Before he turned his attention to quality improvement, Don Berwick, MD, practiced pediatrics for nearly two decades. During the years since then, he has traveled the world, exploring what works in health care and what doesn’t—and pushing everybody he meets to make patient safety and waste reduction a bigger priority.
Despite that breadth of experience, he has not identified the best way to incentivize physicians to deliver high-value care. “I was always on salary, and part of me says that was the best incentive system I ever could have had,” he says. “I didn’t get paid more for doing something, and I didn’t get paid less for not doing something. All I had to do was think about the well-being of the patient, and I was supported to do that.”
The rap on straight salary is that it does not encourage productivity, acknowledges Berwick. At the same time, the fee-for-service system is criticized for promoting overuse of services, capitated pay schemes risk underuse, and pay-for-performance systems—in Berwick’s view—work better at the corporate level than at the physician level.
The federal government’s use of penalties for hospitals that have high readmission rates and other poor outcomes have been shown to be effective incentives. “At the individual level, it’s a little more dicey because metrics at the individual physician level are very, very difficult technically,” he said. “Most doctors would rather be appealed to on the high ground about their professionalism, their missions in life, their craftsmanship, their peer relations. I think we have to be very careful about identifying where pay for performance is an asset and where it actually may do some damage.”
Even though the best payment strategy for physicians has not yet been revealed, another element of physician practice has: Economic pressures have prompted the majority of physicians to be hired by health systems, a situation that many physicians never expected.
While some physicians may feel victimized by the changes in their profession, Berwick is optimistic about the healthcare workforce of the future. A co-founder of the Institute of Healthcare Improvement (IHI), he believes younger physicians recognize that being a good clinician is no longer sufficient for success. He points to the IHI’s Open School for Health Professions, which invites students in medicine, nursing, health administration, and related fields to learn improvement methods, patient-centered care, and patient safety.
“That enterprise right now has 130,000 students in more than 55 countries working together to learn and study and try out methods of improvement,” he says. “They are not depressed. They are not feeling like they are victims. They are taking control and saying, ‘I think I can lead improvement,’ and they can.”
Indeed, he is counting on physicians and other clinicians to guide the industry to a safer and more sustainable place. Yesterday’s physicians may have defined “professionalism” as being above anything that had to do with money; today’s physicians must redefine what it means to be a professional caregiver.
“Just like hospitals are being forced more and more to think about business models that are not volume-based, so physicians have to think about their roles in the larger system—teamwork, exchange of information, and how to be a leader in cost reduction without harming patients,” Berwick says.
In fact, he believes that physicians, nurses, and other clinicians are the only individuals who can distinguish the elements of care that actually benefit patients from those that are wasteful and potentially dangerous. “They are in the best position to do that,” he says, “so the leadership opportunity is enormous.”
Donald Berwick, MD, is president emeritus and senior fellow, Institute for Healthcare Improvement, Cambridge, Mass.
Berwick spoke at HFMA's 2013 annual conference. Read a recent Q&A with Berwick from the May 2013 issue of hfm magazine.
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