Saturday, February 8, 2014

It's not About the Money: Why Monetary Carrots-and-Sticks are Detrimental to Healthcare

In describing why Cooper Union, a unique college that offers absolutely free education to students, would effectively die if it starts charging tuition, Kevin Slavin wrote:

"For many of us, Cooper wasn't even the cheapest way to go to school...So the question is: why did we go? We went not because of the financial value of free--that is, zero tuition--but rather, because of the academic value of free. At Cooper Union I was paid poorly, and I was proud of it. I would have worked all day just to be able to teach at Cooper Union at night. I would never have done that in an institution that charged their students. Because "free" affects far more than a fiscal bottom line. It affects the intentions, behavior, ambition, and performance of everyone in the system. In other words, it determines the academic quality."

Kevin Slavin, an alumni and a teacher of Cooper Union, understood that money affects human motivation, and not in a good way. The phenomenon he describes is equally true in medicine.

Let me give you an example. I work in an academic hospital, one so large that it was impossible to survive financially without succumbing to the craze of monetary carrots-and-sticks that is sweeping the nation, such as Physician Quality Reporting System (PQRS), a Center for Medicare and Medicaid Services (CMS) initiative to promote better health outcomes through incentive payments/penalties.* Unfortunately, the actual outcomes are not what was intended, and the road to hell is truly paved with good intentions.

As a geriatrician caring for older adults, I would be remiss if I do not engage my patients in advanced care planning - helping them pick health care proxies in the event that they cannot make decisions for themselves, explaining the details of mechanical intubation, guiding them through the conversations of how to obtain a good death. These are difficult conversations - taxing, uncomfortable, time-consuming. But, I often stay late at work, skipping meals and foregoing sleep, to make sure I give these conversations the time and sensitivity that they deserve.

Why did I stay late? I sure was not paid overtime, not that overtime would make me stay longer. I was not paid by the number of health care proxy forms that I filled. Money does not drive me, and doctors should not be reduced to horses that live for a carrot on a stick. I helped my patients plan for the future because I care that their wishes regarding their life and health are followed, because it matters to me that I do a good job.

Sure, it makes sense that doctors are driven by altruism, but how is money as motivation detrimental?

Here's how: in an attempt to succeed in the age of carrots-and-sticks, my outpatient geriatric clinic created a competition in which the clinic provider with the most documented health care proxy forms filled wins a $100. It did not matter how many health care proxy forms were actually completed in reality, because that number was never used to determine the winner - only health care proxy forms recorded in the right slot on electronic medical records count, because those are the ones our clinic will get paid for. It was never said but one notion was undeniably true - the most important and direct purpose of this effort was to get the clinic paid. Having care plans for our patients was a side event.

Because advanced care planning slots in the electronic medical records were inadequate, undescriptive and user-unfriendly, I recorded my patients' wishes in free text. To reflexively participate in our clinic's proxy-form sweep stake, I would spend time transferring my free-text work into slots of electronic zeros and ones that count for money. That time cannot be spent on something else, like caring for patients or educating myself to become a better doctor, because time is limited, and knowing this I refused to participate in this shenanigan. I refused to be reduced to a primitive horse.

Once upon a time I happened upon a CMS policy maker and commented to her that incentive payments are not effective in achieving desirable outcomes in healthcare.

"What do you mean? Of course money motivates people. You don't think doctors' behaviors are motivated by money?" she interrupted the conversation, incredulous.

I replied, disillusioned by what I was hearing, "I hope not." I hoped, then and always, that doctors do what we do because our job is a calling.

"Well, maybe individual doctors are not motivated by money, but our healthcare system should be. Research studies have shown consistently that money can motivate behavior change," she was convinced.

I was convinced, too. "Sure, money can change behaviors, but are they behaviors that we want?"

She had no answer.

*Of note, monetary incentives are used by many parties in the healthcare system, both private and public, at a variety of levels. Using PQRS as an example was not an attempt to target or comment on current government efforts on healthcare reform.