Aligning Physician Incentives Doesn’t Do It

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.

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  9. Respect, dignity, appreciation, recognition, validation are words many physicians describe as lacking in today’s attitudes toward doctors. Yes, the economics are reflected as well. In the end, you get what you pay for. Just ask yourself, how much more does the nations “best” Cardiothoracic surgeon get paid for doing a complex heart operation, compared to a doctor who just finished training yesterday, performing the same operation? The answer (by third party government payers), nothing. They are both paid the same. Some may think this is fair, others may not. You decide. But most people would believe that after they have worked at a job for 20 years, and perfected their skills, they should be paid more than they were the day they started their job. http://www.RateHospitals.com is monitoring the healthcare industry.

  10. Lemming – am not “demonizing” anyone – my points are fairly straightforward – how much do you “need” to make …

  11. Am well aware of the rigors of training – did the whole nine yards in surgery …. but nor for the money or for the prospect of making more

    As for being treated “fairly” – that is in the eyes of the beholder – for me the question should be how much do we need to make, how much is “enough” – I have yet to see an open honest discussion about that …

  12. you are talking about the past….procedures….all are paid too low….$1100 for a total knee and 90 days of care? $1400 for a bypass by medicare; mri now pays $300 from mediare, etc. the inflated prices like $20,000 for an amputation of a diabetic foot quoted by Obama are untrue. Specialists make a lot for one reason…not they get paid too much….they work hard, and see hundreds of patients, hundreds and hundreds. I wouldn’t do my ortho residency for 5 years again for $1 million a year. Terrible loss of personal time, health, family life, etc. ON call 10 times a month, etc. and you demonize me like others? wow

  13. the training period is about learning perseverance and self-sacrifice and sacrifice of family life….it is unsustainable as a model for a doctor’s whole practice life. the problem with employment is self-starters/hard workers excel, lazy and slow individuals don’t meet goals in a non-incentive system. Incentives are not the problem…. 60-65 year olds need to feel like they need to work for insurance….if not, they are a load on society. lowering the medicare age would incentivize a lot of them to retire early.
    Monetary incentive has satisfied mastery and autonomy part of “running” your own business, etc. There is a combination of capitation—– to ———fee for service that is the answer, in combination with purpose, mastery, autonomy. Pink states: level of income didn’t matter ONLY when a person felt they were treated fairly…when we see new graduates being paid more by hospitals desperate to recruit, while the new recruit cannot produce near as much/work as hard, etc…….there is your setup for not feeling treated fairly. And for those who think specialists are the problem, try doing the residency/torture program for 5-6 years, being on call and both physically and mentally performing day and night on call frequently, working 5 work days a week, taking 2 weeks vacation a year, etc. which is the average for a specialist in rural America…….most cannot and would not put up with being a specialists–its not a great job even with the remuneration—-certainly not now–as we are the demons of medicine. Neurosurgeons like hand surgeons who don’t do replants, and ortho docs who don’t do spine surgery any more, and family docs who don’t deliver babies, and don’t even have splints in office—–are afraid of lawyers, have migrated to procedures that have good success—patients love you when you fix their acl, when you reattach a thumb and it only works fairly well, they now resent you………………the risk, night work, patient unappreciation for less than perfect and fast outcomes, by definition grates against mastery and purpose. The docs who have been rewarded for doing cosmetic day work, very narrow subspecialty care in areas with low risk, great results give an EXAMPLE for the neurosurgeons and hand surgeons to follow. If I’m paid low(ALL Procedures are paid low now….period..think not? I get paid $1100 for a total knee—-less than plumber/a/c/attorney/mechanic for doing their work? You know learning curve to do them well? residency? etc? wow, patients are abhorred when told how much medicare pays us for any procedure) and I get beat up from family, and it disrupts a whole night, where is the reward? One of my opposite effects rules….as payments for procedures have been lowered, then volumes have gone up….why not raise the amount per procedure—through capitation, fee, bundle, whatever the convoluted system insurers MPHs want to design… and ration care based on effectiveness and function of patient? That is what works…..duh—————–but yes specialists need more money than primary care docs, because they train longer, train harder, work harder, etc. than primary care docs….its not rocket science. they are different. period. sorry, I do believe primary care docs are paid too low… but 4.5 day work week? never go to hospital any more? no casting? no delivering babies? come on….its less work!!!! I have seen all the primary care self-pay musculoskeletal patients from our ER for 20 years along with paying patients to pay the bills….yes, my volume is high…primary care docs don’t do near the self-pay work that specialists do in their practices……and specialists are the demons? I think there are no demons, there is a demographic/resource emergency looming, and we have as a side-distraction(albeit noble and worthy goal) of decreasing waste…. in the end, even by cutting out waste…duh, duh, duh we don’t have enough resources for pathology, so elaborate payment schemes to ration care (through politically correct means like demonizing specialists) have to occur. I am not the problem in medicine. Demographics is the problem. Its math.


  15. Frankly, I think you make the case that i have made in my replies here, for me …..

  16. I meant to reply more timely, but was off the grid on vacation. First, Dr. Painter, thank you for sharing your tragic story and of reminding us of the costs (in dollars and/or suffering and grief) of getting it wrong. I view the carrot and stick approach only as a valid approach to a time-limited programmatic approach for changing behavior – such as adopting ePrescribing or EHRs – but of course not as payment reform.

