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Research

The impact of removing financial incentives from clinical quality indicators: longitudinal analysis of four Kaiser Permanente indicators

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1898 (Published 11 May 2010) Cite this as: BMJ 2010;340:c1898

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Financial incentives. our own motivations?

Financial security is indeed important. Once that is obtained, then
self motivation and vocation should play a large part in performance.

Do financial incentives take away such vocational focus, and in the
long term are they counter productive. maybe it sepends...

The glycaemic control arm would argue for Doctors being
clinically/vocationally motivated (was improving prior to incentives), the
screening data against (dropped after incentives removed).

Perhaps we are more vocationally enthused (or convinced?) by
glycaemic control than screening. Maybe it’s the administrative issues
behind screening that are the differance, wheras HbA1c control is more in
the hands of the physician (more ownership).

Until we know more about our motivations, such studies are too full
of confounders to be used to produce policy, though doubtless governments
will indeed use them for this.

Competing interests:
None declared

Competing interests: No competing interests

19 May 2010
M C Aley
GP
so53 2lh

Pay for performance is ineffective

The recent article, The impact of removing financial incentives from
clinical quality indicators: longitudinal analysis of four Kaiser
Permanente indicators by Lester, et. al. makes an interesting observation
that performnace declines when financial incentives are withdrawn. This
may appear to argue against withdrawing incentives, but I believe this
argues against financial incentives in general.

We have learned a great deal about what really motivates, and for
most of us, money isn't it. While a secure income is essential, financial
rewards for meeting goals actually degrade our work. This article
supports findings elsewhere* that rewards actually decrease long-term
performance.

Our profession needs to rise above P4P. Imagine a report from an air
craft carrier that shows fewer successful landings when bonuses for
reliability are removed! Or that sterility of IV solution goes down when
line workers' incentive bonuses are cancelled! The public expects high
reliability from us, and they deserve to.

Instead of using carrots and sticks, we need to stimulate intrinsic
motivation by ensuring competence; allowing autonomy to innovate and
excel; and connecting performance to the big picture.

Jim Deming, M.D.

*Drive by Daniel Pink and Punished by Rewards by Alfie Kohn

Competing interests:
None declared

Competing interests: No competing interests

16 May 2010
James R Deming
Family physician, expert team advisor, Mayo Health System
Lake Tomah Clinic, 325 Butts Avenue, Tomah WI
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