• How do we best change physicians’ behavior?

    I’ve written many times about how hard it is to change physician behavior. I’ve also talked about how we need a system of both carrots and sticks. Nikola Biller-Andorno and Thomas Lee agree with me, in a recent piece in the NEJM. “Ethical Physician Incentives — From Carrots and Sticks to Shared Purpose“:

    As health care reform’s focus turns to change in U.S. health care delivery, concerns about the use of incentives for physicians are intensifying. One fear is that incentives will undermine physicians’ professional ethos, leading them astray from the primacy of their duty to patients. Another fear is that incentives will be ineffective and merely cause confusion and irritation among patients and clinicians alike, without actually improving outcomes or efficiency. These fears characterize the perspectives of the ethicist and the manager, respectively; we believe that a synthesis of these perspectives is not just possible, but strategically valuable for implementing health care reform.

    It seems clear to us that incentives are omnipresent and unavoidable in health care delivery. In any context, decisions are influenced by whatever decision makers stand to gain or lose — not just in economic terms but also in psychological and social terms. Accordingly, the debate over incentives should focus not only on the effect of individual elements (e.g., pay-for-performance bonuses) but also on the full array of financial and nonfinancial incentives used by a health care delivery system. The challenge for the leaders of health care organizations is to shape and align this web of incentives in ways that promote the institution’s goals while avoiding unintended harmful consequences, such as over- or underprovision of services.

    They are concerned about finding incentives that are both ethical and effective:

    Given the complex realities of health care and human behavior, we believe that a simple carrot-and-stick model won’t do. The economist and sociologist Max Weber offered a typology of motives for social action that might be useful in the design of a more appropriate incentive scheme (see table). As Weber stressed, these categories — which a widely used adaptation has labeled “traditional,” “self-interest,” “affective,” and “shared purpose” — are ideal types, and real-life actions will frequently result from mixed motives. But we believe this typology provides a useful framework for health care organizations to apply in considering their incentive strategies.

    The piece isn’t that long. It’s worth reading in full.


    • It isn’t the behavior of physicians that needs to be modified, it’s the behavior of patients. Physicians don’t order every diagnostic test and resort to every treatment in a vacuum. They do it because their patients expect it, no, demand it. If physicians are rewarded primarily on the basis of outcomes, then physicians would avoid taking on the most difficult patients; and that means poor patients, the patients who suffer the most due to inadequate health care, bad life-style choices, and ignorance about their own health. Sure, reining in health care costs will require changes in health care delivery, but by far the biggest obstacle are the patients themselves.

      • I second Bill’s comment. The problem isn’t primarily patients. As previous post’s here have cited patients don’t want more services; if there is anything they want more of it is explanations for the care they are receiving. While this point about patients is a fun talking point is distracts from the myriad problems associated with supply-induced demand.

    • C’mon, man — with all the literature on (1) supply-sensitive care and (2) financial incentives for MDs to test and treat, you want to blame the patients? If only they had more skin in the game — oops, as we see in a later TIE post, Medicare pays for less than half of beneficiaries’ health care expenses. And I guess Brill’s magnum opus on health services pricing in Time established that “the biggest obstacle” to reining in health care costs is “the patients themselves.”

      To appreciate how wrong this view is, you only need to examine what happens when payment systems change — like when hospital payments went from per diem to DRG-based. Suddenly, all those very lengthy hospital stays got shorter and shorter and shorter, and patient preferences had nothing to do with it.

    • As someone who continually rails and rants about the “market model of medicine”, one of the most unseemly aspects, IMO, of that wonderfully American “market model of life”, I almost stopped reading the article recommended at this, re ACOs ” …they must also maintain or increase their market share,”

      Frankly i would have no interest in an ACO who expected that i would have a “shared interest” in “increasing market share” …