Everyone agrees that the US healthcare system is too costly. The challenge of public policy is deliver higher value by improving quality while reducing costs by eliminating waste and increasing efficiency. Historically physician compensation has been tied to productivity, which encourages procedures and over-utilization.
How can we motivate physicians to provide preventive, cost effective and quality care without incentive programs? Alfie Kohn in 1993 published ”Incentive Plans Cannot Work.” Clearly, poorly devised compensation plans are even detrimental. Incentive plans do not work because they are poor motivators, can be punitive, discourage risk taking and inhibit teamwork.
Once wage earners receive adequate compensation to meet there physical needs, money is not the major motivator. There are much better motivators than money as elucidated in Drive by Daniel Pink. People are self-motivated by pride and accomplishment. Workers thrive on recognition by respected leaders and coworkers. Most employees want to achieve the goals of their employer and produce value for their services. Employees loose motivation when treated as automatons, chastised for outcomes that are beyond their control and denied adequate tools to succeed. A manager who provides educations, tools and efficient systems will achieve far more than devising a compensation system that rewards a specific behavior.
Bonuses for accomplishing goals can temporarily improve productivity and improve employee satisfaction, but when goals are not met the initial incentive when taken away, becomes punitive. Effective incentive systems must reward for doing the right thing, using resources efficiently and producing quality outcomes. Glasziou in 2012 developed a checklist of 9 items that must be reviewed before implementing a financial incentive system. Designing and implementing an incentive system that meets the checklist is nearly impossible.
Physicians motivated by rewards, concentrate on their incentive system avoiding innovation and risk taking. They are also distracted from achieving the overall goals of the organization or the welfare of their patients. Any time taken to improve quality and improve efficiency could threaten their current incentive bonus.
Often compensation systems create additional competition between providers, which inhibits cooperation. Instead of competing based on patient satisfaction and quality care, providers may compete through contracting. If referrals are based on perceived quality then providers will be less likely to share best practices with others in the community. Engendering teamwork to devise more efficient systems that achieve the mission and goals of the community will accomplish much more than a complex reward system.
Helping many satisfied patients achieving optimal outcomes with the least resources should be enough to motivate physicians. The trick is not to pay for a behavior but to measure the desired activity or outcome. The science of quality improvement has taught us that one must measure to improve. Physicians can be encouraged to change their behavior by measuring performance and providing positive feedback. Recognition by their peers and community leaders for high practice standards can be worth more than money.
Jeffrey V. Winston is an ophthalmologist.
