Last night I followed an invitation by Professor Étienne Minvielle to speak in front of France’s senior hospital executives (“Les hautes dirigeants des hôpitaux de la France” – almost everything sounds much better in French) about my international experiences with designing and implementing incentive systems. The current environment in France is in flux and the thinking circles around adding selective monetary incentives (“Pay-for-Performance – P4P”) like in many countries. But do we get what we pay for if we follow this path and haven’t other countries, such as the US and Germany tried this out as well? Yes, they have. And was it a success. We don’t know. But why don’t we know?
The almost desperate wish to control doctors and their decision-making has encouraged managers and policymakers to focus on money as the primary tool to tame in self- and other interests that are intrinsic, extrinsic or just human in general. And since money is said to make the world go around it might also work for doctors around the world?! Why not try it out?
However, first, it helps to understand what we are trying to do here and second to reflect on what we are targeting. Third and probably most importantly we need to realize whom we are dealing with. I say this in a very generic and non-judgmental way, but doctors are probably the least studied human subjects although they are in the key position to influence everything else, such as costs, quality etc as a result of their decisions. So why don’t we try understand their motivations better? Because it is hard. Hard to recruit them, find time, tolerate rejection and ego. It takes time and a good story to get into the door (especially if you have no money). But once you are “in” you learn that the range of tools beyond money that you and/or management have at hand to influence or rather empower decision making is huge. And it would be foolish to close your eyes and stick to money. Doctors are motivated by their work, their peers and actually – believe it or not – turned off by organizations and everything that comes with it – control, reporting, management. Everything that takes away time from medical care is not cool! And they have gone through a long process of being socialized into their profession. It’s the profession that defines right or wrong not the organization. It is a set of believes. Professional culture is thus stronger than organizational culture all around the world (please see my article on professional culture in the Journal for Healthcare Management).
Getting back to the second issue: what are we targeting? Is it the performance of a certain simple task or a rather complex (decision-making) process that has many unknown variables or are we targeting a proceeding somewhere in between? It will probably be somewhere in between. But remember that as soon as it is not completely and straightforward, a selective incentive such as money does not work. And we know this for a long time. In particular, since specialization and the amount of accessible knowledge is rising even a simple decision gets more complex. Even worse, we will harm the decision-making process if we incentivize certain tasks that will then be executed (whether it makes sense or not) and this will take time and thinking away from the slightly more complex tasks. The result is more fragmentation, danger for patients if they end up in the wrong bucket/pathway/silo/department and nobody has a big picture perspective to rethink the initial diagnosis. If it does not work, why are we still doing it?
We really want to do something good and that gets us back to the third issue: what are we actually trying to do. We would like to ensure quality care for the patient. Maybe also contain costs, but in essence we have good intentions. We are just using the wrong tools for an alpha-type profession that wishes to be autonomous. Let’s rethink this for a moment. In any other industry, you would now start with market research to define the status. Then think about the tools at hand and start to develop the strategy. Not so in healthcare. Technology is implemented without ever asking doctors (who should use it later) whether they would actually do so. Strange and even worse: we are trying to “control” which will cause opposition, dissatisfaction, gaming the system, and alienation from the whole process of complex medical decision-making that doctors get a kick out of. The best example of misled incentives is P4P in science – bonus payments for the number or impact points of publications. The difference is that science has gladly accepted the piecemeal treatment and focus on quantity instead of quality and enlightenment. It is sad to see that curiosity has vanished and the publication game has become a tactical business, leading itself ad absurdum.
What are our options then if money’s impact is limited, professionals have lost interest and quality is not bad but also not as great as we had aspired?
The organization can define rules – a framework, but also has the obligation to talk to doctors’ egos, cherish autonomy of highly skilled experts and invest in knowledge workers. This gets increasingly difficult as social media permeates organizations and professions bring – in addition to their culture – their individual communities inside the organization. All of this has to be considered, especially if we are targeting vague constructs such as creating a collaborative spirit, trust and reciprocity. A refocus on the human side of the enterprise is in order which requires more complex sophisticated incentives, supporting the autonomy of experts and their joint action within a framework that sets only ground-rules, but does not enforce, but enable. To be continued…
The most wonderful experience when talking about own experience is to learn from the audience. The French hospital executives were that perfect example of an interactive and creative group of healthcare actors who care and are inspired “soi-même”. Like at a performance of the Alvin Ailey dance theatre last summer in Paris I realized again that maybe the Anglo-Saxon way of performance is the most advanced in the world, but nobody can appreciate a performance/talk as the French do. Thank you for the invitation and the positive feedback. I look forward to staying in touch – C’était très inspiratoire!