    I am 33 years into my career as a primary care internist, and got my first lesson in payment policy stupidity pre-managed care. In my primary care internal medicine training program I had the good fortune of spend 18 months out of 3 years in outpatient settings, including every day in a primary care HMO setting and pieces of each week in specialty clinics. A derm professor saw a patient concerned that a mole might be a melanoma, and in a few seconds we both knew it was not, and after spending a few minutes educating the patient as to how to identify suspicious lesion – she ended up removing the lesion (took perhaps a minute to do a core biopsy and put in one stitch). My prof explained to me that under exisitng UCR payment policy then – procedures were paid at 100% with no copay to the patient, whereas cognitive care (all the patient needed) had copays and was subject to a deductible. The misaligment there affected docs and patients, and certainly reflected views toward physician / provider work – which was the thinking is of little value, and doing was of tremendous value. And not to slam my procedural colleagues – I should add that new procedures seemed always to generate higher revenues than old ones. Thus, use of a laser to remove suspicious appearing vascular lesions (10 or 15 minutes of provider time) could easily have paid the dermatologist more than a general surgeon doing a cholecystectomy.

    In an invited editorial for the Annals of IM in 2005, I wrote that EMR technology will never be optimized without a “sustainable business case for information management and quality outcomes.” This was not a call for more P4P but rather for payment reform such that payment was fair and aligned with what made societal sense. For example, it has been technically possible since at least 2000 (and probably years before) to create a care delivery model for chronic care that made extensive use of eVisits, proactive monitoring, home devices, etc. – and made visit based care as something that was done only when F2F care was medically necessary or when the patient desired it. Such a model could markedly decrease the costs of managing chronic illness, as well as some acute illnesses. We modeled concept in our primary care practice, and determined that if fully implemented, our incomes would go from the low end of the physician pay scale to negative (our practice like most PCP practices ran on about a 50-60% overhead rate).

    So while we dont do that, I have been doing a variation – which is to “max-pack” visits (address all unmet care opportunities during visits) and to make treatment adjustments via letter, phone or online – effectively cutting visit volume by about 50%.

    My quality scores are mostly excellent, and I am driven not by P4P as we dont really have any. And while people have commented after hearing me present variations of this story that what I am doing should count for eVisit payment – as there is none where I practice – its all talk.

    As you mention – motivation to do the very best you can for each patient should be the driver for excellence in care delivery. Health care payment should not stand in the way of that motivation – it now does.

    And while some descriptions of P4P incentives are nonsensical (I am making this one up – I will pay you $600 for an appendectomy and $630 if you wash your hands first), payment reform that looks towards outcomes but removes the barrier of always requiring a visit, and removes the barrier of payment for doing, but no payment for use / interpretation of existing information makes sense to me.

    Imagine a payment for managing a healthy diabetic for the year. One could set a schedule for guided self-care, regular reporting, proaction and interventions based on lack of understanding of self-care, not reporting sugars as appropriate, etc – as well as judicious use of visits. I believe it would promote innovation in care delivery which hopefully would lead to better results at a lower cost.

  17. Leonard–exactly–thanks for pointing to Ashish’s post–to me that’s yet another story about how the extrinsic incentives have created a dysfunctional environment (the ER world vs. the untainted bike path world)–that warps and deranges the basic wonderful motivations of health professionals. Really fascinating.

  18. Leanord–really excellent points–and precisely the ones we’re trying to make in the RWJF report (see link above–and herehttp://www.rwjf.org/en/research-publications/find-rwjf-research/2013/08/improving-incentives-to-free-motivation.html ) Getting the incentives right is key–and getting them right means making sure the dollars move in the right way to support physician efforts to do the right thing–without, however, letting the incentives–even so-called “aligned ones”–undermine the motivation and drive to find creative ways out of the dysfunction. Great points.

  19. I see this at some great, world-renowned institutions. There’s talk of patient engagement, and the practitioners really want it, but when it comes down to engaging vs. another expensive procedure, the procedure still wins in the allocation of funds.

    Where I do see changes are all strangely timed with the announcement of 30-day readmission penalties and a focus on infections. Important, certainly, but the investment of time and resources is still tied to the expected return, and that ultimately influences how many decisions are made, to the culture of the organization itself.

    In Predictably Irrational, Ariely makes the key distinction between social conventions and transactional ones. We’re more likely to do the right thing when social conventions are in place, but when we start getting paid, the expectations of behavior change.

    Docs are forever feeling the pull of both directions. Changing the incentives to align with the goals of the patient makes this dichotomy easier to navigate.

  20. BTW, Leslie–love the capuchin monkey fairness video-that’s a good one.

  21. Sorry – I still think it goes back to motivation – if one’s motivation is the patient’s health, then one will protest, buck, work to change, etc – the policies that mitigate against it – if that is not one’s motivation, it seems to me there is little difference between a lone ranger and a collaborative setting ….

  22. When you divide by zero you get a whole lot of nothing.

    Keep dreaming.

    I do not seeequally capable people emerging from medical eucation. Today’s new doc is timid and willing to hide under the corporate veil. They wre not responsible.

    In the near future the outcome of a case will be measured against whether or not the policies were followed, and NOT against whether or not the best care was provided.

