Sunday, October 14, 2012

My arm's getting tired

What's the right metaphor?  Am I beating a dead horse or what?

As a person who has been engaged in public policy in a multitude of industries for well over three decades, I remain shocked at the lack of rigor involved in such matters in the health care field.  The issue is this:  There should be a number of preconditions before one seeks to use financial incentives or penalties to influence behavior.  If these conditions are not met, the financial tools will either not work or will have unintended consequences.

What might those conditions be?  Let's start with a few:
1)  Have a clear sense that the metric to be measured is determinative of the result sought.
2)  Ensure that the recipient of the financial payment or debit controls the work flow associated with the metric.
3)  Be confident that the recipient is likely to be influenced in the correct direction by the financial incentive.
4)  Ensure that the amount of the financial incentive is sufficiently meaningful to the recipient that it is likely to influence his or her behavior.
5)  Consider how to avoid the unintended consequences of the financial incentive, e.g., impacts on other metrics that are of concern.

We've talked about this problem with regard to penalizing hospitals for higher than average readmissions.  Now, Kaiser Health News summarizes a recent NEJM article, as follows:  "CMS penalties don't change hospital acquired infection rates."

A Medicare payment policy designed to push hospitals to cut their infection rates has had no effect in reducing two types of preventable infections among patients in intensive care units, researchers say in a study out Wednesday in the New England Journal of Medicine.

“The financial penalty did not further reduce infection rates, which were already going down because of multitude of (infection control) campaigns and interventions that were already ongoing,” said the study’s lead author Grace Lee, associate professor, Harvard Pilgrim Health Care Institute and Harvard Medical School.

Other studies have found the payment policy resulted in increased attention by hospital leaders – sometimes at the expense of other infections not targeted by the policy.

As policy efforts expand, the researchers say “careful evaluation is needed to determine when these programs work … and when they have unintended consequences.”

Piling on, Steffie Woolhandler, Dan Ariely, and David Himmelstein offer insights from behavioral economics in a post on Health Affairs Blog, entitled "Will pay for performance backfire?"  The introduction:

Paying for performance (P4P) has strong intuitive appeal.  Common sense and rigorous studies tell us that paying more for, say, angioplasties or immunizations yields more of them.  So paying doctors and hospitals for better care, not just more of it, seems like a no-brainer.  Yet while Medicare and many private insurers are charging ahead with pay-for-performance (P4P), researchers have been unable to show that it benefits patients.

Findings from the new field of behavioral economics may explain these negative results.  They challenge the traditional economic view that monetary reward is either the only motivator or is simply additive to intrinsic motivators such as purpose or altruism.  Studies have shown that monetary rewards can undermine motivation and worsen performance on cognitively complex and intrinsically rewarding work, suggesting that P4P may backfire.

Further on, they note:

The quality improvement literature has pinpointed many causes of quality breeches in medical care: fatigue; poorly designed workflow and care systems; undue commercial influence; knowledge gaps; memory lapses; reliance on inappropriate heuristics; poor interpersonal skills and insufficient teamwork, to name just a few.  But “not trying” is rarely cited.  Yet P4P implicitly blames lack of motivation for poor quality care.

But even when motivation is the problem, money isn’t always the solution.  Findings from the new field of behavioral economics indicate that performance bonuses often backfire, particularly for cognitively challenging work.

Are there financial incentives that could work in the complex environment of hospitals and physicians' offices?  Maybe so, but they will have to be much better designed that what we have seen so far.  We'll explore this in future posts.


Anonymous said...

Perhaps they are all concentrating on the wrong thing. As Clayton Christensen says:

"There really is a difference between incentives and motivation. What an incentive is ‘I am going to pay you to want what I want.’ And as along as you pay people to want what you want they do it. The minute you stop paying them, to want what you want, they stop. And they are not motivated to do anything. They were just incentivized to do just that.

What motivation is in contrast, is an engine inside of you, that you are so committed to, that whether you are paid or not, it causes you to want to keep sacrificing and serving for the cause that you’re engaged in.

And so if you want people that are working with you or for you to be motivated, then what you have to do is help them see in the work what it is that causes them to be motivated."

The question is, how do you do that? Sometimes it just doesn't seem possible - especially with the indisputable evidence that these needed changes haven't happened on their own, either, despite your and others' constant exhortations.

nonlocal MD

e-Patient Dave said...

So, to "pile on" nonlocal:

Got any suggestions?

3+years into this, part of me is thinking that at some level when you agree to manage (or own) a hospital you take on a sacred trust to make it a safe place, and if you refuse or fail to improve in known ways, you frickin' get DELICENSED and aren't allowed to be a public menace, exactly the same as if you're a drunk driver who won't improve.

