When the Beatles claimed that they “don’t care too much for money, money can’t buy me love,” they did not provide scientific references. While we might hope that statements of fact or causation in popular songs are based on a systematic review of the controlled trials, my guess is that we are a long way from evidence-based pop songs (evening entertainment at Cochrane Colloquia excepted). But if money can’t buy love, maybe it could be better spent on clinical quality improvement? That certainly seems to be a strong current fashion, known as “financial incentives,” or its close cousin “Pay for Performance.” Mention these terms in medical company and there seems to be a polarized reaction. The camps might be characterised as either the “Albert Schweitzers” who believe that clinical work should be driven by an altruistic interest in the benefit for patients (with an adequate but unlinked remuneration), and the “Gordon Gekkos” (who said in the movie Wall Street: “Greed is right; greed works”) who believe that money drives all behaviour and is therefore the key to improving quality.
I should declare a bias and sympathy toward the Schweitzers, but recognise we also need to look at the evidence. The psychological literature suggests that for mundane tasks, rewards can improve productivity, but for complex tasks such as problem solving rewards and incentives can have a paradoxical negative effect: they act as a distraction rather than a motivation. Medicine of course includes both mundane and complex tasks, which might help explain the mixed results in the Cochrane review which concluded that “there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary healthcare.” The review also noted that the studies had not sufficiently assessed the downsides (gaming, resource shifting, demotivation, ignoring patient preferences, etc) and suggested “Studies should also examine the potential unintended consequences of incentive schemes.”
Despite the mixed evidence and potential downsides, financial incentives are being increasingly used. While sometimes that may be reasonable, there have been uses that have been clearly ineffective and costly, and even harmful. I suspect if financial incentives came as a tablet, they would be rejected by most medicines licensing agencies, or at best they would be classed as a second-line expensive agent to be used with caution because of the price and the nasty adverse effects. If “listed” we would also need a clear set of indications and contraindications. With that in mind, a group of us decided to develop a “checklist” to help assess whether a financial incentive might be a reasonable option—somewhere between the Schweitzers “never” and the Gekko’s “always.” The development and background to the checklist is described in a BMJ article, but a stand-alone checklist is freely downloadable from: www.crebp.net.au/resources.
Scott A, Sivey P, Ait Ouakrim D et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD008451. doi: 10.1002/14651858.CD008451.pub2.
Glasziou PP, Buchan H, Del Mar C, et al. When financial incentives do more good than harm: a checklist. BMJ. 2012 Aug 13;345:e5047. doi: 10.1136/bmj.e5047.
Paul Glasziou is professor of evidence based medicine at Bond University and a part time general practitioner.