Motivating Physicians: Dollars and Sense

Jo and I had a great conversation last week with Dr. Joe Bujak, MD, FACP,  the author of several books including Inside the Physician Mind: Finding Common Ground with Doctors (2008).  Bujak’s premise is that physicians are driven by their personal visions and goals, and that organizations need to align their interests with physician’s interests and medical vision.  This alignment must be done on a foundation of trust.  In his book (2008, p. 62), he states, “When the organization’s goals align with individual physician self-interest, success will follow.”

Bujak reinforced that economic motives cannot preempt physicians’ commitment to the pursuit of excellence from a patient-centric perspective.  When economics is primarily pursued it misplaces the focus away from patient-centeredness and vocational professionalism toward the selfish pursuit of economic gain.  He said to us, “Too frequently the business side of medicine is preempting the clinical.  It isn’t that business success isn’t important, it’s just that it cannot be the primary driver.”

Dan Pink (Drive: The Surprising Truth About What Motivates Us, 2009) describes the power and supremacy of intrinsic motivation over extrinsic motivators to make long lasting change.  Extrinsic rewards, like gainsharing, need to be coupled with intrinsic rewards such as autonomy, purpose and mastery.  What we have seen is that the gainsharing approach, where financial incentives are relatively moderate, arouses and supports intrinsic motivation.

The “Freakonomics” authors Levitt and Dubner in their latest book (Think Like A Freak, 2014) concur:  “If there is one mantra a Freak lives by, it is this:  people respond to incentives.  As utterly obvious as this point may seem, we are amazed at how frequently people forget it, and how often it leads to their undoing.”  Bujak made clear that assuming that money is the sole motivator of physician behavior is not just simplistic, it’s also impertinent.  Climbing inside the physician’s mind, there may be other motivators, such as accomplishment (wanting to be successful), acknowledgement (wanting to stand out in a crowd…or not stand out), and altruism (wanting to do what’s right for the patients).  If incentives serve a measure for objective performance and for meeting other motivators, then they become mutually consistent.  Finance is not the sole motivator.  “It should never be for a professional,” he affirmed.

The AMS gainsharing program balances quality, outcomes, and financial rewards.  Core among program requirements is the creation of a Steering Committee that consists of at least 50% physicians who oversee care redesign efforts.  The steering committee places conditions on payment, including performance on core measures, HCAHPS scores, and other patient-centric measures.   Furthermore, it is a rewards-only program; there are no penalties if physicians need to treat “train wrecks” based on a physician’s medical opinion.

For example, one area where we’ve seen significant change in physician behavior is in decreasing intensive care LOS.   In one case, we found a physician who was admitting and discharging a large percentage of patients directly in and out of the ICU.  The doctor felt that he was providing the best quality of care for his patients.   With gainsharing, the doctor was able to clearly see the cost he was unnecessarily imposing on his hospital, how his peers were treating similar patients (APR-DRG severity adjusted) at lower costs, and how his outcomes are no better than his peers.  While some would argue that the physician should simply change admitting behavior given the available data, game theory works well in understanding why the physician ultimately changed behavior to “win” – and the win occurred with not just an incentive payment, but with the hospital, and ultimately with patients.

Our discussion with Dr. Bujak was a rare treat where ideas were shared and perspectives were defined.  He thrives on the challenges that we have in healthcare, and brings a joy to the healthcare profession.  On a personal basis, though, he left us feeling that we are making a difference.   That’s a great gift to give.  Thank you, Dr. Bujak.

References

Bujak, J. S. (2008).  Inside The Physician Mind: Finding Common Ground with Doctors. Chicago, IL: Health Administration Press.

Levitt, S. D., & Dubner, S. J. (2014).  Think Like A Freak. New York, NY: Harper Collins.

Pink, D. H. (2009).  Drive: The Surprising Truth About What Motivates Us. New York, NY: Riverhead Books.