Flat salary is an incentive to do the easiest option or least work. You can’t win with the incentive game.
One nasty way that can manifest is to under test because if you don’t find anything you don’t have to do anything.
One nasty way that can manifest is to under test because if you don’t find anything you don’t have to do anything.
In Canada we have fee for service, with incentives to care for specific populations (remote or chronic conditions etc.) Doctors (or their clerk) do their own billing direct to provincial health services. It works. We rely on individual morality and they generally do the right thing. Our outcomes are good.
Healthcare in America is a prime example. So is higher education, in which the lenders and universities collude to raise prices as much as possible.
IMO the effectiveness of carrot (variable bonuses/pay, a many-tiered level structure with promos between as “carrots”, being disciplined or fired as “sticks”) incentive structures depends on how easy it is to evaluate good vs bad work at a job. In tech it can be hard to distinguish mediocre vs bad work which is why we don’t have a lot of stick incentivizes; good work is a lot easier to recognize so instead we have carrot incentives.
While for some medical jobs like being a surgeon good work is easier to recognize vs mediocre work, it’s a lot easier to identify bad work: bad medical outcomes, low patient satisfaction, less patients seen per hour. So as a result you don’t need as many carrot incentivizes as in tech and can probably get by with more stick incentives. Fwiw I think carrot incentives often have a lot of drawbacks as people optimize for the carrot directly rather than “doing a good job”. With sticks you optimize against sticks, but when you have signals like patient satisfaction to account for, you have a very strong stick signal.
We're already selecting a highly motivated subset of the population with the med school process.
Traditional American fee-for-service medicine has been absolutely shown to (a) drive practitioners to do unnecessarily risky and expensive things and (b) fail to produce better outcomes than salaried physician facilities.
I agree that incentives are frequently and perhaps typically exploited, especially when crafted carelessly or not iterated upon, as most incentives seem to be.
I would be eager to contemplate a clinical outcome based incentive scheme.
Young child with cancer? Nope, not worth the risk.
Patient with mental health problems? Takes too long, outcome not easily measurable.
Obese patient with back pain? Let's do surgery instead of investigating and treating the root causes.
Just like schools, you can tell which teachers are good, even in districts with bad kids.
Have a torn meniscus and given age is dumped into "excise meniscus tear" bucket. While Dr knows that shortens the path to knee replacement (which he no less pointed out on several occasions).
Going to Dr. Now seems like you are a walking revenue center vs. patient in need.
(ps. Many current accredited studies suggest repair attempt vs. removal)
Young child - I have trained in mostly adults with some pediatric experience. Can I do a simple procedure on a teen? Probably. If something goes wrong I’m afraid I’ll be punished for not referring them to a pediatric center that specializes in these things. Of course if I’m at my main hospital where they do these often, I feel more comfortable doing pediatric procedures to an extent.
Mental health not really in scope of radiology
Obese back pain - I do a lot of procedures for these and certainly there are some surgeons that will operate on anything but I’d say 80-90% of spine surgeons will refer out to rule out every last cause before operating.
We are kind of incentivized to do procedures right now in American healthcare but I will say all my partners are cautious about just doing stuff.