One of a growing number of blogs and studies that are questioning the value of pay for performance systems - a literature worth knowing about.
This post come from a well respected medical blog, making it a useful source of information to follow the current conversation about medical practice and issues related to health services research.
This post also qualifies as an example of the law of unintended consequences, one of the arguments in favor of systems theory thinking, as I understand it.
Cheers,
jd
Why pay for performance does not work and may impair patient care | KevinMD.com
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ReplyDeleteIt would make for interesting reading if the author was to include in his post the following aspects of the BMJ study:
ReplyDelete- How were the financial incentives actually put to use (repeated reminders is the only mention made)?
- How were these incentives used to motivate the caregiver – clinical, paraclinical and support personnel?
- What were the reasons for which a certain percentage of the population defaulted in their periodic screenings in the first place, and how were the incentives used to address these reasons?
The author’s reasoning of the ‘external rewards – internal motivator’ mechanism being responsible for the failure of the P4P (law of unintended consequences) and the use of a higher base pay with education to motivate, are perfectly logical. However, in today’s restive healthcare scenario, governments of the developed and developing world are constantly looking for new and innovative methods to attract citizens to avail of preventive health programs as well as motivate healthcare facilities to enhance the efficacy and efficiency of care delivery.
The reward system approach of the P4P, with its wide scope for customization to local settings becomes an appealing alternative. P4P studies within the US and projects in the developing world have delivered positive outcomes. Enhanced accountability (in terms of clinical outcomes and meeting ‘business’ targets), workforce competencies, willingness of the population to avail of services (especially in the developing world) are some of the documented benefits. As with every other system, the P4P too has its share of demerits, and addressing these is critical to the success of the program.
However, just the development of an alternative thought process is an encouraging sign and provides the much needed challenge to accelerate the formulation of even better methods for the future.
Financial incentives to employees tend not to be as successful a tool for motivating performance as the intrinsic factors such as satisfaction of contributing to a cause or collaborative effort and pleasure from quality and excellence. This seems to be the case everywhere (not just medicine) and it also seems that financial rewards do not always encourage the best behavior --- I am thinking of the rash of corporate scandals with high paid executives and base activities like cheating.
ReplyDeleteI agree that investing in an organizational culture of safety or prevention should yield better outcomes. Even as a national culture, we should try to move away from paying people for essentially 'being engaged'. Dan Ariely, in his book "Predictably Irrational", describes an experiment exploring the effects of social norms and market norms. They paid people various amounts of money to drag circles into a box on a computer screen; the people paid 50 cents dragged fewer circles than those who were paid $5, but the group that dragged the most circles were those who were asked to do the task as a social request. And they learned that once market norms enter a situation, the social norms depart. (although, social norms can include friendly gifts as long as a monetary value is not attached to the gifts)
Encouraging social norms and organizational culture around performance may not only be useful in eliciting goal-oriented behavior, but may also facilitate cooperation and collaborative environment. Emphasizing only competition and self-interested goal-orientation may actually be counter-productive to the organization (including the nation as an organization).
Pay for performance has not only been applied to providers. Kevin Volpp and colleagues have investigated Pay for Performance for Patients (P4P4P). The argument is that the benefits from changing unhealthy behaviors to healthy ones are far downstream while the costs are immediate. Dean Ornish's philosophy on this is that there are really many immediate benefits that just need to be pointed out, recognized, and acknowledged to provide incentive for healthy behavior change. Benefits such as increased or improved energy, clarity, mood, and reduced stress and pain can be experienced in increments as people switch to healthier behaviors. The public opinion of this strategy is mixed. Again, we can't pay people forever to create good habits, and if we stop payment at some arbitrary time, the gains during payment may be lost.
Does this kind of P4P4P indirectly punish people who are healthy and are not getting paid for the effort and time and money they have always invested in their health?