Minchin, et al. report on the use of interrupted time series analyses of electronic medical records to track the effect of removal of financial incentives on provider behaviour. Incentives were withdrawn for 12 quality of care indicators in 2014, while they were retained for six indicators.
The results showed a sharp and almost immediate fall in adherence to the 12 indicators for which the incentive was withdrawn. There was no such drop in performance for the six indicators that were retained.
Many of the measurements of adherence were based on clinician entry into the electronics records to confirm compliance. For example, to confirm that advice on disease prevention had been given. It is therefore possible that clinicians continued to adhere to the tenets of good practice after withdrawal of the incentive, while simply omitting to record this detail in the electronic notes. However, not all measurements were dependent on active clinical entry – for example, the electronic record is populated automatically with blood test results. There was a fall in adherence to previously incentivised indicators, such as blood tests, where physician entry was bypassed, as well as on those that required physician entry. However, the fall in compliance with practice standards that did not depend on physician entry was not as great as the fall in compliance with indicators that depend on physician entry.
The results reported here are broadly in-line with the literature; removal of financial incentives for clinical care standards is generally followed by a decline in performance.
What does this mean for the use of performance measures? One must assume that they cannot be retained in perpetuity; at some point the world must move on, even if only to implement a further set of performance measures. But my overarching impression is reconfirmed – the use of incentives, measurements and targets is of limited value. In the last analysis, the only way to bring about a sustained, lasting and self-perpetuating improvement in care, is by winning the hearts and minds of clinicians. It is important to kindle a set of high rectitude values, and it is important to select individuals with the right characteristics, i.e. highly principled people with a deep sense of altruism. This is, I am afraid, an ultra-long-term solution – a person’s attitude starts on mother’s knee and is reinforced or supressed by the totality of life experience. Inspiring teachers at medical school and good role models throughout life are critical. That is one reason that I continue to argue that medical ethics and, so-called, ‘communication skills’ should be taught by doctors and not farmed out to philosophers and psychologists. When I was a clinical professor these valuable colleagues taught me, but I taught the students.
— Richard Lilford, CLAHRC WM Director
- Minchin M, Roland M, Richardson J, Rowark S, Guthrie B. Quality of Care in the United Kingdom after Removal of Financial Incentives. N Engl J Med. 2018; 379: 948-57.
- Lilford RJ. Doctor-Patient Communication in the NHS. NIHR CLAHRC West Midlands News Blog. 24 March 2017.