While pay-for-performance (P4P) is logical and all the rage, there is a contrarian view upon a deeper, more critical analysis. From that analysis, three concerns come to mind: (1) can incentives cause a reduction in intrinsic motivations; (2) how often, when, and why do incentives lead to abuse and corruption; and, (3) why do we (and the government) assume that providers who chose an altruistic career with a relatively low return on investment for the amount of training necessary in time and money would be susceptible to financial incentives anyway?
In a 2013 study published in the journal Health Psychology, researchers examined the ability for financial “incentives to undermine or ‘crowd out’ intrinsic motivation.” Ironically, it found that financial incentives for improved healthcare behavior did not interfere or “crowd out” intrinsic motivation; however, only because the intrinsic motivation of patients who were being financially incentivized was so low to start with. However, this result suggests the converse may be true. Namely, that those with a high intrinsic motivation (e.g., providers) may have this intrinsic altruistic motivation “crowded out” by financial incentives. (Marianne Promberger, 2013)
Moreover, any financial incentive to coerce providers to behave in a certain way can cross a free-will Rubicon wherein once they agree to modify their treatment in exchange for money, the providers are being controlled by the incentive instead of their best natural medical judgment. The New York Times did an examination of this very issue in 2014, wherein they coined the term “moral licensing,” which they described as when “the physician is able to rationalize forcing or withholding treatment, regardless of clinical judgment or patient preference, as acceptable for the good of the population.” (Pamela Hartzband, 2014)
Finally, as the author has noted in other writing for Northwestern University, arguably the most comprehensive meta-analysis of pay-for-performance in healthcare, conducted by the Rand Corporation in 2016 examining 49 studies published in peer-reviewed journals found that pay-for-performance had minimal impact to improve the quality of care. (Cheryl Damberg, 2016) While that may be because institutions choose the wrong metrics to measure, or definitions, or baselines for comparisons, it may also just be that providers took their Hippocratic Oath seriously and, largely, try to stay focused on acting in each patient’s best interests without outside interference, coercion, or influence.
One viable and promising solution in the form of a new standard of care is decision-support systems. While their existence has been around for decades, improved processing power, artificial intelligence, cloud computing, the Internet-of-Things, and patient-generated mhealth data create a confluence wherein purely objective standards of care can be recommended for every patient. Beyond decision support systems, but using their systems and methods, is personalized genomic medicine. One strategic goal of our work at Bioinformatix’ Rx&You is to collect Total Satisfaction Quality (TSQ) data from large cohorts of patients in regard to the efficacy of their medication regimens. This information, when combined with their adverse event history, cost data, and patients’ genomic variants we believe can create a “Codex” via comparative effectiveness research (e.g., which medications work best for whom and when, which are the most dangerous, which are the best value).
Works Cited
Cheryl Damberg, M. S. (2016). Measuring Success in Health Care Value-Based Purchasing Programs. Santa Monica, CA: RAND Corporation.
Marianne Promberger, T. M. (2013). When Do Financial Incentives Reduce Intrinsic Motivation? Comparing Behaviors Studied in Psychological and Economic Literatures. Health Psychol, 950–957.
Pamela Hartzband, J. G. (2014, November 18). How Medical Care is Being Corrupted. The New York Times, pp. https://www.nytimes.com/2014/11/19/opinion/how-medical-care-is-being-corrupted.html?_r=0.
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