Have We Reduced CV Care to a Rote Physical Activity?

Friday, March 18, 2022 | Joel Sauer

Over the past few weeks, there has been a robust dialogue amongst cardiovascular physician executives on the challenges of leading today’s programs. Topics range from creating an attractive environment for young talent - who have very different motivations than previous generations - to how to compensate physicians in a very complicated profession.

There may be no industry or profession that spends as much time and energy on compensation as healthcare does for our physicians. Yet despite this inordinate resource consumption, there has yet to emerge a “best practice” for physician compensation models – at least not in cardiology. The data above show that there are still many different models deployed in our national workforce with the largest segment (53%) being paid entirely on production.

Resurfacing in the recent dialogue was a decades old Ted Talk by Dr. Daniel Pink summarizing the findings from his book, Drive, The Surprising Truth About What Motivates Us. His conclusions, based on over 50 years of research and validated by esteemed institutions around the world, are that incentives, whether based on carrots or sticks, simply don’t work for knowledge-based workers. The only exception is when the task is dominated by physical repetition with little or no cognitive skill required. Does this sound like cardiovascular medicine?

As Dr. Pink kindly reminds us, the data conclude that what truly motivate us are:

  • A high level of personal autonomy
  • Being put in the best position to succeed or become masters of our craft
  • A strong sense of purpose to a cause bigger than ourselves.

In my experience, these are right in line with the majority of many conversations with physicians on why they entered healthcare as a profession.

Accordingly, to get cardiology compensation right, we must get past some well-established, but in my opinion false assumptions that I still hear regularly. One being that if physicians aren’t paid on production they won’t work hard. While on the surface the data may support this assumption (see below based on pay model) it is only true if our notion of “work” is defined solely as individual wRVUs. Most of us who work in healthcare know that physician “work” and effort cannot be captured entirely by wRVUs. For instance, not captured in these one-dimensional production data are questions like:

  • Did access or evaluation and management (E&M) visits suffer in deference to high individual production?
  • Was patient care delivered by the right professional at the right time?
  • Was the work appropriate?
  • Was the care done well?

Even more concerning in the data below, is that we see these production differences at all. Given the multiple peer-reviewed sources cited by Dr. Pink relative to incentives, what these data may be telling us is that we have unwittingly dumbed physician work down to rote, physical tasks – the one area where production “carrots” work. As I reflect on my personal healthcare journey, it is possible to see how even fair-minded and trusting observers could come to that conclusion.

Now pushing 60 years old I consume more healthcare than I did when I was 30, so I’m viewing the system through a different prism. I’m overly blessed to be surrounded by good people and have access to sophisticated resources. However, I often feel like I’m on an assembly line where it is more about my providers and the system efficiency than it is about me. Granted I’m an N=1 but I’ve heard the same story from friends, family, and colleagues around the country. I’m concerned this experience has become the rule rather than the exception.

When my physician, or that of a loved one, is paid on production it creates a shadow of doubt when expensive things are ordered. Are the recommendations based on standards and guidelines or provider preference? Would the same recommendations be made independent of the payment model? Having these doubts is certainly not welcome on my end, and I doubt my physician would be thrilled to hear of it either. With production models, we have introduced this perception of a conflict of interest. Even if my physician truly has zero personal motivation from a production-based model, the perception can be there and impact trust.

As an industry we must push for better physician rewards; rewards that sync up with our missions and core values. When there’s a mismatch it seems inevitable to lead to high provider burnout, desecrating one of the three rails of happiness, which is purpose. The science is clear in this area, so maybe it’s time to follow it. We have examples in the MedAxiom community who have moved away from production models and are willing to share their stories – the secret sauce of MedAxiom!

After over 30 years of doing physician compensation work, the only thing I really know for sure is that programs need strong leadership regardless of the compensation model. Every pay model has advantages and disadvantages. To all you physician leaders out there, please hang in there and keep fighting the fight. Lives depend on it.

Illustration: Lee Sauer

About the Author
Joel Sauer

Joel Sauer, MBA, is Executive Vice President of MedAxiom Consulting. Joel consults around the country in the area of value-oriented physician/hospital partnerships preparing health organizations for the value economy. His work includes vision and strategy setting, creating and implementing effective governance and leadership structures, co-management development, joint venture and other innovative partnerships, and provider compensation plan design. Beyond the above, Joel has a wealth of experience in service line development, clinical strategy development, provider workforce planning; including care team creation and physician slow-down policies, MACRA and bundled payment planning, and operational assessments.

To contact, email: jsauer@medaxiom.com

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