Health Economics, Policy and Law (2015), 10, 361–365 doi:10.1017/S1744133114000528
© Cambridge University Press 2015
Debate
Instrumentality in health care: a response to Adam Oliver SANDRA J. TANENBAUM* Department of Health Services, Management and Policy, College of Public Health, The Ohio State University, Columbus, OH, USA
Abstract: In his paper, ‘Incentivizing improvements in health care delivery’, Adam Oliver discusses recent efforts to manage the performance of health care workers in the United States and United Kingdom. Overall, the results of performance management seem to be mixed, but Oliver’s discussion hints at a more fundamental question about this approach, specifically: what are the limits of a focused instrumentality in a context as rich, fluid and collaborative as the delivery of health care? Might performance management schemes actually frustrate the efforts of conscientious health care workers? Indicators make few allowances for the heterogeneity of treatment effects or patient values or preferences. Health care workers may also face pressure to appear to satisfy indicators that are actually impossible to satisfy. Submitted 25 July 2014; revised 3 September 2014; accepted 12 September 2014; first published online 6 February 2015
In his paper, ‘Incentivizing improvements in health care delivery’, Adam Oliver discusses recent efforts to manage the performance of health care workers in the United States and United Kingdom. He explains that various types of performance management have been deployed in response to quality and safety concerns and reviews the available evidence as to their levels of effectiveness and unintended consequences. Overall, the results of performance management programs seem to be mixed. Oliver ultimately recommends ‘public ranking with modest financial incentives’, based in part on the successes of the U.S. Hospital Quality Incentive Demonstration Project and the U.S. Veterans Health Administration (VHA).1
*Correspondence to: Professor Sandra Tanenbaum, Department of Health Services, Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, OH 43210, USA. Email: [email protected] 1 The VHA is a government agency providing health care to veterans of the US military. Unlike other US provider systems, it is public and centralized, and its personnel are salaried government workers.
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SANDRA J. TANENBAUM
Performance management, as Oliver makes clear, is the application of economic and psychological (behavioral economic) principles to the health care workplace. It is an attempt to shape the behavior of workers, including professional and nonprofessional staff, i.e., to induce them to do things they would not otherwise do. It is perhaps beyond the scope of Oliver’s paper to evaluate performance management in general as a means of improving the quality of health care. His charge seems to be to review and assess its varieties. His discussion, however, hints at a more fundamental question about this approach, specifically: what are the limits of a focused instrumentality in a context as rich, fluid and collaborative as the delivery of health care? For example, Oliver refers to the opportunistic quality of performance measurement and the limits imposed by ‘target fatigue’. He raises the possibility of ‘gaming’ the system and even outright cheating, as well as the prospect that secular trends in health care account for some of performance management’s successes. In addition, what is to be made of ‘integration’, which is clearly important but poorly conceptualized? Oliver seems to suggest that these are minor challenges to a sound regime of performance management. They may, however, be indicative of more systematic limitations of this approach, which conceives of performance as behaviors and of workers as objects of management by others. The task of performance management strategies is to construct the right incentives to change discrete behaviors in a positive direction without changing others in a negative one. For example, pay-for-performance schemes ‘have to be cleverly designed’ so as to achieve sustained improvement; workers must be incentivized in just the right way, in just the right amount and during just the right time period to effect changes on specific measures. ‘Performance’ is construed as selected health care behaviors and ‘management’ as the inducement of behavioral change among the ‘targets’ (Stone, 2012) of a given method. In this sense, performance management views health care quality as incremental rather than global and health care workers as objects rather than subjects, participants or contributors. Whether or not performance management is effective in the mission it defines, it seems not to address the dense human context of health care delivery or even the other instrumentalities that may already be in place (Stone, 2012). As Oliver makes clear, performance management is predicated on the identification of workers’ economic or psychological self-interest and the ability of policy makers and others to enlist this self-interest in satisfying performance indicators of various kinds. Health care workers, including physicians, are the targets of this inducement, and any self-interested behaviors of gaming and cheating are not unexpected. Although performance management may ‘creat[e] workers … who identify with the goals of the firm’, this is no less instrumental for engineering intrinsic as opposed to extrinsic motivation. In both instances, workers are acted upon rather than engaged. Like inducements for ‘teaching to the test’ in education, performance management in health care responds to a perceived crisis that workers putatively do not recognize, do not know how to fix or do not care about
Instrumentality in health care 363
fixing. This may describe some health care workers in some settings, but others have called for and instigated quality improvement practices. Oliver suggests the contribution that knowledgeable and intrinsically motivated personnel might make to improving the quality of care. Might performance management schemes actually frustrate the efforts of conscientious health care workers? First, performance management methods center on performance indicators or quality standards that may or may not be met by health care workers. Indicators may be chosen based on criteria ranging from prevalence of disease to availability of guidelines to ease of monitoring. Many proponents prefer that they be ‘evidence based’, i.e., derived from randomized controlled trials (RCTs) or meta-analyses of these trials. Although RCTs have long been considered the ‘gold standard’ for determining effectiveness, they cannot predict effectiveness for every patient. The statistical methods employed analyze mean effectiveness across treatment and control groups, and even when an intervention is highly effective for the treatment group, it may include patients who did not improve and who may have gotten worse. Performance management, however, makes few allowances for the heterogeneity of treatment effects or, for that matter, for patient values or preferences. Although some performance indicators may represent universally beneficial practices, such as infection control, others are inappropriate to the circumstances of some patients. Whether performance indicators are process or outcome measures, they neglect important heterogeneities, and may force physicians and others to ignore the best interests of the patient or risk financial or reputational loss (Tanenbaum, 2012). Pogach et al. (2007), e.g., report that implementation of a common performance indicator, A1 (c) rate of