    Better retain your private physician to care for you rather than to be your survivors’ expert witness.

  23. I am well aware of the monkey “fairness” studies – but that rather begs the question. One could well argue that it is not “fair” that a doc who saves a life by bypassing a blocked coronary artery is paid considerably more than a doc that saves a life by bypassing a blocked colon – but that argument, per se, isn’t set up to answer the question of whether one is paid “too much” or the other “too little” – not to mention how to compare the worth of either procedure to a doc’s keeping a patient from developing one or the other condition in the first place ….

    That is why I think an open public discussion needs to be based on what a doc needs to comfortably take care of one self and one’s family – does one need to make enough to have a Maserati and a second house in the Hamptons? I think some docs might be hard pressed to convince folks they “need” what they are making …
    If we could agree that any doc “deserves” to make enough so that (s)he can support his/her family so (s)he can focus on improving the care of the patient without worrying about finances – then we might actually be able to decide on “salaries” – At that point docs who are in it for the money can split and those in it for patients can go back to work feeling they can focus on them … After all, once baseline needs are met, does any health care professional worth his or her salt need a greater incentive than improving the health of the patient?

    Unless you can put a pricetag on a person’s life, it is foolish, IMO to discuss this in terms of what a service is “worth” – so let us, instead base it on what a provider needs to be able to focus on those lives without having to worry about his/her own … Frankly, i think that is why we are having so much difficulty with this “incentive” routine – In a field where it is frankly rather absurd, IMO, to talk about which life saving technique. e.g., is “worth” more, ISTM the discussion of $$$, in any format, as a suitable incentive is rather, not to put too fine a point on it, bonkers ….

  24. They are unwilling to be the headline defendant when they are not appreciated and were not in charge of the case.

    Everyone meddling in the care of the patient should have their own equal coverage for the medmal system and be equally accountable.

  25. hi Mike, just to clarify: I think we can find ways to give clinicians that motivating sense of automony in tomorrow’s healthcare system, such as helping them tailor care to a patient’s individual circumstances rather than focusing excessively on following guidelines. But it won’t be the exact type of autonomy that physicians used to have. As we focus on nuturing medicine’s human capital, it’s worth thinking about how to navigate these changes in autonomy. (which is what you’re doing; thank you!)

    In response to Aquifer & the question of how much physicians need to make: there’s what people need to make and then there’s how fair the pay feels, which is framed by how much others around you are making. (Prob a factor in considering primary care.)
    This video of capuchin monkeys rejecting unequal pay is worth seeing; a sense of fairness is deeply embedded within most people!

  26. MD-I think you pretty much capture the point here–and the reservoir of frustration caused by existing extrinsic incentives in health care. That loss of respect is more than just a feeling-it’s responding to facts. And you’re right doctors did not create that toxic incentive environment or cause these problems. We do need doctors and other health professionals to be as creative and innovative as possible to help get us out of the dysfunction–that’s why we better understand how to free their inherent powerful motivation to do that kind of innovative work.

  27. Leslie–thanks for this note. I think you are absolutely correct. It cannot just be about health professional autonomy and purpose. Certainly, there are many other considerations to balance–including most importantly patient and family–and their autonomy–they are the most important player in these stories. Still, we clearly have not paid sufficient attention so fart to the things that actually motivate physicians and other health professionals to innovate toward better and better care experiences with and for those patients.

  28. Yeah – the ones who cannot/will not collaborate and those in it for the money will leave and a whole new class of collaborating, less $$ concerned, but no less capable folks will take over the profession – and that, for me, would be a breath of fresh air ….

  29. Great comment! – I know this is a sticky wicket, but I think there are gender issues involved, in more ways than one, in both marriage and medicine …

    As mentioned in the article, as salaried residents, the issue of financial “incentives” was moot – are we to assume that residents are therefor insufficiently motivated, or that their motivation is all the dough they’ll get later?

    And as Pink points out – once basic financial needs are met with “sufficient” funds, any more oft gets in the way. Frankly i think if physicians are on salary the profession will be one in which the motivation for entering will “return” to a desire to take care of patients and not pad the pocketbook – I would love to see a discussion among physicians as to how much they, personally, really “need” to make – if lives are priceless, can we really talk about how much it is “worth” to save one ….

  30. “Autonomy is going to be a tricky one when it comes to physicians. It’s doable but tricky because we are in the midst of a massive culture shift, in which physicians will have to do more shared decision-making with patients, as well as with other professionals. (This shift could be considered similar to the shift in the husband-wife dynamic that has occurred over the past 50 years, no?)”

    Marriage rate is at all-time low.

    Make that “the remaining physicians will have to do more……”

  31. GREAT post and terrific comments. I read Daniel Pink’s Drive last fall & have been wondering ever since why intrinsic motivation isn’t discussed more often as part of healthcare reform. Thank you for bringing this issue to the fore!

    Autonomy is going to be a tricky one when it comes to physicians. It’s doable but tricky because we are in the midst of a massive culture shift, in which physicians will have to do more shared decision-making with patients, as well as with other professionals. (This shift could be considered similar to the shift in the husband-wife dynamic that has occurred over the past 50 years, no?)

