Joanne Conroy, MD


Pay-for-Performance Programs Ignore True Human Motivators

I often listen to books on CD during long trips in the car. They’re a great way to catch up on reading and provide the added bonus of letting me avoid the mind-numbing “hit list” of pop tunes on the radio.

After a trip that flew by while I laughed to Tina Fey’s Bossypants (worthy of a future post if I can figure out to link it to health care), I tried another nonfiction selection from my local library: Drive by Daniel Pink. Pink worked as an aide to Secretary of Labor Robert Reich, and from 1995 to 1997, he was chief speechwriter for VP Al Gore. He graduated from Yale Law School and has written five best-selling management books. His 2009 TED talk on “the puzzle of motivation” is one of the 10 most-watched.

In Drive, Pink discussed the science of motivating people. Most people believe that the best way to motivate is with the carrot-and-stick approach, using rewards, usually monetary, to increase productivity. This works for some simple, algorithmic, routine, rule-based sorts of tasks: adding up columns of figures, turning the same screw the same way. However, there is an incredible amount of scientific evidence that says these types of incentives are ineffective and even demotivating for creative, conceptual, complex work.

When incentives don’t work, we don’t ask ourselves if we are approaching the problem in the best way. Rather, we throw more carrots on the table or look for sharper sticks! Pink reveals that the key things that motivate people are: autonomy—the desire to direct our own lives; mastery—the desire to continually improve at something that matters; and purpose—the desire to do things in service of something larger than ourselves.

So what does this have to do with health care?

As I was listening to the audiobook, I began to think about the massive pay-for-performance programs we are spending tons of money and time on. People are spending an incredible number of hours identifying, developing, testing, and validating performance metrics; and creating a gigantic national infrastructure to monitor, measure, and incentivize performance.

But which of these performance metrics measure tasks that will respond to incentives, and which are tasks for which incentives would actually be demotivating? There are many examples of how financial incentives drive behavior in health care (usually behaviors of the less altruistic kind), and rewarding quality makes sense. But how do we know that these national pay-for-performance programs will work?

There is a great policy brief that was published last year in Health Affairs that addresses just this issue. The authors conclude their comprehensive review of the programs with these questions:

How large do rewards need to be to produce desired changes? How often should rewards be distributed? How can improvements in performance become sustained over time? How can provider acceptance best be gained and maintained? What impact will these programs have on health systems that are weak financially or that serve greater proportions of racial and ethnic minorities?

I have several questions of my own:

  • How can we be honest about what health care tasks financial incentives will work on (algorithmic tasks) and focus our first performance incentives on those?
  • Who will monitor the effectiveness of pay-for-performance programs? If they don’t work, the worst outcome would be that quality is not improved and providers become de-motivated.
  • Federal payers demand some measure of compliance with standards of good practice. Can we get this from the low performers without disenfranchising and de-motivating the high performers who are subjected to the same incentive process?
  • I think most health care workers are motivated by the intrinsic drivers of performance. No one would go through the long training process, the grueling hours, and the daily emotional and physical demands of our profession unless they truly believe that they are serving a purpose. How can we leverage the need for autonomy, mastery, and purpose in the health care workforce to achieve improved outcomes in an innovative—perhaps even transformative—way? What would that look like? Is it just too complicated to develop or is it easier to ignore the mismatch between what science knows and what business does?

What would Daniel Pink and his team of social behavioralists say?

Originally posted on

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