“Incentives are there to try to change behavior, to try to move things along,” says John Jenrette, Executive Vice President for Cedars-Sinai Medical Network, during his talk on physician incentives and on aligning incentives for other health care providers — whether allied health professionals, pharmacists, case managers, nurses, or “the incredible teams that make the work we do shine and move forward.”
“We’re hopeful that the behavioral changes that we’re initiating or stimulating are going to move health care the direction that we think it needs to go in the future, in this value-based direction,” he says.
The Experience Equation
When talking about aligning incentives, we generally look at the value equation of quality over cost. Next is the experience component, an extremely important dimension for patients, who are health care’s consumers. “Some people don’t like to think of patients as consumers, but they are, and they’re going to continue to be in more and more ways as we move forward,” Jenrette says.
“Equally important,” he adds, “is the experience for our providers, because honestly, if we’re going to move behavior and place incentives appropriately, we have to have healthy physicians, and we have to have physicians who have joy in their practice. We know we have a critical and national problem with burnout. I want to highlight that experience part of the equation that is really important when we think about our incentives, and what we tend to put in motion.”
Importance of the Why
“Today, the word that I want you to walk away with is the single word ‘why,’” Jenrette says. “Why is everything. We’ve heard a lot about different incentives, programs, and advancement, but it doesn’t mean anything unless we answer the why. Why is everything we do as people. The why is the passion, the effort. The sustainability of anything we do is wrapped into the why.”
Jenrette cites Simon Sinek’s Golden Circle theory of how great leaders inspire action, in which why is the center, and only following that why can we look at what and how.
Before digging deeper into applying the why to physician incentives, Jenrette describes his 30 varied years of experience in incentives, working with physicians in independent practices and associations, small group practices, resident programs, and the broad foundation employed model at Cedars-Sinai.
The recipient of metrics and outcomes pushed across his desk during his 20 years as a family physician and geriatrician, Jenrette was often a naysayer, asking, “What are you trying to do? What are you loading on my plate? Why is this important? Why should I care?”
“It comes back to those pieces,” he says.
As a physician leader, Jenrette struggled with the financial part of physician incentives. “What’s enough: 5%, 10%, 15%? What makes a difference?” he asks. Often, we say, “How many times can we split that dollar into smaller and smaller pieces and put more and more on the plate until I don’t care what you’re telling me? I can’t pay attention; it’s not worth my time and effort.”
Jenrette has worked on aligning incentives in a number of different financial models, ranging from fee-for-service environments to shared savings programs and full and partial capitation. He has found capitation to be the strongest and best-aligned financial incentive for population health, to take accountability for our populations.
Four Tenets of Physician Incentives
All that work has led Jenrette to four tenets of physician incentives and behaviors:
- Follow the money. “Physicians like money and financial incentives, yes, but they’re not at the core, at all. They aren’t,” he says. “They maybe have this kind of incremental impact if you can put them in the right direction, but I truly believe that if physicians are compensated appropriately for the work they’re doing, the incentives become that icing on the cake, that top performance, the things that we want to pay attention to, want to try to focus on, and reward physicians for that type of behavior.”
- Produce meaningful data. “That data has to be accurate, it has to be reliable, it has to be meaningful,” says Jenrette. “If you have walked into a room with a bunch of physicians with data, and they begin to poke thousands of holes into it, you walk out of the room with your tail between your legs, completely discredited, and you will spend so much energy trying to get back there, and even have another conversation. The reliability and meaningfulness of the data and how that applies is important to the why I take care of patients and do the work that I do.”
- Involve physicians. “Physicians want to be a part of the process. They want to be in the conversation. They’re smart people. They want to help guide that and direct it, and make sure the data can be meaningful and helpful to their practices and the work that they do. It’s a very important component.”
- Ask why. Jenrette stresses that this fourth tenet is the most important of all. “It goes to the core of why we are physicians, in taking care of our patients, in taking care of families, in creating great outcomes and seeing people live healthy and happy. That’s why we become physicians, and why we need to continue to focus in that direction.”
“Sometimes the why feels like it should be easy to do, but it’s not always simple, and there’s a certain energy to describe that,” Jenrette explains. For primary care physicians, it might be easy to see the why in hemoglobin A1c controls, in making sure patients are getting the appropriate preventive services — that becomes important to physicians, who believe their patients will benefit.
An additional why in our current value base is affordability: “Why is health care imploding under the fee-for-service model? Why does it cost too much in medicine? What part do we play as physicians in the orders, in how we direct our patients, in how they are treated and what happens?” And the most critical affordability-related why: “Why are our patients suffering with their deductibles, their copays, and their coinsurances, and maybe not even being able to get their pharmaceuticals to complete the treatment plans, that we, as physicians, want them to complete and be a part of?”
“There are ways to move physicians in that direction,” Jenrette says. “When I look at what we do from here, the first thing I’ve learned is that I need to take time to develop relationships with physicians. I need to develop trust. I need to convey the why. And then, once we do that, you can begin to move into the how and the what. And then physicians are ready to look at the dashboards to help you move them forward. It is more effective and more efficient, and the physicians can help you drive that direction.”
Simply walking into a physician’s office with a fancy dashboard and telling the physician that doing X is in their best interest does not work.
“I leave you with that message of always thinking about doing and talking about the why,” says Jenrette. “I can guarantee you that you can move physicians then into the how and the what and begin to change health care.”
From the NEJM Catalyst event Provider-Driven Data Analytics to Improve Outcomes, held at Cedars-Sinai Medical Center, January 31, 2019.