WASHINGTON -- Improperly aligned incentives could undermine healthcare reform efforts by being either ineffective or leading physicians to think more about economics and less about the patients' interest, according to a perspective article.
Instead, reform-related incentives should focus not just on economic motivation but on an array of financial and nonfinancial incentives across the delivery system, stated the piece published in the March 14 edition of the New England Journal of Medicine.
"The challenge for the leaders of healthcare organizations is to shape and align this web of incentives in ways that promote the institution's goals while avoiding unintended harmful consequences, such as over- or under-provision of services," stated Nikola Biller-Andorno, MD, PhD, director of the Institute of Biomedical Ethics at the University of Zurich in Switzerland, and Thomas Lee, MD, of Harvard Medical School and the Harvard School of Public Health.
"The importance of this process is increasing as financial risk begins to be shifted to provider organizations along with responsibility for patient outcomes, as is currently occurring in accountable care organizations (ACOs)," they said.
A simple carrot-and-stick model won't provide incentives that are both ethical and effective, the authors wrote.
Purely financial incentives such as rewarding quality or efficiency targets can have perverse consequences, the authors argued. For example, they can introduce conflicts of interest. They can also provide targets for critics inside and outside the health system.
Nonfinancial motives such as open and transparent performance rankings can influence change through peer pressure and allow colleagues to learn from each other. "However, peer pressure is a powerful, double-edged tool that carries some risk of manipulating behavior against individuals' moral judgements," the authors wrote.
Goals must be broadly accepted within an organization to gain traction and be successful. The perspective states that medical professionals must commit to improving patient outcomes, bettering the population's health, and reducing costs. Once that happens, that commitment can be translated into performance through incentives such as performance report cards for value-based care.
"Using incentives both effectively and ethically requires a shift away from a simple, one-lever model that relies on tradition, self-interest, or emotional responses to reward participants for a desired action -- or punish them with financial loss or shame for an undesired one," the authors wrote.
They said badly designed incentives that don't include this shared purpose can be perceived as manipulative and disrespectful of physicians' identity.
When doctors have a genuine shared interest, they said, reform efforts protect and promote physicians' sense of moral responsibility and also promote ethical standards that allow them to take responsibility for their performance rather than having it forced upon them.
"When teams feel ownership of the shared goal, they can display creativity and flexibility that go beyond what's possible with incentives based on tradition, self-interest, or affective responses alone, while maintaining health professionals' sense of moral agency and responsibility," the authors wrote.
Biller-Andorno and Lee suggested principles that can lay the foundation of a suitable framework for aligning incentives properly:
- Tradition, culture, and mission professionals can identify with
- Climate of respectful social interactions allowing physicians to uphold their professional standards and moral responsibility
- Transparency about institutional aims
- Taking a proactive attitude toward monitoring effects of incentives on the quality of patient care and conflicts of interest perceived
- Encouraging physicians to develop a shared purpose and continuous evaluation and revision of incentive schemes
"Under such conditions, incentives -- in the sense of financial or nonfinancial drivers of action -- need not be antithetical to a morally acceptable practice of medicine," the authors wrote. "In fact, they may prove to be valuable instruments in the attempt to realize both the economic and the ethical visions of high-performing healthcare delivery organizations."
New England Journal of MedicineSource Reference: Biller-Andorno N, Lee TH "Ethical physician incentives -- From carrots and sticks to shared purpose" N Engl J Med 2013; 368: 980-982.