    Although I do think most physicians want to do the right thing for patients, many of them are used to and comfortable with a model in which they get to quickly decide what that right thing is…as opposed to negotiating a mutually acceptable path forward with the patient, and maybe also accessing decision support. (I am routinely approached by families who are unhappy with the way doctors have gotten pissed when the family asked too many questions.)

    Still, I think it’s possible to create better working conditions that allow physicians to engage in the hard, meaningful, rewarding work of medicine. Less nickle and diming is definitely needed. I sincerely hope to never be bugged about productivity again as I make efforts in the visit trying to address thorny topics such as a possible dementia diagnosis or a declining life trajectory. In general, a little stress in the workplace helps one perform optimally, but too much stress and hassle is a bad thing.

  32. Congress, CMS and all of the other do-gooders have created impediments to safe, efficacious, and creative care.

    In essence, they have injected a relenting chronic disease on the health care professionals and health care system, sapping energy, while enriching those who have nothing to do with medical care.

    Implosion soon, but the US Government is shameless. Vote them all out of office.

  33. Docs are mad as hell for the loss of respect for them. All the systems from EHR to CPOE have been inflicted by outside forces, essentially rounding up docs into corralls where they can be controlled and fed and contained.

    That does not create an atmosphere for the altruism of old.

    If you want the doc to show up and save your bacon at 3 in the morning you better treat him better than you do now.

    Stop stealing my profession and calling it reform.

    Physicians never were the original cause of any of these problems.

    They arose from governemnt commoditizing something that was indiviually customized for each patient. But they did not want to pay the price.

    The government also fell into the durable medical equipment business and the home health business, essentially squandering billions for political returns and no change in outcomes.

    The government took over the system.

    All we here from government is how bad we are. The doc is leaving the system.

  34. Jeff – “THey spend their entire training period sheltered from the “incentives” issue by salaried employment …..”

    Hmmm – seems to me the answer is in there ….

  35. Steve – i was about to reply with much the same observation – unless you have a lot of neurosurgeons available in an area, asking one to cover “all the time” simply isn’t reasonable – One wonders if it isn’t possible to train ER docs to be able to do “simple cranies” – burr holes, e.g.. That wouldn’t solve the problem presented here – a massive intra cranial bleed – but epi- and acute sub- durals could be handled – This of course opens up another potential can of turf war worms – but if the focus is indeed the patient, it would seem to me that could/should be bridged …

  36. IJ-I think you’re right–that past efforts and current attempts to address major health care dysfunction still have blunted rather than freed the inherent motivations of our doctors and other health professionals–with all sorts of negative results–that impact the profession and importantly our patients and families.

  37. Thanks, Steve–that’s really helpful to understand. Would love it if we set up care so that creative physicians like yourself and other health professoinals felt free and motivated to make sure those kinds of procedures were available every single time for patients and families that desperately need them, when they need them. Thanks so much for the note.

  38. Bobby–the list is long of great, superb healt professionals–we just need to make sure we’re promoting that impulse not quashing it. Great examples here.

  39. Jeff–thanks for this note. I think you nailed it–especially your last sentence.

  40. Leonard–thanks for the note. You make a very important distinction between organizational incentives and behavior and that of the humans in those organizations. It’s almost as if we need to get the incentives right–money pointing in the right direction for the organizations–but somehow insulate the humans from the negative impact of the financial incentives on their motivation to do great, creative work. Very important–and difficult.

  41. As others have said above, I think the issue is concerns of autonomy and purpose mixed with financial and malpractice concerns. That said, autonomy and purpose have long been drivers of innovation and quality, and with all the healthcare legislation coming in driving physicians into a corner in regards to where they can work, it’s concerning. I’m especially intrigued to see what happens with the dwindling of private practices starting to happen. This article outlines it nicely:


  42. “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.”

    Love it. Great post, Mike!

    I’ve been writing about motivations in health care as a theme and agree. This is spot on. But incentives have to change before anybody could really pay attention to deeper motivations, including the motivation to make the right decision.

    Organizational behavior and individual behavior are different. Without value-based care, it’s too easy to just do profitable procedures. Priorities tend to shift toward just doing more. There needs to be the context of value in order to focus on scaling effective decisions. Only in this context (with a lot of data capture) can we begin to uncover what makes an effective decision, how to motivate the right decisions, and then how to make the right decisions repeatable for the patient’s benefit.

  43. Prior post didnt work, so will hope this shorter one goes through. Anyway, our neurosurgeons do lots of emergency cranis. I know because I stay up at night with them. We have lots of time to talk, they are neuro cases after all. Since no one here seems to be asking neurosurgeons why this is a problem, I can least recount what they tell me.

    Since there are are relatively few neurosurgeons, and most hospitals have none or very few on staff, doing these kinds of cases means that a neurosurgeon must cover multiple hospitals. That means doing emergency cases at night with unfamiliar staff and unfamiliar equipment. It then means turning over that patient to an ICU staff that probably doesnt have much Neuro ICU training. Now, add in the fact that it is a lifestyle killer and it hurts income and you have little motivation to do these cases. In theory it is fixable to make it possible to have uniform levels of staffing and equipment at every hospital. In reality, it is not. (There is building body of literature showing that high risk surgeries have better outcomes when staff are familiar with each other.)