I'm so tired of people in "health" "care" (double dumb quotes intentional) and won't do this. And I'm also getting tired of people saying "Intervention X won't work." What will work, Paul? What will? After all the talk at BID about, for instance, central line infections, they're nowhere near the zero that Cleveland shows is possible.

What will work? I must say, unintended consequences or not, it makes me sick to keep giving people full pay for avoidably sub-competent work.

Anonymous said...

I agree with you Dave, that I disagree with people saying this won't work or that won't work. We must try SOMETHING. Perhaps Paul is going to explain further. To answer your question about suggestions, I suggest reading Makary's book "Unaccountable" which, while not saying anything we insiders don't already know, explains why these insiders give up trying to change the system.
The thing health care workers respond best to is, regrettably - shame. It's how we're trained. So. Start publishing names? That's what Makary thinks......about hospitals at least.


Kerry said...

Patient's bear the full physical and emotional burden of infections, historically we bear the tremendous financial burden as well. It seems to me if that whether non payment motivates anyone in healthcare to do anything is irrelevant we should continue non payment simply because morally it is the right thing to do.

Anonymous said...

Morally??? Really??? Sometimes things like infections happen no matter how good the care is--we don't have control over everything as much as we would like to. So you will punish the caregivers by making them "pay?" if someone hits your car through no fault of your own, do you tell the body shop that "morally" it's the right thing to do that they should fix it for free?

e-Patient Dave said...

Anon 8:27,

Are you a regular reader of this blog? If so you've seen the years of writing about the question of how much "sometimes" is reasonable.

What level of "sometimes" event is reasonable, to you? Do you work in a hospital, btw? If so, what's its rate of hospital-acquired infections, and its rate of death from these infections? And what is the hospital doing, on-goingly, to reduce that rate of accidental death?

(Did you know that 1.5% of all Medicare admissions end in accidental death, and a panel of MDs said half of the deaths were preventable?) (I presume the other half are the ones in the "sometimes" category you cited.)

Speaking of which, have a look at this post here from March 2007: These Things Happen. And really, honestly, think about my questions above.

Anonymous said...

I have been reading this blog from the beginning, and you already know the infection rates in my hospital because our former CEO is a well-known champion of transparency. (yes, that one)
As you know, we take great pride in our efforts to proactively decrease complications and in our leadership in this area on a national level. CQI in the truest sense of the word.
Nevertheless, as much as we would like to have control over everything, there are some things we can't change (such as infections that result from patients' own flora in the setting of immune system compromise. When a truly "unpreventable" complication occurs, do you really think the hospital should not be reimbursed for its treatment? What about the nurses doing the wound care, the plastic surgeons debriding the site (who never even met the patient before the infection) and for that matter the manufacturer of the antibiotics etc etc? Is it a moral imperative that they must now work unpaid? What about the environmental service folks and the nutrition services folks who are also contributing to the patient's care? Now it's getting ridiculous, right? So exactly where do you draw that punitive line?

The most important point is that there is absolutely no evidence that these "incentives" improve care in the least. (I am pretty sure it improves the insurance companies' bottom line, though, which is likely the real "incentive.")

e-Patient Dave said...

Thanks, anon.

I understand all your points, and I'm not arguing. I'm still left wondering, what can be done that will create change??

For some time "my" own hospital, BID, pretty much stopped dead in its tracks in reducing central line infections, while the whole Cleveland area has hit zero. (Q3 had a spectacular drop though!)

Handwashing compliance continues to be just plain silly-bad on surgical floors. And that's at BID - in my home town of Nashua NH, a relative was hospitalized at St. Joseph's last December, and NOT ONE employee washed their hands on the way in or out, even though the patient had C.diff. And when I asked one woman, she looked at me like I was nuts and said "I'm not gonna touch him..." I thought, "Did your mother never tell you that germs get on things??"

So, no, I don't think irresponsible, ignorant, schlock slackers like that should get reimbursed for the consequences of their incompetence and carelessness. Sorry.

Mind you, I know changing behavior is a separate issue from the money! But after years of talktalktalk about bounceback, the only thing that got people holding CONFERENCES about it was when Medicare said they'll stop paying.

Are we as a culture powerless to say "STOP THAT!!" to the hospitals that simply Will Not Do what what Cleveland and others have done?

I'm open to any suggestion that will work.

And if you want to know what I REALLY think is appropriate, here it is:

- Yes, pay for consequences of things that happen when professionals are doing all the right things.

- But TAKE AWAY THE LICENSES of people who have professional trust and do such irresponsible, incompetent things as I saw in that local hospital. ENFORCE that you can't practice at full pay in ignorance of what works.

Because yeah, tolerating crappy performance - and then arguing about who should pay for the mess - is pretty dysfunctional.