Incentives without forethought


Category : Medical Rants

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 – 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.  RBRVS and the RUC represent a classic example.  This system is harming medical care through incorrect incentives.  The current implementation of EHRs 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.  CMS 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, HL 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.

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

Comments (11)

Forethought must not be confused with planning.

Planning in a simple system is about prospectively mapping out responses to expected circumstances. IFTTT. In a complex system (by definition) future circumstances are unexpected and unpredictable. It is not possible to plan an effective response to something one cannot imagine. In fact, planning (in the sense of mapping out a response to unknowable circumstances) becomes counter-productive in that it limits flexibility of thought and action. It anchors one’s thinking and acting in the outdated paradigm and tool kit.

Forethought is different. It is about trying to imagine all the things that might happen. While forethought is essential, it is not sufficient. It must be coupled with humility and flexibility: the humility to accept that predicting the future accurately is impossible, and the flexibility to adapt to a changed and changing environment.

Planning guarantees that we will fight tomorrow’s wars with yesterday’s weapons. Forethought, with humility and flexibility, allows one to respond to the new context without being constrained by the planning that wasn’t able to predict the new context.

Don’t ignore the bigger issue. What WE see as incentive might actually NOT be the intended carrot and or stick it might be the one that is “sellable” to us when in reality there is a FAR different one imbedded into the system to generate it’s own end. That is the situation with the EHR process. the verbalized intention is to make the quality of care more open and easier to evaluate and quantify when in REALITY the entire EHR process was and is designed to allow for fraud reduction and isolation. It is cloaked as quality assurance but if that were the case then along with it would have been a universal mandate that all software be based on a common database structure as is ASCII or similar. The fact that all software vendors were free to do what they want with structure and not to work in unison to create one universal interchangeable database so that patients can go anywhere and with it their medical record demonstrates the underlying real reason for EHR. It is to isolate errors and to create more stumbling blocks to prevent billing and procedural errors from being hidden by “I didn’t do that” types of comments
The concept of incentives in healthcare is tantamount to offering free toys in Cracker Jacks. It won’t alter the activity and it surely won’t change the process but for some reason we feel that an incentive rather then an outright compensation system will suffice. Cracker Jacks would do much better to fill the box rather then include the toy as would the nation in terms of incentives for us. We would do much better if we simply were offered payment in exchange for service rendered but instead they offer us incentives as opposed to realistic payments because we are gullible enough to accept them. Look at the incentive more closely you might actually find that we would be better off saying no more games just the contents please! Dr D

So what are you doing to change things?

“So what are you doing to change things?”

If this question was directed at me rather than at the OP, my answer is that I attempted at a local level, but the more engaged I tried to be, the more resistant leadership and management became. Gradually I was marginalized (ghosted in current internet terminology) and ultimately retired, planning to teach in our local residency. Our institution said that, though my clinical and teaching skill were excellent, they would not allow me to remain part of the organization because of my persistent and vocal advocacy for clinical rather than administrative criteria for metrics and for putting patients first.

“Our institution said that, though my clinical and teaching skill were excellent, they would not allow me to remain part of the organization because of my persistent and vocal advocacy for clinical rather than administrative criteria for metrics and for putting patients first”

This is so sad, and it is so wrong.

It’s hard to be optimistic about our profession when I hear things like this.

That is AMAZING. So they went from great teacher/ provider to “get lost”
As far as me? What I do is I am the US Senate’s health subcommittee advisor. I work directly TRYING to educate Senators and their aids on the other side of the equation. The issues are hugely complex there is no direct or simple solution for every direction has atleast 20 sides all weighing in. Everything from labor to various Business Bureaus to Insurance to consumer advocates and then the dreaded political fools I call the “big box morons” like the AMA, every specialty and disease based group AHA ACS ADA etc… and the like.
Even simple alterations take months to debate them then evaluate the outcomes and then educate the aids to educate the Senators to then have them vote on things then the votes go up the food chain to the main committees then up the line from there to the floor votes and then the same thing is happening on the House side and if they are not similar then the results never move ahead.
It is most certainly a Buzby Berkeley type situation with VERY little getting done. EVERYTHING is a compromised outcome no one wins basically as all compromises everyone loses.
The biggest problem for us as providers is the Big Box group as they “appear” to be supportive of us outside but in reality they do whatever is best for the administration members and ANYTHING to prevent outsiders taking even a tiny piece of the action immediately creates a firestorm of activity. Even if the storm is worse then the intrusion.
Dr D

@Dr Dave: “So they went from great teacher/ provider to “get lost” .”


“CMS looks for quick fixes to complex issues”

Why is this glaringly obvious to individual physicians, but completely invisible to our medical societies?

I would love to support our medical societies. But they have been completely impotent when it comes to the big issues we all care about.

Defining quality
Midlevels and what training is needed to practice medicine
EMR absurdities
Meaningful use

and special attention should go to their support of MACRA, which most of us on the front lines realize will be an utter disaster.

See my post on this issue please

[…] Regulators and insurance companies are impacting patient care through their well-intended rules. They do not seem think deeply about their rules. If they would use premortem examinations, perhaps we would have less of these problems. I wrote about this 2 years ago – Incentives without forethought […]

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