  44. As a Psych grad, and “quality improvement” operative, I love this:

    “Physicians are not lab rats, and it seems like a large chunk of the policy community’s energy the past ten years has been spent searching for the perfect operant conditioning schedule for physicians (and hospitals)- set the incentives right and voila the right things get done.”

    Indeed. LOL. My wife is a Psych grad as well. She was a lab rat student, doing Skinner stuff. Skinner has by now been kicked down into the basement at Harvard.

    I worry that some of this “Lean” workflow stuff we promote is disturbingly implicitly close to gussied up Skinner. I look back and reflect that MOST of the organizations within which I worked across my career were too toxic, too morally ill to benefit from any durable TQM / CQI / PDSA / Lean “improvements.”

    Read Dr. Victoria Sweet’s excellent “God’s Hotel” for some painfully funny takes on destructive “process improvement” at Laguna Honda in SF.

    I bought the Daniel Pink book after reading this post. It’s very good. Nothing much I didn’t already know, but I’m just getting started with it.

    “We load them [physicians] up with debt, and then turn them loose in this jungle of mistrust we’ve built for them. We both tempt them with ridiculous, if transient, temptations to over treat, and also load up their days with meaningless busy work “documenting” things that don’t matter- the latter designed to compensate for the former.”

    I will have to quote that.

  45. This is one of the most important posts and comment threads I’ve seen in the five plus years I’ve been watching this space. Physicians are not lab rats, and it seems like a large chunk of the policy community’s energy the past ten years has been spent searching for the perfect operant conditioning schedule for physicians (and hospitals)- set the incentives right and voila the right things get done.

    We know better, and so do most of the physician commenters. Most physicians entered medical practice to help people one way or another. THey spend their entire training period sheltered from the “incentives” issue by salaried employment. We load them up with debt, and then turn them loose in this jungle of mistrust we’ve built for them. We both tempt them with ridiculous, if transient, temptations to over treat, and also load up their days with meaningless busy work “documenting” things that don’t matter- the latter designed to compensate for the former.

    Lots of the latter was a reaction to “Crossing the Quality Chasm” and to an almost Marxist/materialist economic model of what motivates people. It may be old fashioned, but I think complex professionals are PRIMARILY motivated by values.

    When we align with and reinforce values, we get great care. That’s what I’ve seen at Mayo and Virginia Mason, the two really fine group practices I’ve had the closest contact with. The hard part is removing the pernicious incentives (a value and political judgement) and getting our payment system to a state of neutral buoyancy that enables the values to shine thru. Complex systems of micromanagement of physicians thru payment are an insult to the profession and, ultimately, the patients they take care of.

  46. Mike,

    Thanks for sharing the thoughts – and RWJF paper.

    You are absolutely correct in that “elegant payment schemes” won’t work – because we’re (yet again) shifting $’s around in a way that isn’t all that transparent.

    My biggest objection with ACO’s is that they are effectively – yet another layer of opaque legal/financial gymnastics that the patient has no visibility into – let alone control of. Good in theory – perhaps – but I think they are likely to become simply another experiment in our long road out of the healthcare wilderness.

    The core of the problem remains price and profit. Churchill couldn’t have said it better …..

    “You can always count on Americans to do the right thing – after they’ve tried everything else.”

  47. Thanks, Francois. I did read the HA piece and I do understand (I think) what you are proposing. I fully agree with the criticism of the pervasive “carrots & sticks” approach, for both patients and doctors, but as you mentioned these are two very different problems.

    Regarding physicians: If we want these folks to exhibit awesomeness, as Dr. Painter is expecting, and as most likely every medical student is hoping and dreaming, then we need to just let them do that. We need to stop interfering, more than we need to, and we need to quit trying to influence (regulate) the emergence of excellence from above. If you listen to physicians surveys (JAMA – Tilburt), it is pretty clear that physicians are on board with all sorts of quality improvements, but very much opposed to elimination of fee for service, readmission penalties and bundling. We could say that this is all financially motivated, but since we assumed that they want to do the right thing, then perhaps what they are saying is that this is what will help them do the right thing.
    I have no idea why the war on FFS was declared, particularly when looking at some wealthy European nations. People need to be paid for effort and for honest work in a field where they by definition cannot control the final outcome for many reasons, not least of which is incomplete scientific knowledge.
    Bundling and all other risk assumption schemes are only suited for large systems, corporate systems. I am not sure how those institutions are more suited for physician autonomy and moral behaviors. Perhaps some are better than others…

    As to people, and not all are patients, and consumers doesn’t seem to fit an activity that provides unpleasant experiences for cash, I thing nudging with financial incentives and penalties is humiliating. I guess I just don’t recognize the moral or intellectual superiority of insurers (public and private) and employers that gives them rights to decide that folks are shortsighted or somehow flippant in their decisions.

    To summarize this long and probably unwarranted reply, I would think that a unified financing system for all health care for all people, with private physicians to serve as checks and balances, should go a long way to address most failures of a market based system where there can be no ethical market.

