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Focusing on Non-Financial Incentives

Submitted by Barry Saver | 09 Dec, 2015

Most of us go into medicine out of a desire to serve and help - primarily intrinsic motivation. Extrinsic motivation (financial incentives) should only be applied to incentivize activities that should not be carried out primarily based on intrinsic motivation and are sufficiently onerous that they are either not being undertaken sufficiently or are causing significant unhappiness/distress. Our wholesale adventure into "Payment for Performance" has been primarily a faith-based activity with most research showing little effect. Some of this comes from underpowered financial incentives, but given both the sad state of quality measures and that higher-powered financial incentives for specific performance measures will inherently crowd out non-incentivized activities. Therefore, 2 simple rules should guide us:
1) quality-related activities should be addressed via nonfinancial incentives - quality-focused organizational culture, comparative performance reports, recognition for significant improvement/innovation, etc.
2) financial incentives should only be used for activities that place unequal/"extra" demands on providers - e.g., after hours and weekend work, on-call work.

An obvious corollary is that fee-for-service payment, which provides a high-powered financial incentive for increased volume, will undermine intrinsic motivation. It may have some role in minimizing free rider problems, but should not be the primary payment method.

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Chris Desmond Advisor Replied at 4:48 AM, 10 Dec 2015

This is a very important point - especially when you consider Dan Ariely's point, that in different domains of people's lives they apply different norms, and if you apply the wrong norm, people are offended (like offering to pay cash to your host at a dinner party as a thank you, rather than giving a present). And moreover, if you start with one norm set and shift to another - sometimes it is hard to shift back. Some people have been seen to stop donating blood once it is paid for - not clear if they would start again if the payments stop... Incentives are key - but we do need to exercise caution.

Maggie Sullivan Advisor Replied at 12:44 PM, 11 Dec 2015

I agree. When I'm offered additional financial compensation (aside from my salary) for doing things I should already be doing, it creates an internal chain of events: first, I feel a little like I'm working on commission at a sales job; then I worry that I'm perceived as being purely motivated by money; then I wonder why we're having to be 'goaded' at all to work toward quality of care and patient wellness. In the end, if feels cheapening. I think this is exactly what Chris points out to when referring to appropriate norms. Financial incentives could certainly have a place at the table, but among a whole host of other incentives. Each organization/group of providers could determine their own incentives. This route would assign value to the culture of practice, rather than only to peoples' pockets.

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