Newtown, CT – November 30, 2012
We should remember that knights could afford their knightly behavior. Even then, extrinsic incentives were in play — A recent post by Bob Wachter reignites the debate about knights and knaves, and highlights the evidence to-date, for and against, the use of incentives to drive certain behaviors. Before slicing the shrubberies, it might be time to recast the debate in its proper terms. Let's start with a simple point: when knights roamed the land (not this one because there were none here), they did so without a care in the world. To be a knight, one had to be a landed gentry. In other words, the monarchs made sure that those who would be called to defend the realm and honor the code of chivalry couldn't be bought (or at least that the purchase price would be exorbitant). Freed from the pull of extrinsic incentives, knights were able to fully give in to their intrinsic incentives (and of course, let's not forget that treachery and failure to uphold the monarch's will led to death and/or ruin). And now for another simple point: a mass of tenant farmers were toiling the fields, sowing crops and harvesting them, all for the benefit of the lands' lord…the knight and/or his family. So let's leave knights and knaves alone and put the debate in its proper terms: How do we free dedicated professionals from the pull of extrinsic incentives, and leave them to fully give in to their natural desire to do good for the patient? The answer, unfortunately, is also simple: we can't, not unless we bring back indentured servitude (which we don't recommend).
What this means to you? Let's get real folks. I like fairy tales as much as anyone else, but there's a reason they call them fairy tales. Unless we remove money from all of healthcare, we cannot remove extrinsic incentives. They exist and are here to stay. The moment a medical device manufacturer or any supplier to the industry gets paid for producing a new device, a new prescription drug, a new treatment, there will be an incentive to sell that product. And so the supplier will find ways to increase sales. The moment any form of monetary compensation is given to producers of care services, they have an incentive to produce those services. That's the way commerce has existed since the first caveman realized he could exchange the excess food hunted for something of equal or greater utility. And with that realization came another: amassing excesses led to greater power, comfort, prestige. As such, our collective efforts need to be focused not on wondering whether intrinsic behavior will overcome strong and persistent negative extrinsic incentives, but rather on how to minimize those negative extrinsic incentives that pull the clinician away from the good intrinsic behavior. Here are a couple of ideas: don't discourage the delivery of preventive care; don't encourage the delivery of defects; don't encourage the production of waste; don't discourage the efforts to reduce patient safety failures. You'll note that these ideas are not framed as an exercise in optimizing, but rather as an exercise in minimizing. And you'll recall that the knight wasn't encouraged to be good…he was simply not encouraged to be bad.
Francois de Brantes
Health Care Incentives Improvement Institute, Inc.