  48. Hi Margalit, we have a companion post on the Health Affairs blog (http://healthaffairs.org/blog/2013/08/07/physician-payment-forget-carrots-and-sticks-its-motivation/#more-33633) that focuses more on the incentives piece. Mike’s story, and many of the responses here, show that motivation to do right by patients is very strong. However, external incentives often get in the way because their design goes against the grain of what motivates clinicians.
    As such, the delicate balance we must take is to understand that motivation and remove the incentives that take away from it. There are some early signs that redesigned financial payments to clinicians and health care organizations are doing far less damage to motivation than current FFS and past attempts at capitation. However, there is still much work to be done to get this right.
    Mike and I feel strongly that the simple “carrots and sticks” approach to designing clinician incentives isn’t right. Instead, one must look at the issues as minimizing bad incentives. And from that, perhaps, a more optimal state will emerge.

  49. Good points Dr. Bailey. Note that clinically nuanced incentives are designed to move individuals in the right direction. Contrarily to what motivates professionals, consumers end up by being far more pragmatic, trading off short term gains for potential long term benefits. And that’s why many companies, including most recently Penn State, have deployed penalties for consumers who don’t abide by simple preventive care requirements. Others are increasing premiums for non compliance, and so on.
    So employers are actually doing their part. Medicare still lags way behind, while many Medicaid plans are also experimenting with plan member incentives.

  50. You’re welcome. Another riff on that theme, a snip not contained in the “1 in 3” essay:

    It is the soggy and crushingly sad el Nino L.A. winter of 1998. My now- brain-met stroke-addled daughter is painfully traversing the final months of her life. While admitted to acute care facilities (she has been an acute care patient in seven across the two years of her horrific cancer struggle), she gets the best clinical attention available, no strings attached, courtesy of Medi-Cal (the California Medicaid agency for the poor and otherwise medically indigent). But, outpatient care is another matter. Sissy has ongoing need of follow-up physical and occupational therapy, regarding which Medi-Cal will not authorize reimbursement.

    Her therapy team from Brotman Medical Center — at great individual and aggregate personal and professional risk to themselves — arrange to have her routinely come in incognito off the books to an outpatient rehab clinic in Beverly Hills where they work on the side, to continue her therapy — notwithstanding that we all know by that time that she will not likely survive much longer.

    That is an utterly unembellished true story. There are numerous unsung heroes within our health care industry, people whose unrelenting focus is “patients first.”

  51. Mike-thanks so much for the note. We completely agree with you–payment matters–the trick probably is to pay our health professionals reasonably, rationally, transparently and well–and stop talking about payment. We also need to make certain that those extrinsic incentives aren’t suppressing those hard working professionals inherent yearning to be great and creative.

  52. Thanks, Bobby–very moving-agree–you cannot pay great people to do that sort of heroic work.

  53. Rick-nice post–agree it’s very relevant to this discussion. Thanks for sharing it.

  54. Dike–thanks so much for the kind note. I also agree with you that perceptions about risk are important–and malpractice risk is important. Our point in this report, though, is that many kinds of extrinsic incentives led us to this sort of health care dysfunction–like not providing craniotomies to desperate families who’s father might need one. Maybe if we had focused instead on things like autonomy, mastery and purpose–rather than the long list of toxic incentives that created the current mess–we wouldn’t have arrived in that mess–but we didn’t do that. The point of the report is that we cannot assume that simply by flipping the incentives–or pointing them toward great results–that health professonals will suddenly do all the creative designing to get those great results. There’s nothing wrong with our health professionals–it’s the toxic incentives that got us here–to get us out–we need to find ways to free their inherent motivation to do great things–that’s the point.

  55. Thanks Dr. Painter

    Agree with much of what is articulated here. Especially-“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”

    My essay published by NPR series “This I Believe” may be relevant?

    see http://thisibelieve.org/essay/91393/

    Dr. Rick Lippin
    Southampton Pa

  56. Margalit, Hi. Great points. Even if we wanted to drop incentives altogether–we couldn’t–because payment and money matters–if nothing else, we need to pay highly trained professionals well for their incredible work. I think the point here, though, is that if we think that we can design intricate payment models to motivate health professionals to design the way out of the existing dysfunction–that will not work. We do however need those very people to get creative–to do that designing work–freeing their inherent motivation by focusing on things that matter like autonomy, mastery and purpose, for instance–are much more promising than assuming that aligned incentives will do it.

    I also do not necessarily agree with you and Dr. D that in the craniotomy instance–surgeons were avoiding that procedure merely because of perceived risk–I think that much more goes into that dysfunctional system that ends up with that sort of result. I do believe that existing extrinsic incentives no doubt created the dysfunction that got us to that point. Just aligning them–won’t, though, get us out. That’s the main point here.

  57. As I wrote in my 1998 “1 in 3” essay about my late daughter’s experience:

    Money-grubbing, egotistical docs

    Late one quiet evening on the 4th floor at Brotman, a double-shift weary Dr. Mittleman and I leaned on the counter at the nurses’ station and mused at length upon some of the more absurd alternative therapy allegations. Responding to the notion that his profession was raking it in while suppressing the “competition,” he quietly countered “right; I’m getting rich on the sixteen dollars a day I get from Medi-Cal for seeing your daughter.”

    Here was a man repeatedly to be found perched on the edge of Sissy’s bed at odd hours, talking with her for 30-40 minutes at a time– a temporal generosity he shared time and again with me in the halls as we discussed the more technical aspects of her situation. This is a man who continues to field and return her calls, sees her on a moment’s notice, and jawbones the Medi-Cal bureaucracy on her behalf, even though she is technically no longer his patient.

