Newtown, CT – August 9, 2013
Getting high on life. It's a funny expression, but sums up the discussion between internal motivation and external charges – Those who get high on life don't really need external charges to keep moving. But those who "get a charge" from an activity will invariably need another one, and another, and another, and another. And at some point the charge needs to get greater to keep the person going. The bottom line is that these charges have been pretty much proven to be ineffective in motivating professionals to succeed, because motivation is its own charge, and far more powerful. However, and here's where it gets interesting, motivation can be a force of good or evil depending on the motivator. Judeo-Christian theology teaches us that the seven virtues and their opposites, the seven sins, constantly tug at the human soul. Pride competes with humility, avarice with generosity, gluttony with temperance, sloth with diligence, and so on. To tilt the moral balance we've had a growing tendency to "engineer" behaviors, to rely on prods…carrots and sticks….sometimes knowingly and sometimes by accident. And so it has been with fee-for-service. While it should encourage diligence, it has proven to encourage gluttony. Similarly, capitation, which should encourage temperance has proven quite effective at encouraging avarice. These external charges, by and large, tilt the balance to "bad" as much as, if not more than, to "good". In a new report published this week we examine these issues (not the theological/moral ones) and propose a different approach to improving incentives.
What this means to you – When designing incentives for health care professionals, we must first remember that for the vast majority, it's not just a job, it's a calling. As such — and maybe I'm just naive here — the internal moral compass and motivation is pre-titled to "good". I've been at this for a while, and apart from the few cynics and yahoos who blame everything on everyone else, clinicians basically want to do good for their patients. And so instead of worrying about carrots and sticks, optimizing some external charges, we must instead focus our efforts on reducing as much as possible the negative effects of payment schemes. In other words, trying to optimize a charge is a fool's errand. Trying to minimize all charges that can detract from the "good" motivator is job #1. Of course, it's a different story when we deal with health plan members, whether they are patients or not, and designing incentives for them is much more of a balancing act that will require a fair amount of continued experiments. It's also a different story when dealing with the organizations that surround the clinicians — they can have their own sets of motives for what they do. Our report suggest options and a framework that could be helpful. And we will continue to develop that framework, building a family of associated tools, to help everyone get as close to good as we can collectively strive to. Because being high on life is always more powerful and lasting than being high on a charge.