What motivates health care workers is needed to explain health care costs

As part of the new health care legislation, the government has instituted Medicare’s Physician Quality Reporting Initiative (PQRI) in an attempt to motivate health professionals to do the right thing.

According to the legislation, PQRI asks physicians to report how the care they furnish aligns with evidence-based clinical guidelines for a variety of medical conditions, such as diabetes or heart disease. In 2010, physicians who successfully report these measures will receive a 2% bonus on charges received from Medicare. The bonus tapers down to 1% in 2011 and 0.5% from 2012-2014. However, starting in 2015, physicians who fail to report these measures will receive a penalty of 1.5 % deduction from their Medicare revenue from that year, increasing to 2% penalty in 2016 and each subsequent year.

But before we march forward to the trial and error of this new measure designed to induce higher performance, it is important to step back and ask ourselves, what motivates us as human beings?

According to Daniel Pink’s book Drive based on numerous researches replicated in various settings over time, humans are motivated by three intrinsic drives: autonomy, mastery and purpose.

In a book by Deci et al published in 1985, multiple researches on school children randomized to autonomy-supporting versus controlling teachers conclude that autonomy-supporting environment correlates with more creativity as well as enhanced intrinsic motivation and self-esteem. The concept of autonomy is replicated in the real world today by a successful Australian software company called Atlassian.

Inspired by FedEx’s promise to deliver a package in 24 hours, Atlassian instituted “FedEx day,” when, once in each quarter, software developers are allowed 24 hours to work on anything they want, enjoying full autonomy. Results are brilliant bug fixes and new innovative features that otherwise would not be explored as successfully.

Another landmark article in 1959 by Robert White, a professor emeritus in clinical psychology at Harvard University, proposed that the inherent satisfaction in exercising and extending one’s capabilities is a strong motivator. It later inspired numerous experiments on mastery motivation which show multiple positive effects on performance, from leading test subjects to spend more of their free time on tasks to increasing cognitive development in children.

The 21st century example of these validated experiments can be found on YouTube, where there are millions of videos on the how-to of everything, from using make-up to writing computer programs, made by folks who enjoy the subjects in their free time, free of charge.

An interesting study by Adam Grant at Wharton demonstrates the power of purpose as a motivator. The study shows that employees working in a call center at a university fundraising organization who were given stories of how the money they raised affected the lives of beneficiaries earned more than twice the amount of donation compared to before the intervention. Volunteers exemplify the power of purpose in the real world, where people from all walks of life are driven, not by the extrinsic motivation of money, but by the intrinsic motivation of being part of a cause.

Interestingly, within decades of social studies research on motivation, the most surprising finding of all is that monetary rewards actually lead to poorer performance for cognitive tasks. The pervasive belief that higher monetary rewards lead to higher performance only applies to straight-forward, mechanical tasks – as soon as the job requires even the least amount of rudimentary cognition, monetary rewards produce negative effects on performance. This finding has been shown in works by numerous researchers, including Dan Ariely (a professor of behavioral economics at MIT) and Dr. Bernd Irlenbusch (a lecturer at the London School of Economics).

Despite the repeatedly validated science of intrinsic motivations, managers and organizations continue to use money to motivate workers for the more and more complicated cognitive tasks of the 21st century, the Medicare’s Physician Quality Reporting Initiative (PQRI) included. The monetary penalties of PQRI will narrow physicians’ minds onto the goal of mechanically completing reports, eliminate autonomy and distract away from mastery and purpose. It sends the message that physicians should do a good job, not because our work has a higher purpose of keeping other human beings healthy, but because we will earn more money for it.

In a way, it views physicians as rudimentary horses easily lured by rudimentary carrots, when in reality I would like to believe that physicians are human beings driven by the ability to direct our own fate, the desire to be good at what we do, and the heart to be part of something bigger than ourselves.

angienadia is an internal medicine physician who blogs at Primary Dx.

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  • http://fertilityfile.com IVF-MD

    Very nicely put :) We are all driven to attain happiness. Money can certainly help us acquire things that give a short-term fleeting feeling that we mistake for happiness, but only purpose and integrity can gain us the amazing satisfaction that comes from long-term happiness. I still believe that medicine can be a great profession.

  • Alina

    Awesome post!

  • Anon

    Very nicely written. No answers, but good thoughts. The most important point is that P4P and it’s ilk will kill medicine.