    I recently emailed Dr. Mittleman to express my gratitude, joking that “should they ever decide to start cloning the best doctors, I’ll be by your office to pick up a DNA/tissue sample.”

    Likewise for Dr. Sherry Wren, the swaggering, 5’3″ supremely confident surgical wizard who saved Sissy’s life in April of 1996, and who continues to stay in touch with us. Likewise also the innumerable doctors, nurses, therapists, and support personnel who have rarely failed to accord my daughter the utmost respect and compassionate, knowledgeable care throughout the past year and a half– many of whom will earn less in a lifetime than Dennis Rodman was debited by the NBA last season for unsportsmanlike buffoonery…

    bgladd [dot] com/1in3

  58. Very good post and discussion here. Maybe a lot of people enter into med school with visions of mansions and and Maserati’s in their dreams, but I have yet to meet one.

  59. I would agree that more than money is at stake. But I would put it back on the neurosurgeons, not the system, to come up with an answer if the rest of us can’t understand it. I don’t see that sort of introspection happening in my world.

    I also picked up (from another subsequent comment) that perhaps our focus on stroke care blinded the caregivers to other possibilities. That is in part a result of financial and other “best in class” incentives that may not lead us in healthy directions.

  60. Hi Kathy–thanks so much for your note. I agree–there was nothing warm and fuzzy about our interaction with the physicians at that time. The system simple was set up–and my family did not know it–so that they physicians would not provide the craniotomy in that specialty hospital. Again, we were not looking for blame–but intensely interested in why–how could that happen. And paying good docs to provide craniotomies (and other procedures) when the rest of the incentives in place had completely discourged them from providing them–was clearly not the answer. The point here–to get health professionals to get creative and innovative and figure out how to provide great care (including providing unprofitable procedures when families desperately need them) does rely on things that some may call warm fuzzies–aligned payment sure won’t do it.

  61. Hi Dr. Painter. Thanks for the response. However, if we take your opening thesis to its logical conclusion, which implies that people by and large want to do the right thing, why not drop the term incentives all together?
    There are localized reasons why certain behaviors occur in certain circumstances, and those should be addressed through specific repairs to the broken part. For example, I would agree with Dr. D. that neurologists are reacting to excessive risk (perceived or real). Primary care referring out too much and lacking coordination is reacting to insufficient payment (again, perceived or real). Each one of these examples requires a different tool and procedure to fix, and there quite a few more like these. I sort of think that going around and making small repairs is both more tenable and more likely to succeed than gutting the entire thing and changing the paradigm.
    I am also not convinced that the newly preferred model of corporate systems of care is as sensitive to the right thing as individual people (understatement), and perhaps that’s where the incentives belong if we must take this route.

  62. Kathy, you are looking at this issue from outside the skin of the neurosurgeon. Your 3 numbered points are a logical review of malpractice risk from an outsiders perspective and that is not the perspective of the neurosurgeon on call. I am not saying what is happening is right / just / appropriate / logical … and this is not a financial issue IMHO.

    I can tell you for sure that malpractice risk is one of the key drivers of over and underutilization of tests and procedures as well as one of the key stressors leading to burnout. In order to understand it … you cannot rely on a logical external analysis of the situation. You have to climb inside the skin of the doc … with careful questioning to see what their inner, whole body experience is. Money is only a minor fact in the case presented in the article.

    Dike Drummond MD
    TheHappyMD (dot) com

  63. 40yearold doc–thank you. The point here is a starting one–trying to get people to back off the assumption that all we need to do is structure an elegant payment scheme to get physicians and others to do all the complex problem solving necessary to improve care. That’s not going to work. Instead, folks should focus on ways to enhance (recapture?) the things that actually motivate our awesome doctors.

  64. Cannot argue with that–payment matters–and stabilizing payment for primary care is very important–but–the point here–we can’t assume that structuring payment in this way or that will prompt or motivate physicians and other health professionals to do perform complex problem solving–like redesigning the way they care for patients, for instance.

  65. I agree with you, Dr. Mike–it’s so much more than money. But money obviously matters–and getting paid matters–so the strings and hassles for payment become sort of an additional external disincentive for health professionals.

  66. I have worked in risk management and malpractice defense for 30 years. I don’t think neurosurgeons are afraid of “tough situations.” They deal with them in other scenarios all the time. If a surgeon (1) meets expectations for timely response, (2) sets expectations of the pt/family fairly, and (3) communicates with them before (as much as possible) and after the procedure about what’s going on, then their chances of being sued go down dramatically and their chances of being sued successfully should be almost zero. There may still be a suit related to the original injury, but that is true in any trauma situation.

    I noted that the financial incentives were the original demotivator mentioned in the article. I agree that it is difficult to mess with those without unintended consequences, but I don’t think the warm fuzzies of caring for people in a less directed environment were motivating in the author’s father’s situation, and they are not in most situations I’ve seen.

    And this hospital was just lucky the family didn’t want to sue, because I’d have settled that case in a heartbeat.