© Cambridge University Press 2015
Debate
Instrumentality in health care: a response to Adam Oliver SANDRA J. TANENBAUM* Department of Health Services, Management and Policy, College of Public Health, The Ohio State University, Columbus, OH, USA
Abstract: In his paper, ‘Incentivizing improvements in health care delivery’, Adam Oliver discusses recent efforts to manage the performance of health care workers in the United States and United Kingdom. Overall, the results of performance management seem to be mixed, but Oliver’s discussion hints at a more fundamental question about this approach, specifically: what are the limits of a focused instrumentality in a context as rich, fluid and collaborative as the delivery of health care? Might performance management schemes actually frustrate the efforts of conscientious health care workers? Indicators make few allowances for the heterogeneity of treatment effects or patient values or preferences. Health care workers may also face pressure to appear to satisfy indicators that are actually impossible to satisfy. Submitted 25 July 2014; revised 3 September 2014; accepted 12 September 2014; first published online 6 February 2015
In his paper, ‘Incentivizing improvements in health care delivery’, Adam Oliver discusses recent efforts to manage the performance of health care workers in the United States and United Kingdom. He explains that various types of performance management have been deployed in response to quality and safety concerns and reviews the available evidence as to their levels of effectiveness and unintended consequences. Overall, the results of performance management programs seem to be mixed. Oliver ultimately recommends ‘public ranking with modest financial incentives’, based in part on the successes of the U.S. Hospital Quality Incentive Demonstration Project and the U.S. Veterans Health Administration (VHA).1
*Correspondence to: Professor Sandra Tanenbaum, Department of Health Services, Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, OH 43210, USA. Email: [email protected] 1 The VHA is a government agency providing health care to veterans of the US military. Unlike other US provider systems, it is public and centralized, and its personnel are salaried government workers.
361
362
SANDRA J. TANENBAUM
Performance management, as Oliver makes clear, is the application of economic and psychological (behavioral economic) principles to the health care workplace. It is an attempt to shape the behavior of workers, including professional and nonprofessional staff, i.e., to induce them to do things they would not otherwise do. It is perhaps beyond the scope of Oliver’s paper to evaluate performance management in general as a means of improving the quality of health care. His charge seems to be to review and assess its varieties. His discussion, however, hints at a more fundamental question about this approach, specifically: what are the limits of a focused instrumentality in a context as rich, fluid and collaborative as the delivery of health care? For example, Oliver refers to the opportunistic quality of performance measurement and the limits imposed by ‘target fatigue’. He raises the possibility of ‘gaming’ the system and even outright cheating, as well as the prospect that secular trends in health care account for some of performance management’s successes. In addition, what is to be made of ‘integration’, which is clearly important but poorly conceptualized? Oliver seems to suggest that these are minor challenges to a sound regime of performance management. They may, however, be indicative of more systematic limitations of this approach, which conceives of performance as behaviors and of workers as objects of management by others. The task of performance management strategies is to construct the right incentives to change discrete behaviors in a positive direction without changing others in a negative one. For example, pay-for-performance schemes ‘have to be cleverly designed’ so as to achieve sustained improvement; workers must be incentivized in just the right way, in just the right amount and during just the right time period to effect changes on specific measures. ‘Performance’ is construed as selected health care behaviors and ‘management’ as the inducement of behavioral change among the ‘targets’ (Stone, 2012) of a given method. In this sense, performance management views health care quality as incremental rather than global and health care workers as objects rather than subjects, participants or contributors. Whether or not performance management is effective in the mission it defines, it seems not to address the dense human context of health care delivery or even the other instrumentalities that may already be in place (Stone, 2012). As Oliver makes clear, performance management is predicated on the identification of workers’ economic or psychological self-interest and the ability of policy makers and others to enlist this self-interest in satisfying performance indicators of various kinds. Health care workers, including physicians, are the targets of this inducement, and any self-interested behaviors of gaming and cheating are not unexpected. Although performance management may ‘creat[e] workers … who identify with the goals of the firm’, this is no less instrumental for engineering intrinsic as opposed to extrinsic motivation. In both instances, workers are acted upon rather than engaged. Like inducements for ‘teaching to the test’ in education, performance management in health care responds to a perceived crisis that workers putatively do not recognize, do not know how to fix or do not care about
Instrumentality in health care 363
fixing. This may describe some health care workers in some settings, but others have called for and instigated quality improvement practices. Oliver suggests the contribution that knowledgeable and intrinsically motivated personnel might make to improving the quality of care. Might performance management schemes actually frustrate the efforts of conscientious health care workers? First, performance management methods center on performance indicators or quality standards that may or may not be met by health care workers. Indicators may be chosen based on criteria ranging from prevalence of disease to availability of guidelines to ease of monitoring. Many proponents prefer that they be ‘evidence based’, i.e., derived from randomized controlled trials (RCTs) or meta-analyses of these trials. Although RCTs have long been considered the ‘gold standard’ for determining effectiveness, they cannot predict effectiveness for every patient. The statistical methods employed analyze mean effectiveness across treatment and control groups, and even when an intervention is highly effective for the treatment group, it may include patients who did not improve and who may have gotten worse. Performance management, however, makes few allowances for the heterogeneity of treatment effects or, for that matter, for patient values or preferences. Although some performance indicators may represent universally beneficial practices, such as infection control, others are inappropriate to the circumstances of some patients. Whether performance indicators are process or outcome measures, they neglect important heterogeneities, and may force physicians and others to ignore the best interests of the patient or risk financial or reputational loss (Tanenbaum, 2012). Pogach et al. (2007), e.g., report that implementation of a common performance indicator, A1 (c) rate of
