Internal Motivation

Everyone is very excited about Congress’s elimination of the annual CYA known as The Doc Fix.  For a refresher go to the excellent piece at The Health Care Blog by Steven Findlay (http://thehealthcareblog.com/blog/2015/04/08/sgr-rip-hopefully/).  Also in that legislation was an increasing push toward paying doctors for a group of patients, instead of by individual or by service, and giving monetary rewards to doctors who have better quality metrics.  This is supposed to save money by taking away the doctor’s incentive to see more patients and order more tests.  It is also supposed to increase quality by tipping the doctors, as I’ve discussed before.

OK, so I have a primary care doctor.  I am healthy, I eat right, I don’t smoke, I drink moderately (most of the time), I (used to) exercise.  Most men and women in my particular demographic do all of these things as well.  I have access to quality food, a gym membership, and health insurance.  Say my doctor participates in the proposed arrangement: she gets paid for a block of patients and, if those patients do well, she gets a bonus.  I love my PMD, but she would be getting a bonus for doing NOTHING.  I haven’t seen her in at least 5 years. The annual physical has been largely discredited, I haven’t reached the age-related screening test juggernaut, and I have the freedom to do everything I can to be healthy.

Let’s say I am not healthy.  I’m overweight, in my 50’s, I have a bad knee and had a heart attack last year.  My blood pressure is high and I quit smoking, but not soon enough.  Maybe I live in a low-income neighborhood and healthy food is not readily available.  I can’t exercise because my knee is bad, and also because I’m working two jobs, one during the day and one at night.  Let’s say my PMD has been seeing me once a month, has given me blood pressure medication, sent me to the office nutritionist and the social worker, checked my blood sugar and cholesterol, ordered my mammogram and colonoscopy, and kept the office open on Saturdays so I can actually make an appointment.  Despite these interventions I’m still overweight, my blood pressure is still high (because I can’t afford the co-pay), I haven’t had my screening tests (because I work two jobs and those guys don’t work weekends).  Now my PMD, who has worked her butt off for me, gets no bonus.

Health care administrators seem to be operating under the assumption that doctors won’t do good work without monetary incentives.  They also assume that people’s health depends on the good work of doctors.  They further assume that the quality indicators they have chosen actually indicate quality, and finally, that doctors have full control over their quality numbers.

But Shirie, you say, you are always complaining and moaning about how broken the system is.  How about you give us an alternative?  Not everyone can be an arrogant one percenter like you.

Provide health care for all patients who want it, change malpractice laws, and salary everyone.  Give every doctor a salary commensurate with the amount of money and time doctors spend in training so that they can support their student loans, their office overhead, and a moderate lifestyle.  So doctors go to school, graduate, and get good jobs.  If said doctors want to make more money they either a) quit and go into banking, or b) earn bonuses by taking care of sicker patients, or underserved populations, or the poor.  This solution offers the following advantages:

1. Doctors have good jobs that they don’t have to stress over.  Each patient gets the time they need and there are no production pressures. Quality rises as a result.

2. All patients have access to health care, so there are no uninsured folks waiting until their diseases are really bad before seeking help.  On the other hand, people who don’t choose to take charge of their health don’t penalize their doctors as a result.

3. Bonuses earned are for useful work, not data points.

4. Tests and medications are not ordered on-demand or because of fears about litigation.

5. All the overhead and CEO salaries for private insurance companies goes away.

But Shirie, you say, you arrogant one-percenter socialist, won’t that make doctors lazy, since they have no incentive to do a good job?  They can just while away their days because they get paid regardless.  Well, isn’t that what all the members of the US Congress are doing most of the time?  My kids’ kindergarten teacher gets a salary.  Why wouldn’t she do the same?  My mailman gets a salary.  What prevents him from wrinkling and/or soaking my mail and delivering it days late?  There is the threat of being fired, of course, but there is also the possibility that the teacher and the mailman like what they do and care about doing it well.  Why do we assume that doctors, or anyone else, will do a terrible job unless we incentivize and/or punish them?  We are not toddlers.  Most of us have an internal motivation to be good at what we do.  We just need to be given the right environment in which to do it.