incentives Archives - shawn whatley md

Physician vs. State Paternalism

Medical students learn to despise paternalism. Patients must be given all information and helped to make their own decisions. It is better to cause pain and suffering with brutal honesty and unfettered autonomy than to presume benefit on a patient’s behalf. Students are taught that physicians must never bias patients in any way.

What about depressed, suicidal patients?
People who want to stop medications they need?
Demented patients who won’t eat?
Homeless people who won’t come in from the cold?
Diabetics who won’t comply with treatment?

Should physicians be paid more when patients make healthy decisions? Should the outcome of patients’ decisions determine physician payment?

Paternalism

Refers to the limitations of personal liberty/freedom for an individual’s own good by the state, an organization, or other individual (Wikipedia and Stanford Phil).

Soft versus Hard – Soft paternalism supports intervention when decisions are not truly voluntary (e.g. person does not understand a poison label). Hard intervenes even when people know what they are doing (e.g. suicide).
Broad versus Narrow – Narrow relates only to concerns about state paternalism.
Weak versus Strong – Weak paternalism interferes with freedom to promote an end valued by the individual (e.g., seatbelts; most people value safety). Strong interferes when an individual’s values are suspect (e.g., motorcycle helmet laws).
Pure versus Impure – Impure paternalism changes a whole system to benefit a group (e.g. preventing cigarette manufacturing).
Moral versus welfare – Welfare paternalism benefits health/safety only.

Should we force people to live healthy, safe lives?

Physicians get bonuses based on how many of their patients get flu shots, mammograms, and other screening tests. Definitions and explanations can steer patients, while giving the impression of free decision making.

Should patients be informed that physicians get rewarded for specific outcomes?
Would it call into question the physician’s advice?
Is this paternalistic?

Medicare provides, rations, and decides service based on beliefs about need/benefit. Medicare is paternalistic. Where do we draw the line between supporting state paternalism and opposing individual paternalism?

Please share your thoughts below!

(photo credit: wired.com)

Physician On-Call System: Physicians Fight to GET Called

Sometimes patient volumes swamp the emergency department team. Most on-call systems work so poorly, they aren’t worth discussing. Here’s a great on-call system that actually benefits patients.

If being home is more attractive than rushing in to see hordes of waiting patients, your call system will fail.

Most on-call systems pay a few hours’ worth of income to be available, and a small premium for the first few patients seen. Physicians weigh the costs and benefits, then try very hard to stay home by being hard to reach, debating whether there’s really a need for extra help, etc., etc.

Tipping point

Hospitals often pay non-physician staff double-time. They pay operating room staff to come in for a case, even if the case gets cancelled.

Expect to pay physicians double what they would otherwise make on a full shift for coming in on-call. If they get at least as much as they would make on a whole shift, just for showing up, no matter how short they stay, physicians will fight to come in. All of a sudden, you’ll find the first or second ring answered, even at 0300. Put everyone on the on-call list and call through the names in order. After each call, move the top name to the bottom.

Where does the lottery money come from?

At worst, each member contributes to a pool. Far better, get additional funds from grants, educational stipends, drug studies, hosting conferences, recruitment funding, or government programs.

Again, you need to pay physicians far more than you would expect to build an on-call system that impacts wait-times and actually benefits patients. Build a fund.

Activate On-Call System

The charge physician, responsible for ED flow at the time of need, must activate the on-call system. Charge nurses, administration, and fellow physicians take part in the discussion to varying degrees. If the team can’t manage, they must call for more help.

Unbalanced incentives could create dozens of calls bankrupting the on-call system. You need to balance the ease of calling for help with incentives for physicians to work harder and stay late. Paying out un-used funds from the on-call pool to the overnight shifts provides balance.

What if MDs refuse to activate the on-call system to save the un-used funds for night shift?

Hold physicians accountable for wait time performance each day. If certain docs always have longer waits, or often activate on-call, schedule more shifts when they work.

Try it. MDs will fight to get called in with this on-call system.

(photo credit: dartmed.dartmouth.edu)

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)