shawn whatley md

Medicare Dilemma: Equality or Excellence, But Not Both

Who wants average healthcare? We want the best for our children and loved ones, not average. Canadian Medicare can never deliver excellence, because it’s made to deliver equality.

Excellence does not occur by chance. We design systems to produce and reward excellence. But, Medicare hates reward based on performance.

Medicare delivers equal pay and equal performance, but not excellence.

Most big healthcare organizations are unionized in Canada. Unions discriminate on seniority; the longer you work, the more you make. Volume or quality of work does not change unionized income or job status.

But, we DO discriminate by punishing the very lowest performers. Gross negligence will get you fired, or sent for remedial training.

So, more accurately, Medicare just refuses to reward excellence. In fact, Medicare finds distasteful the idea that some perform better than average.

Every Olympic race has a few speedy people out in front, a pack in the middle, and a few of the slowest at the end. Medicare denies that bell curves exist; that there’s any race at all.

Excellence requires effort, exposure, and risk. Why reach for excellence to earn weak kudos from your boss and disdain from colleagues for making them look bad? Inspiring leaders can squeeze out extra effort, but always backed by the promise of rewards: better pay, better positions, or better intangible benefits.

When we remove the concept of excellence, all measures of excellence, and refuse to reward excellence, we leave nothing for management to lever. All that’s left is process and structure. Management defines work that needs to be done and relies on punishment if it’s not done. Punishment invites union scrutiny. Performance management gets tried, found difficult, and left undone.

Refusal to reward excellence drives revision to the mean. Everyone clusters around the average; the bell curve becomes narrow and steep…equal and safe.

When everyone’s performance is average, patients get average care. Unless we have unlimited budgets, excellence can never show up, except by chance or revolution.

Do we care about excellent patient care, or provider equality? In times of fiscal restraint, ideologic commitment to equality cheats patients of excellence by offering only average healthcare.

(photo credit: blog.ubc.ca)

Canadian Chaos: Medicare’s Misaligned Incentives

Imagine a professional hockey team where some players earned income by scoring goals, and their teammates were paid just for showing up to play for games even if they did not score. Assume that both groups love hockey.

Imagine there are separate coaches and budgets for each group. One coach looks after goal-paid players; the other coach looks after game-paid players. The first coach pays players for all goals scored with a flexible budget. The second coach pays players for time spent on the ice with a fixed budget.

Which players would:

Try to keep scoring goals after games officially ended?
Push themselves for extra goals?
Hold back from scoring to avoid penalty or injury?
Take sick days and miss the game completely?

Which coach will:

Want shorter games?
Let the other coach play in overtime?
Try to save money by limiting his players’ duties and time on the ice?

Welcome to Canadian hospitals.

Misaligned incentives create chaos. Just because players wear the same jersey, does not mean they are a team. Winning teams have aligned incentives and drive toward the same goal.

All healthcare providers and administrators want to help patients. It’s why they entered healthcare. But the system makes them pull in different directions.

Canadian Chaos

Nurses get paid for hours of work.

Physicians get paid for work accomplished.

Nurses get paid from the hospital budget.

Physicians bill the province.

Nurses negotiate contracts specifying duties, hours of work, benefits, and grievance processes.

Physicians negotiate contracts specifying billable services.

Instead of hiring staff, hospitals save money by making MDs do non-medical tasks. Only Medicare would make its most skilled, highest paid workers do clerical work.

Hospitals spend money to help more patients.

Physicians earn money to help more patients.

Helping patients must be the only objective that matters in healthcare. Incentives must be aligned towards one goal: helping patients. All providers must be rewarded for helping patients and how well they do so.

Medicare providers wear the same jerseys, but are they a real team?

(Photo credit: GetItNext Hockey)

4 Features of an Outstanding Clinic

Helping in new clinical settings over the past year, I find these core features in great clinics and hospital departments.

Outstanding clinics:

1. Remember Their Core Motivation

Most of us run from task to task without asking why. At some point, we chose to do what we are doing right now. Even with years of training, people don’t have to keep providing patient care; they could look elsewhere.

People need help to remember why they do what they do, and why they work in a particular place.

Most people who work in healthcare applied from a desire to help people. They looked for specific jobs that allowed them to help and serve patients.

Outstanding clinical groups never forget that serving patients comes before anything else.

2. Support Their Core Business

Especially in large groups, staff might think the clinic or hospital pays them. In a sense, that’s true, but also very wrong. Every business gets paid for doing something.

Although revenue flows through the clinic before it gets to the staff, employees must know that the clinic stays open if physicians see patients. Anything that slows, or stops physicians seeing patients results in poor patient service and less revenue.

Great clinics keep physicians working at what physicians do best: seeing patients.

3. Think About Governance

Governance refers to how organizations are governed and controlled, how decisions get made, and how decision-making units fit together. A solo physician deals with everything, or delegates to an office manager.

Problems arise as clinics grow. At some point, groups need to think about a formal, simple governance structure. Communication, authority, and accountability must flow in a line through the structure. If structure gets ignored and leaders start talking like customers expecting to be heard like owners, chaos ensues. (Check out: The Imperfect Board Member)

High performing clinics have an explicit governance structure that everyone follows.

4. Manage Performance

Once everyone remembers why they are there, knows how the clinic earns income, and understands how decisions are made, staff needs support to perform well. With clear expectations, most staff members excel; some do not. Even in a small group, staff needs performance reviews, incentives to improve, rewards for excellence, and follow-up on underperformance.

Outstanding clinics measure performance using explicit criteria supported by everyone. When members do not perform well after attempts to help them change, great clinics help low performers find work elsewhere.

Final Thought

Oppressive workplaces leave you emotionally exhausted at the end of a day, fill you with dread at going to work, and require you to tiptoe around icy colleagues. Dennis Bakke wrote bestseller Joy at Work suggesting that we embrace human values as ends in themselves, not just means to business ends.

Outstanding clinics foster uplifting, healing work environments.