Monday, March 18, 2013

How Can Care Management Programs Manage Physician Incentives?

One ingredient for physician cooperation?
Years ago, when the Disease Management Care Blog was helping to lead a care management program, it was paired up with a nurse-administrator who was troubled by the notion that docs should get paid to sign-off on a disease management care plan. Why, it was asked, should docs get any extra compensation to do something that's a fundamental part of caring for patients?

It listened politely to its colleague's input.  After a careful review of all the issues, risks, benefits and alternatives, the physician-DMCB decided to compromise by paying the docs to sign-off on the care plans.

Drs. Nikola Biller-Andorno and Thomas H. Lee, writing in the March 14 New England Journal, point out that that physician enticements are far more complicated than shekels for signatures. They think economic incentives in health care are a complex mix of "traditional," (social status) "self-interest, (one example is money) "affective" (being appreciated) and "shared purpose" (for the greater good) motives.  They also suggest that they are unavoidable.

A nurse care management administrator might as well join 'em rather than fight 'em.

Armed with that insight, it's easier to contrast the underlying cultures of a non-for-profit community health center versus a for-profit hospital chain. It's also easier to understand that performance measures can not only appeal to self-interest (as in pay for performance) but to the "affective" reward of being given an excellent rating by a community of colleagues.  The authors also point out that a sense of shared purpose cannot be underestimated, since it speaks to the "core principles of the medical profession."

The DMCB's insight here is that there is no single incentive "lever" that can change physician behavior.  Rather, the best approach to incentives is to capitalize on all four incentive domains.  What's more, if "shared purpose" is undervalued, physicians are more likely to feel dissed and ignore the best laid incentive plan.

It turns out paying the docs was the right thing to do as well as appealing to their sense of shared purpose.  What the DMCB and nurse administrator should have done was to also look for some way to leverage the other domains of social status (perhaps a recognition program) and being appreciated (asking a lead physician to express appreciation for the extra work.

Image from Wikipedia

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