  • RKP

    Actually, you are misinterpreting some of the research in behavioral economics. Financial bonuses do not hamper performance uniformly. Ariely’s experiments showed that those receiving huge, disproportionate bonuses did worse than those receiving middle or low bonuses.
    Do you honestly think a 1-2% bonus is a significant amount? Even a busy, large volume practice might see 1 to 2K from this over a year, at most. Peanuts.
    This amount is probably just right to spur improvement, but not hamper performance as a huge bonus might.
    I would actually give credit to whomever came up with this calculated amount.
    If you were designing policy around PQRI, what incentives or intrinsic/extrinsic motivators would you propose as an alternative?!?

  • J.T. Wenting

    “In a way, it views physicians as rudimentary horses easily lured by rudimentary carrots,”

    Which is not surprising, as the current US administration (in fact pretty much any government) views its subjects as little children who need to be shielded, controlled, and told what to do, and of course spanked if they misbehave.
    That’s the nanny state, something a lot of physicians have always wanted to impose on other (“have you had your checkup yet?”, “visit the dentist every 6 months!”, “breastcancer checks should be mandatory every year”, etc. etc. etc.) but now find out isn’t fun if applied to themselves.

  • jsmith

    2% rewards and punishments? Not much of a bold stroke, really. Wake me up at 10%or 15%.

  • ErnieG

    JT Wenting

    The nanny state and the advice of a physician are not the same thing. Going against physician advise carries no legal punishment, and an adult does not have to see a physician (unless they are in a certain profession or are seeking licentures).

  • Marc Gorayeb, MD

    The author is quite correct, and we have all been down this path before. Physicians will give this program the attention it deserves:
    In very short order, a series of ‘magic words’ will emerge that – if expressed – will require the bureaucrats to certify compliance. (Remember, bureaucrats have relatively little discretion if the physician makes the ‘correct’ statements).
    Physicians will learn these magic words, and arrange to have their office staff enter them in whatever bureaucrat-generated form has been provided.
    Then, to maintain their Medicare reimbursement at its already paltry level, all they will have to do is sign another useless form sitting on a pile of other useless forms.

    Remember how they said that a single payer system would eliminate most of the “administrative” costs and lead to a more efficient health care system?

  • David Hager, M.D.

    Brought to mind also the HITECH program with Medicare carrots and sticks to herd docs into adopting EHR systems. This discounts our spontaneous willingness to assess and adopt technologies that actually work.

    Clinicians want usable, reliable, secure, affordable EHR systems that feel intuitive and smooth, and make us work faster, smarter, safer, and more profitably at the point of care.

    Give clinicians these things, and federal incentives won’t be needed. (The phenomenon of nearly ubiquitous smart phone adoption by physicians is evidence of this.)

    Don’t give clinicians these things, and federal incentives won’t be enough.

  • angienadia, MD

    Re: RKP
    Thank you for your comment. Here’s an excerpt from the link you posted, by Dan Ariely:
    “We found that as long as the task involved only mechanical skill, bonuses worked as we usually expect: the higher the pay, the better the performance. But when the task required even rudimentary cognitive skill (as we might suppose in- vesting and banking do), the outcome was the same as in the Indian study: a potential higher bonus led to poorer performance.”

    It is true that in their Indian study, only huge bonus leads to poorer performance, but the more interesting point is that there is NO difference in performance between middle and low bonus – this means that pay-for-performance does not work for cognitive tasks, and could lead to poorer performance when it is too big.

    Magnitude aside, the more interesting point in Dan Pink’s book is that the best way to use money in management is to pay people enough to take the issue of money off the table, so that people can focus on the work itself. For me, the profession of primary care has paid me enough (as I’m a single intern taking care of no one). Other commentors have rightly pointed out that 1-2% is puny, so the issue with PQRI is not about money, by any means. It is the cumbersome paperwork that comes with it, which will take my time away from patients while in no way changing the way I practice. I vaccinate my patients because I take pride in my job and that’s the right thing to do – no amount of money will change that. In the end, I don’t believe PQRI will bring about real improvement that will last once the extrinsic motivation of money is removed – only more paperwork.

  • http://www.talktoyourunconscious.wordpress.com BobBapaso

    People who are not motivated to do the right thing should be screened out at the medical school entry interview. The rest should be taught mastery of their subject and the given autonomy ( a license) to pursue their purpose.

  • Luke

    I don’t see how these bonus studies can be extrapolated to actual compensation practices. There’s a big disconnect between a 20-minute study and an annual/quarterly performance bonus.

    It seems like the obvious explanation to these studies is that a large bonus makes people nervous, and being nervous leads to poorer cognitive performance.

