety problems, sustain improvement, and, most of all, innovate to save more lives.

But do financial incentives to promote and reward behavior work?

In his book, "Drive: The Surprising Truth about what Motivates Us," Daniel Pink emphatically says that all too often they don't. Research shows that financial incentives do work – for narrow, routine, mechanistic tasks. But the more complex the task, the more financial incentives targeted at it fail. In fact, they may even degrade desirable behavior by dulling creativity and inhibiting motivation. Larger rewards can even lead to worse performance.

That's a problem when we're trying to solve big complex problems like fixing health care. But there is hope. And there are motivators more effective than dollars.

Pink suggests we focus instead on what really matters to the people we're trying to motivate – like autonomy, the ability to direct one's own life; mastery, the desire to get better at something that matters; and purpose, the chance to serve something larger than ourselves. These three motivators allow human beings to look broadly, get creative, innovate and be energized. That's the basis of a critique on health care payment reform efforts in a new RWJF report.

And that brings me back to my Dad. In 2005, several years after he died, several of us at RWJF were travelling the country trying to understand what was happening in health care markets. We were gathering information to develop the Aligning Forces initiative, and that work led me to my hometown. During interviews, one leader volunteered several major problems they were experiencing, including access to some emergency specialty services. High on the list of those services was access to neurosurgery specialty care for emergent but unprofitable craniotomies. That's that surgery my Dad desperately, urgently needed—the one he didn't get.

In 2004, a couple of national surveys by the American College of Emergency Physiciansand the American Association of Neurological Surgeons and the Congress of Neurological Surgeons (AANS/CNS) highlighted a growing reluctance by specialty physicians to provide emergency on-call coverage. Half of neurosurgeons who served on call had limited their call in some way. One third of them refused to offer craniotomies.

To fix this specialty on-call problem, some like the American Association of Neurological Surgeons advocated for a payment change, a bonus or stipend to surgeons for on-call coverage. But a subsequent 2006 AANS/CNS survey showed that, while stipends might be attractive, they weren't the solution.

No doubt part of the reason was it took surgeons away from non-emergent, profitable care. That reason though does not sync with the experience we've all had with individual compassionate physicians we know. Perhaps instead by putting these surgeons in extremely difficult situations, in trying to force or entice them to do these procedures, we are degrading their sense of control, their autonomy and mastery and, ultimately, their incredible sense of purpose.

I'm going to make a bold assertion: Until we get these human motivators right in health care, we can try all sorts of complicated, elegant payment models and formulas and still ultimately not get to the goal of sustainable high value. It will always be just over the horizon. Let's absolutely be smart about incentives in health care, but let's also get away from talking about simple carrots and sticks. Instead, let's find the right mix of motivators to promote the creativity we need to get the best care every single time for people who are relying on us, like my Dad.

I believe we can do it. I must believe. Because for me, as you can see, it's personal.

Michael W. Painter, JD, MD is the senior program officer at the Robert Wood Johnson Foundation.

Categories: OP-ED, Physicians, THCB, The Vault

Tagged as: AF4Q, behavioral economics, financial incentives, HCI3, Michael Painter, Patient Safety, payment reform, Physicians, Quality, RWJF