Monday, September 12, 2011

Doctoring financial incentives

Mixed results are reported in a recent paper entitled, "The effect of financial incentives on the quality of health care provided by primary care physicians."  In the paper, Australian researchers collected and analyzed data from studies of incentive programs in the US, the UK and Germany.

As noted in this summary article by Reuters:

In those studies, researchers looked to see if financial incentives made a difference in how often doctors screened for different diseases, referred patients to follow-up care or achieved a certain health outcome -- such as helping a patient quit smoking. Overall, the effects were mixed.


"Many doctors who already do well simply claim the money with no change in behavior," Anthony Scott, one of the review's authors from the University of Melbourne, told Reuters Health in an email.

"Incentives aren't often targeted at those doctors providing the poorest quality of care. And (sometimes) the amount of money may not be enough, or doctors simply aren't motivated by money by a great degree," he added.

I don't find any of this surprising.  If you are a primary care doctor, you simply have too much to do in a limited amount of time to calculate whether a given step in the clinical process is going to generate more revenue for your practice.

The authors raise an important cautionary note:

Despite the popularity of these schemes, there is currently little rigorous evidence of their success in improving the quality of primary health care, or of whether such an approach is cost-effective relative to other ways to improve the quality of care. There is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution and incentive schemes should be carefully designed and evaluated.

Specifically, they say: 

Studies should also examine the potential unintended consequences of incentive schemes by having a stronger theoretical basis, including a broader range of outcomes, and conducting more extensive subgroup analysis. . . . Further research comparing the relative costs and effects of financial incentives with other behaviour change interventions is also required.

I have made this point with regard to plans to introduce capitated, or global payments, in the health care system.  There has been little analytical support for this kind of plan, and yet policy-makers seem to be in a big hurry to endorse it.


76 Degrees in San Diego said...

I think it would be hard to find a purely capitated system at the individual provider level. What exists are mixtures = some services capitated; some fee for service. Even for capitated services, copayments commonly are applied.

To make it more interesting, add in "pay for performance" and change the criteria each year.

Anonymous said...

The other problem with this idea is that it promotes 'teaching to the test', encouraging physicians to concentrate on the incentivized initiatives and perhaps neglecting others. The challenge of medicine in general is that patients - or rather their diseases - 'don't read the books' and may present ir behave in an unusual manner. We need somehow, while ensuring good medical practice is followed, to continue encouraging the independent thinking once known as 'clinical judgment.'

nonlocal MD

Bruce Ramshaw said...

In Dan Pink's book Drive, he summarizes about 50 years of research clearly showing that extrinsic motivators (money, for example) do not work and actually cause poorer performance over time for complex tasks. This is one of many problems in our current health care system. Intrinsic motivation is better and much more sustainable, however it has been destroyed under our legalistic and incentive-based current health care system (Practical Wisdom, book and TED talks, by Barry Schwartz is a good resource for this