    The studies don’t address long-term motivation or aligning incentives. In industry, bonuses are a way of motivating people to work harder/longer (people start to require a very high premium to work beyond 60-80 hrs/week), and aligning incentives of employees with the firm (focusing on what’s commercial rather than what’s fun to do).

    I’m not in medicine, but when I read that a bonus will be paid to write a report how you do something, that sounds silly. You’re incentivizing people to create more paperwork, and moreover asking them to report on how they themselves performed? As angienadia says, “I don’t believe PQRI will bring about real improvement that will last once the extrinsic motivation of money is removed – only more paperwork.”

    • gzuckier

      Another aspect is that once a reward is instituted, eliminating it results in a drop in performance larger than any improvement in performance attributable to the reward.

  • Boiler Bro Joe

    Forgive my ignorance on the subject, but what exactly is the problem that these government measures attempting to solve? Risky treatments? Inadequate care for the purpose of saving money? Or something else? I’d love to brainstorm about how some of your conclusions regarding incentive could be adapted to the problem at hand. Great article angie!

    - Joe

  • http://fertilityfile.com IVF-MD

    Rather than all these artificially-set incentives, why not just leave people alone and let them express their own priorities. It’s ridiculous to have distant central planners try to enforce arbitrary incentives on a diverse population rather than let the individuals decide for themselves. There is no one-size-fits-all reality. Different people prioritize different things. Some patients value a luxurious office. Others value short waiting room times. Some like a doctor who graduated from an Ivy League school. Some prefer a doctor who spends quality time communicating with them. Some like friendly energetic medical assistants. Some prefer older, more experienced RN’s. Some will wait hours to see the doctor only. Some are willing to see PA’s and NP’s in order to be seen sooner. Some don’t care about any of these as long as their medical problem is solved.

    On the flip side, some doctors want the fulfillment of having quality time with patients. Other doctors want to maximize revenue and provide care for high volumes of patients. Some doctors are willing to sacrifice their weekends and evenings. Others value their personal life more and restrict patients to being serviced only during a tight time span of certain hours.

    Let the market loose so that each party eventually gravitates to interacting and transacting with the parties that best fit their needs.

    The most common argument that I hear against this basic free-market idea is the “patients are not smart enough to know what’s best for them” argument. Well that’s a self-fulfilling prophecy. The more that central planners try to interfere in the daily activities of people, telling them what to eat, how to work, what to watch on TV, where to get their health care, what to think, etc, the more you get a population that becomes accustomed to being coddled. Once you remove this harmful attitude, the population will quickly evolve into being smarter shoppers and better thinkers, more able to protect their own interests. At least this is my opinion. :)

  • Anon-MD


    I just had the pleasure, or dissatisfaction of hearing one of these “central planners” speak to our medical society – there is simply no room on their “grand plan” for individual decision making. It does not fit into their models.

    Great things are coming

  • http://fertilityfile.com IVF-MD

    My disdain is not for the bureaucrats as people. Instead, what I see as flawed is the system. Anytime you put decision-making into the hands of anybody who does not have a vested interest in the outcome, you will ruin things for those involved. So if you take decision-making out of the hands of the patients and of the doctors and put it under the control of the insurance bureaucrats and politicians, you end up with a scenario that is good for the bureaucrats (more government power, more taxation) and bad for the doctors and patients (over-regulation, job dissatisfaction, high stress, loss of autonomy, bad reimbursement, bad medical care, loss of consumer choice).

    • David Hager, M.D.


      Bureaucrats are merely fellow humans subject also to mundane human motives. As a bureaucrat, if I want to assure myself job security/promotion and thus put my kid through college and secure a better retirement, there are some things I must do well:

      1. Enforce existing rules more rigorously
      2. Create new rules
      3. Work to preserve the existence of my bureaucracy

      I don’t believe there’s any incentive to reduce the number of rules, or the scope of my responsibilities within the hosting society.

      Unfortunately, I think bureaucracies risk becoming evolutionarily unsuccessful parasites. If they kill their regulated hosts, their raison d’etre disappears.

      • http://fertilityfile.com IVF-MD

        Exactly. Such is the history of the rise and decline of all previous empires in civilization. I idealistically hope that this time, because we have the awesome power of free speech via the internet that we can congregate peacefully as a citizenry to regulate the malignant growth of state power. So far it hasn’t looked that way…yet.

        The stakes are among the highest when it comes to healthcare, because it can instantly affect life or death. If our healthcare system is bureaucratized more than it already is, real people will suffer (or have already suffered and are already suffering).

  • Anon-MD

    Well put

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