Productivity bonuses not so productive for high-value care

California hospitalists were surveyed about their institutions' culture of high-value care.

Paying hospitalists for productivity may affect a hospital's value-based care culture, a recent study found.

Photo courtesy of Dr Gupta
Photo courtesy of Dr. Gupta

Researchers at the University of California, Los Angeles (UCLA), surveyed 255 internal medicine hospitalists from 12 California hospitals using the validated High-Value Care Culture Survey, which measures the culture of clinical decision making around high-value care. Survey scores range from 0 to 100, with higher numbers indicating better culture in four domains: leadership and health system messaging, data transparency and access, comfort with cost conversations, and blame-free environment. The researchers assessed the association between the responses and the way hospitalists were paid: 65.1% received salary or wages, 30.2% received salary plus productivity adjustments, 4.7% received salary plus quality or value adjustments, and none were paid by fee-for-service alone.

On average, those paid with salary plus productivity adjustments had significantly lower overall survey scores than those paid with only salary or wages, according to results in the January 2019 Journal of Hospital Medicine. Their scores related to leadership and health system messaging and data transparency and access were also lower.

ACP Hospitalist recently spoke about the findings with lead author Reshma Gupta, MD, MSHPM, who is the interim chief value director at UCLA–Olive View Medical Center, previous medical director for quality and value at UCLA Health, and director for evaluation and outreach at Costs of Care, a nonprofit organization that collects insights from patients and clinicians to promote high-value medical decisions.

Q: What led you to study this issue?

A: Most of my work has been focused on how we can deliver more affordable, high-value care: higher quality and high patient-experience care at a lower cost. I think while most of the country has really bought in that there's a great need for that, we still have not figured out how to create meaningful change. One of my interests is in better understanding how to think about the kind of behavior and components that go into building a high-value care culture where we work. As a collaboration between my research at UCLA and Costs of Care, we developed a high-value care culture survey, which is the first one that has been developed. This survey can be used by division leaders and program directors among their clinicians and teams to assess their culture and identify areas of opportunity for improvement. Similar surveys focused on patient-safety culture are widely used across medical centers, and higher scores are associated with reduced patient mortality and morbidity.

Q: Were you surprised by the findings?

A: We hypothesized that we might see an association between productivity incentives and high-value care culture. . . . We were surprised to see how much the leadership and messaging domain would drive culture. It is the biggest domain of high-value care culture within the survey that we used. It is the same leadership that dictates how the clinicians are getting paid at the end of the day. Even among the 12 study sites, we found a significant association, which we believe suggests that productivity incentives are potentially a strong indicator of high-value care culture and, ultimately, potential outcomes in value-based care.

Q: Why do you think you found this association?

A: The fee-for-service model or productivity adjustments get to the same idea that if you do more, you get paid more. If that's valued more within an institution, that tends to push clinical decision making in one direction towards doing more: doing more procedures, seeing more patients, ordering more diagnostics and referrals. Previous studies have shown us that “doing more” through programs such as fee-for-service payments are associated with poor-quality outcomes, as well as increased hospital utilization. I think the other side of the discussion is the importance of culture and how we haven't had a way to measure it before. . . . Being able to tie these things together gives us really concrete ways to intervene and potentially begin changing the culture. But to do that, it might mean changing some of the ways that we pay our clinicians.

Q: What kinds of changes might this entail?

A: One thing that we noticed is that few programs are actually paying their clinicians with any kind of quality or value incentive. I think that identifies a huge opportunity to both trial and evaluate through studies. Could there be more models? What do those models look like so that clinicians are incentivized in a different way? The second is reducing the emphasis on or removing the productivity component within institutions. I think those are two ways that medical centers could change clinician payment schemes and then evaluate them by measuring culture and outcomes over time.

Q: What are the take-home messages for hospitalists?

A: One take-home message is for the increasing number of hospitalists going into leadership and management roles. I think this is a study around which hospitalists can build new practices or policies. They could ask: Are there ways that we could work with our clinician reimbursement schemes to reduce the emphasis on productivity and actually test pilot ways to provide incentives for certain quality or even efficiency measures? Another take-home message is for the everyday hospitalists. As they look for hospitalist positions, they may want to assess if their medical center includes clinician incentives based on productivity or quality and value. They may also want to know what else their institutions are doing to truly create the environment to practice high-value care.