We get what we incentivize.

This is a basic rule. I’d love to say it’s a basic rule of humanity, but unfortunately, I have a background in psychology, so I know it goes a lot deeper than that—it’s a basic rule of every living creature. Humans are, in many ways, just very big pigeons. We reliably prioritize certain rewards. We prefer smaller sooner rewards to larger later rewards; we push the lever for our treat. Where mice do it for mouse-chow, we do it for money or other, more or less tangible rewards.

The definition of a reward, in psychology, is simple. It is anything that increases the likelihood of getting a certain behavior again. The definition of punishment is likewise simple—anything that decreases the likelihood of that behavior.

Intermittent rewards, or those that do not occur reliably every time an organism behaves a certain way, often increase the likelihood of behavior even more than a constant reward the organism can count on. I could discuss this at length, but I prefer to point to slot machines.

So, knowing what we know about human psychology, are clinics using this effectively? Are they using behaviorism to incentivize the best long-term outcomes for their organizations?

Some are, but many are not. For instance, let’s consider leave. If we look at outcomes purely in terms of money, it is (or at least it should be) most profitable for clinics if providers work all of their contractually obligated days and take none of their leave. This is clearly untenable on a human level, but let’s assume that what clinics want to incentivize is providers working rather than taking their leave.

How do you incentivize that? Well, you can pay providers not to take leave. This looks like “buy-backs” or “payouts.” This is typically done at some percentage of the monetary value of the leave. Most employers will not give a 100 percent payout since providers are mostly profitable but not that profitable. There is complex math involved; clinics need to take into account how much they make per patient visit for that provider, how many patient visits that provider can schedule a day, and what their no-show rate is likely to be. This will give them an idea of how much that provider is worth to them in clinic, and consequently, how much they can afford to pay back.

Policies that are more generous in payouts are going to be more effective at incentivizing providers to work rather than take leave. This is not particularly complicated.

Clinics also need to decide what to do when providers accumulate leave. This is not all that rare since many providers are driven workaholics by nature who experience intense guilt about taking time off. It could be a catastrophic expense if a provider abruptly decides to take 300 days of PTO for any reason, one which a typical budget might simply be unable to absorb, so most workplaces will limit accumulation of PTO. That means these payouts happen on a cyclical basis.

Does your clinic allow rollover of PTO? For instance, if I don’t use a week of my PTO, do I get to carry that with me into the next year, or does it expire completely? Allowing unlimited roll-over raises the prospect of those catastrophic leave expenses, but not allowing any roll-over, and particularly not allowing roll-over while paying back leave at less than 100 percent of its monetary value, incentivizes providers to take their leave. If the goal of an individual provider is to maximize the value they receive for their constellation of salary and benefits, they will take that leave rather than foregoing it.

Some balance of rollover and payout is necessary in order to effectively incentivize providers to maximize their number of days worked.

For instance, I recently left a position; I had put in the full three months of requested notice, used most of my leave, donated some, and was expecting a small payout—but it turns out my employer, pursuant to state law, is not obligated to, and therefore will not, give a payout. I had anticipated this might be the case, which was why I had used and donated most of my leave—particularly in conjunction with a punishingly low payout rate. If a provider knows they won’t get back more than 25 percent of the value of their leave, and it won’t roll over, why wouldn’t they take the leave? What incentive remains for them to work rather than take leave?

We get what we incentivize, and clinics need to ensure that their policies are rational in promoting the behaviors they want. Otherwise, clinics are setting themselves up for failure. Money talks; speak its language.

Kristin Puhl is a family physician and can be reached on Twitter @kristinpuhl.

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