Carrots, Sticks, or Something Else? Motivating Doctors to Transform Health Care

Aug 14, 2013, 2:14 PM, Posted by

Two doctors talking with a patient.

An old joke has it that the doctor’s pen is the costliest technology in medicine, since money typically flows where physicians’ prescriptions and other orders decide that it should go. As a result, influencing these decisions is key to achieving the Triple Aim of better health and health care at lower cost.

But what’s more likely to influence doctors: external factors, such as bonuses for improving the quality of care, or internal factors, such as appealing to their sense of altruism or satisfaction with their work?  In other words, carrots, sticks, or something altogether different—what Daniel H. Pink, author of Drive, calls “our innate human need to direct our own lives, to learn and create new things, and to do better by ourselves and our world”?

This question was at the heart of a recent American Board of Internal Medicine Foundation forum in Vancouver, which Robert Wood Johnson Foundation CEO Risa Lavizzo-Mourey and I attended, along with about 150 others. The question has also been central to much of the health care transformation work supported by the Foundation.          

RWJF’s portfolio, past and present, has included a smorgasbord of grants testing ways to motivate doctors to provide higher-value care:

  • Performance measurement and public reporting. Since 2006, RWJF’s Aligning Forces for Quality program to help 16 local communities strengthen their health care systems has employed these as key quality-improvement tools.  For example, the Wisconsin Collaborative for Healthcare Quality has tracked physician group practices’ adherence to evidence-based care standards and posted comparative results on its website. At the ABIM Foundation forum, Craig Sammit, president and CEO of Wisconsin-based Dean Health System, credited these public reports with helping to induce a major quality-improvement effort that raised Dean physicians’ quality rankings substantially.
  • Financial incentives. Foundation-funded efforts are afoot around the country to align payment reforms with practice transformation to improve primary care. In Oregon, for example, the Physicians’ Choice Foundation’s Program Oriented Payment Demonstration Project is testing a new system of caring for patients with congestive heart failure, chronic obstructive pulmonary disease, or diabetes. Under the pilot, teams of providers work with patients to agree on a set of “patient-centric problem-oriented goals”—for example, maintaining patients’ blood glucose under control. The providers are paid to provide care, but they can also receive incentive payments if those goals are achieved.
  • Transforming payment. Fee-for-service, still the dominant mode of paying the nation’s physicians, has long been recognized as inducing doctors to provide more services regardless of the quality of care. Thus, the Foundation recently helped to fund the report of the National Commission on Physician Payment Reform, which called for moving away from fee-for-service payment “because of its inherent inefficiencies and problematic payment incentives.” The report called for testing of new models of care and payment over a five-year time period, with the goal of “broad adoption” of new approaches by the end of the decade. As I blogged earlier, that conclusion is in synch with other recent reports that RWJF has also funded recommending changes in health care delivery and financing.

As these examples indicate, some of these payment-based, “extrinsic” motivators appear to be making a difference; others are still too new to evaluate or have yet to be implemented. Altogether, how likely are they to motivate physicians to produce higher-value care in the long run?

At the ABIM conference, the consensus was that public reporting, financial incentives and new modes of payment are useful, but need to be part of a diverse package of initiatives to enlist physicians in transforming care. As David Blumenthal, president of The Commonwealth Fund, put it, “We need a robust and evolving toolbox [of physician incentives] that can be adapted to different purposes and contexts.”

In my next post, I’ll describe some of the various tools in the transformation toolboxes employed by several physician-innovators who presented at the ABIM conference, including Dean Health.  They underscore that enhancing the more intrinsic and ineffable motivating factors that Pink identifies will also go a long way toward engaging physicians in the delivery transformation process.