  67. Margalit, Hi and thanks so much for the comment. The point here is indeed nuanced. The key though is that external incentives (say, payment) can inhibit motivation-especially when trying to motivate humans to perform complex tasks and problem-solving–that’s pretty clear. Aligned incentives do, of course, work well–in fact incredibly well–for simple, narrow tasks–that’s why fee-for-service works so well. But you cannot just create “better or aligned” incentives to get people to perform complex tasks. Still, payment and money absolutely matters–so it’s important to get payment right. The key is to improve incentives so that they free motivation–not that they in any way enhance or promote motivation (for complex tasks).

  68. Thank you, Dr. Painter, for the moving article.

    I think you’re absolutely correct that financial incentives can’t be the only thing to focus on – medicine is far too complicated and human-centered for incentives to be a cure-all. I look forward to reading the RWJF report.

    One of Pink’s arguments in Drive is that people need to be paid enough to feel comfortable and fairly compensated – otherwise autonomy, mastery, and purpose become crowded out by discomfort and worry about being treated unfairly.

    Broadly-speaking, I think it’s fair to say that most physicians (not all!) are paid enough to feel comfortable in America. I’m less sure about feelings of fairness – what are the opinions of the doctors you’ve met (and also of the other physician commenters)?

    Of the three motivators that Pink’s framework highlights, it seems to me that autonomy is most likely to be lacking – which may be what Dave Chase was getting at above, too, with his discussion of DPC.

    But can’t payment reforms help increase a physician’s sense of autonomy? Fee-for-service medicine has a lot of problems, one of which is that it financially incents behavior that physicians may see as sub-optimal for the patient – reducing autonomy explicitly or implicitly.

    Whether through accountable care, DPC, global payments, etc., it seems that we have a plethora of options that would provide more autonomy for physicians to make the best decisions for their patients.

    These are financial incentives, of course, but done in such a way as to remove the distortions which currently exist and “gum up the works” for physicians. Curious what you think – thanks again!

  69. Excellent post. So what do we do? How do we get neurosurgeons to return to the ERs? Everything in medicine today is working to create demoralized, exhausted shift workers. Where do we start to fight for positive change (we sure can expect any help from the medical societies)?

  70. It is interesting that the paper begins by stating that financial incentives are not the right way to go, but the bulk of the paper is a discussion on how to design financial incentives so they are more effective.
    The final recommendation seems to be that people should be given financial disincentives (and information) to go out and combat high prices due to market forces, and that fee-for-service should be largely removed from the equation for physicians, in favor of salaries and bundles (i.e. health systems instead pf private practice), which are axiomatically preferred anyway.
    So which one is it? Do financial incentives in general hamper autonomy, creativity, ethics, morals, and all that good stuff? Or is this just a question of proper design of financial incentives?

  71. I am sorry for the loss of your father and the way it happened.

    AND it seems to me the reason neurosurgeons don’t do emergency craniotomies is crystal clear. It is NOT about payment … it is about RISK. They want to avoid being sued for a procedure they perform in a tough situation, where no matter what they do there is going to be a bad outcome and they are going to be caught up in a lawsuit with what is probably a stunning degree of frequency.

    It is also NOT about Autonomy, Mastery and Purpose … it is about avoiding getting sued.

    All actions in healthcare have multifactorial thought processes and inputs prior to the procedure. You can’t dumb this one down to payments and you won’t change it with more money. And I am sorry for your father’s passing and the way it occurred.

    My two cents,

    Dike Drummond MD
    TheHappyMD (dot) com

  72. Just a few thoughts. While too many healthcare providers do what’s in their interest instead of patients’, “aligning” behavior is very difficult. One must always be careful about incentives because you will get what you incentivize – and perhaps not much else. Best to start off with young adults to train as doctors who have a value-set that includes caring for others, commitment hard work ethic, and that sense of satisfaction one gets by healing others and making their family members feel better too. This is easier said than done of course. Another piece that is desperately needed is that Americans need to truly grasp how they are primarily responsible for their health, not the health care system. Eat better, exercise regularly, maintain good body weight, don’t smoke, and know that bad things happen randomly to good people all the time any way. Until this happens, expectations, frustrations, defensive practices, litigation, etc. will continue to dominate aspects of medicine and cost growth will continue to outpace what is sustainable.

  73. Dr. Falkoff – I couldn’t agree more with the “successful” effort to undermine primary care. A few tweaks here or there won’t fix it. In my interviews for my business, it’s my observation that the most unhappy MDs are those in hamster-wheel, insurance-based primary care. In contrast, the most professionally happy MDs (across all specialties) are those in Direct Primary Care. This video gives you one perspective from a successful DPC model – http://watch.knowledgevision.com/cfb78a64059d484b9e3ab5b8eae35349.

    The California Health Care Foundation commissioned a paper on DPC. Email me at dchase at avadodotcom and I can send you a copy. I’ve not seen a more successful model than DPC that serves all income levels and polychronic patients.

  74. Good points Dr painter. But speaking from a primary care perspective of over 26 years in independent private practice, the cards and rules have repeatedly, aggressively and inappropriately, been stacked against us. Every time we manage to accommodate or master some new rule and reset things in a financially viable manner, we turn around to find another hand in our pockets and wallets. Until the financial structure is improved and stabilized, especially for primary care, we are continuing to be hurtling headlong into further healthcare crisis.

  75. Outstanding. It is more than the money, much more. And yet every mechanism put forward so far gives less, much less in terms of what really matters, because the strings attached to getting the money take us further away from what really matters.