I have discussed Thinking Fast and Slow in previous blogs--here and here. A frequently used behavioral economics concept is the power of defaults. You may have heard the success of organ donor programs automatically enrolling new drivers into the system. Once the default is set, rarely is the status disrupted or opted out. The process has also been successful for health systems prioritizing generic drugs for all electronic order-entry systems.
Paying incentives upfront also triggers a behavioral response called loss aversion. A clinician is paid in advance of actual metrics. The "loss aversion" translates into a more focused approach toward quality of care to avoid monetary loss. Think of bundled payments for example.
A variety of behavioral economics concepts have been implemented to determine how to structure incentive payments. Different panel members shared individual incentives vs. group incentives, transparency of incentives, and self directed comparison of peer performance to influence behavior.
Future posts will unpack the specifics of the merit-based incentive payment system (MIPS) and advanced alternative payment models (APMs) but from a topical perspective--they don't seem that different from fee-for-service.
Hear me out. Fee for service benefits quantity of care. The more you do--the more you are compensated. The health system loses as costs spiral out of control. Those hoof beats you hear might be zebras so lets be sure to have the MRI and advanced imaging--just to be certain.
I see a similar conundrum with APMs. Incentive payments can range from tens of thousands to several hundred thousand dollars for specialty care. That amount of money is significant and can drive care to the other extreme. Do physicians with adequate training around evidence quality and high-value care really need cash incentives to make optimal decisions at the point of care? If rationing care brings extra compensation to an individual, group, or hospital--what happens to the patient?
An idea I would like to put forward? Why don't we monitor the fire-hose of marketing messages embedded in clinical trials? How can we improve perception and evaluation of clinical messages? My friend Amy Herman has written a beautiful book about Visual Intelligence that helps me guide discussions about critical thinking and how we communicate evidence in clinical care.
Ellsworth Kelly's beautiful painting Austin, 2015 (exterior rendering) stimulates discussions about what we observe and how we can become better critical thinkers. Take a few minutes to observe the painting.
Now what do you notice if I share the Ellsworth Kelly, Austin, 2015 (model; interior view) image? Do you puzzle at the geometric arrangment of the colored panels on the picture above before peaking around to the edge of the building? Would you automatically assume the interior shot was depicting the obvious angle in the exterior photo?
You might miss the geometric arrangement of the squares and not realize the different perpective in the original image. The actual circular interior shot seems to be from the windows on the side of the painting. No big deal in a painting but what if you confused spatial imagery on an x-ray or didn't notice a discrepancy on a graphic in a research paper? How might this influence your point of care decision making?
Amy Herman, author of a new book on visual intelligence, says you can learn to improve your observational skills and critical thinking. Looking at art is a good place to start.
Observation--the taking in of detail--is objective. Perception--how we interpret what we observe--is subjective. We draw conclusions and make decisions based on our perception, which can be influenced by more than a dozen factors, including education, experience, values, and whether we got a good night's sleep. The better we understand what might alter our perception, the more accurate our observations will be.--BY LEIGH BUCHANAN Editor-at-large, Inc. magazine
Is it possible we are selling clinicians short? Do they really need extreme incentives to "do better" or do they just need better perception and critical thinking tools?
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In a world of "evidence-based" medicine I am a bigger fan of practice-based evidence.
Remember the quote by Upton Sinclair...
“It is difficult to get a man to understand something, when his salary depends upon his not understanding it!”