Blog | Wednesday, July 6, 2016

Incentives without forethought

“In life, as in chess, forethought wins.”
—Charles Buxton

Long time readers know that I worry greatly about the incentives in our health care system. “Every system is perfectly designed to get the results it gets.” But here is the problem. Few managers and leaders think through the implications of their incentives, explicit or implicit.

Farnam Street Blog has a brilliant post on incentives, titled, “Incentives Gone Wrong: Cobras, Severed Hands, and Shea Butter.”

As you read this post, you will quickly recognize that the incentives get created without including any forethought about what could go wrong. Gary Klein's pre-mortem exam process can potentially help us design systems.

We have many examples of forethought deficiency in medicine. The Resource-Based Relative Value Scale and the Relative Value Scale Update Committee represent a classic example. This system is harming medical care through incorrect incentives. The current implementation of electronic health records represent another great example. Performance measures have significant unintended consequences. Richard Byyny has a wonderful piece about these problems in The Pharos, “Time matters in caring for patients.”

Thinking ahead is difficult. Wrong decisions occur because the decision makers think through problems in a shallow fashion. Politicians provide the classic example of shallow thinking. The Centers for Medicare and Medicaid Services looks for quick fixes to complex issues. Their solutions look good to the politicians, but they rarely have the results that they predict implicitly.

Medical care is very complex. Too many systems (political, insurers and researchers) want to measure our care and rate physicians or organizations. They often suffer from shallow thinking.

Incentives must work – and paradoxically they do. However they often do not give the imagined result. Clearly, we need more careful thinking as we develop rules that impact how we practice medicine.

This problem has no easy solution. While he was a despicable person, H.L. Mencken does have an important quote here, “For every complex problem there is an answer that is clear, simple, and wrong.”

We have to make this argument widely. If we understand the complexity herein, we have a responsibility to make these concepts well known. Any redesign of health care systems must include very careful forethought. Unfortunately, forethought is rare.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.