9 key thoughts on incentives for spine surgeons — behavioral economics in healthcare


Physician satisfaction and incentives to produce high quality, cost-effective care will have a huge impact on the healthcare system going forward, according to an article titled "The Role of Incentives in Changing the Behavior of Spinal Care Providers: A Primer on Behavioral Economics in Health Care" published in The Business of Medicine.

Alok D. Sharan, MD, Gregory D. Schroeder, MD, Michael E. West and Alexander Vaccaro, MD, PhD, authored the article.


CMS is moving from the volume-based payments to merit-based incentive systems that incentivize physicians to change behavior.


"A fundamental tenet of economic theory is that when humans are given the proper information, they will make a rational decision that optimizes their overall well-being," wrote the study authors. "This has been the guiding principle in economic models until recently when research demonstrated differing responses to the same incentives."


There isn't always a connection between the economic incentive and the surgeon's behavior. For spine surgeons, here are several key factors:


1. Behavior doesn't always change with education about cost; surgeons who know what implants cost don't always pick the lowest-cost implant. As a result, the article's authors instruct spine surgeons to prepare for a reimbursement hit for using higher-cost implants through risk sharing models such as bundled payments covering the entire episode of care.


2. When surgeons are familiar with one implant or company they're more likely to stick with that single vendor, illustrating status quo bias. However, in the future hospitals may require more flexibility from surgeons on implant choice to negotiate with vendors.


3. There is an abundance of performance measures for physicians currently, measuring the clinical quality and outcomes for patients. Health-related quality of life measures and government mandated questionnaires such as Press Ganey collect hospital- and practice-based performance measures. The article authors recommend designing measures to ensure high quality care at an appropriate cost to bring spine care providers on board.


4. Giving spine surgeons cost reports more frequently can make a difference. Surgeons who see their numbers on a routine basis — more often than every six months — are more likely to identify issues and limit the cost drivers, according to the article.


5. Individuals are more likely to respond to threats of loss than potential gain; if surgeons stand to lose, they are more likely to work harder than if they're incentivized with "gaining something new." The article authors suggest providing surgeons with a bonus at the end of the year if they meet cost goals is less likely to drive change than giving them a bonus upfront and then fining them later for high-cost instrumentation.


6. Physicians are competitive and motivated to rank highly among their peers. Transparent data rankings showing the physician's name along with their outcomes and costs is more likely to drive behavior change than revealing blinded data. Physician-rating websites are becoming more common and playing a role in attracting new patients, and hospitals circulate data on length of stay and costs for procedures.


7. When goals seem too far away, especially for poor performers, it becomes easier to stop trying to reach it. As a result, realistic short- and long-term goals are important and rewarding improvements may make more sense than giving rewards for meeting goals.


8. Physicians always want to go above and beyond for patients, but the constant pursuit of excellence can lead to burnout. Medicine today is moving toward evidence-based treatment algorithms and it's important for physicians to have input on forming algorithms, which will "provide physicians a sense of control over the process."


9. When rewards are separate from larger rewards, individuals are able to account it as an incentive and react more favorably to it.


"Although not all of the aforementioned principles will be applicable to every practice, having an understanding of behavioral economics will help spine practices align their incentives to increase the overall value they are providing," the article authors wrote. "Principles such as loss aversion, immediacy, relative social ranking and threshold effects can be implemented in every practice to improve efficiency of individual spine care, whereas principles such as status quo bias, choice overload and limits of willpower will need to be used by practice executives to improve the value of care delivered by the entire practice."


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