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Using Behavioral Economics to Design Physician Incentives That Deliver High-Value CareBehavioral Economics, Physician Incentives, and High-Value Care

Ezekiel J. Emanuel, MD; Peter A. Ubel, MD; Judd B. Kessler, PhD; Gregg Meyer, MD, MSc; Ralph W. Muller, MA; Amol S. Navathe, MD, PhD; Pankaj Patel, MD, MSc; Robert Pearl, MD; Meredith B. Rosenthal, PhD; Lee Sacks, MD; Aditi P. Sen, PhD; Paul Sherman, MD; and Kevin G. Volpp, MD, PhD
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 24 November 2015.


From the Perelman School of Medicine and The Wharton School, University of Pennsylvania, Leonard Davis Institute Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania Health System, and Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania; Fuqua Business School and Sanford School of Public Policy, Duke University, Durham, North Carolina; Partners Healthcare System and Harvard School of Public Health, Boston, Massachusetts; Advocate Physician Partners, Chicago, Illinois; The Permanente Medical Group, Oakland, California; and Group Health, Seattle, Washington.

Grant Support: In part by The Commonwealth Fund. The funding source reviewed the manuscript but did not make any fundamental alterations.

Disclosures: Dr. Emanuel speaks at paid engagements to discuss the Affordable Care Act, the future of health care, medical ethics, his memoirs, and opinions written in The Atlantic. Dr. Navathe reports grants from The Commonwealth Fund during the conduct of the study. Dr. Ubel reports personal fees from Humana outside the submitted work. Authors not named here have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=M15-1330.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Requests for Single Reprints: Ezekiel J. Emanuel, MD, Department of Medical Ethics and Health Policy, Perelman School of Medicine, 122 College Hall, University of Pennsylvania, Philadelphia, PA 19104; e-mail, vp-global@upenn.edu.

Current Author Addresses: Dr. Emanuel: Department of Medical Ethics and Health Policy, Perelman School of Medicine, 122 College Hall, University of Pennsylvania, Philadelphia, PA 19104.

Dr. Ubel: Sanford School of Public Policy, Duke University, 100 Fuqua Drive, Box 90120, Durham, NC 27708.

Dr. Kessler: Department of Business Economics and Public Policy, The Wharton School, University of Pennsylvania, 3620 Locust Walk, Philadelphia, PA, 19104.

Dr. Meyer: Partners Healthcare System, 800 Boylston Street, 11th Floor, Boston, MA 02199.

Mr. Muller: University of Pennsylvania Health System, Perelman Center A-5, 3400 Civic Center Boulevard 4382, Philadelphia, PA, 19104.

Dr. Navathe: LDI Center for Health Incentives and Behavioral Economics, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 1108 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021.

Dr. Patel: Advocate Physician Partners, Quality Committee, 1661 Feehanville Drive 200, Mt. Prospect, IL 60056.

Dr. Pearl: Permanente Medical Group, 1800 Harrison Street, Oakland, CA 94612-5190.

Dr. Rosenthal: Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115.

Dr. Sacks: Advocate Physician Partners, 2025 Windsor Drive, Oak Brook, IL 60523.

Dr. Sen: LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104.

Dr. Sherman: Group Health Physicians, 320 Westlake Avenue North, Seattle, WA 98109-5233.

Dr. Volpp: LDI Center for Health Incentives and Behavioral Economics, Department of Medical Ethics and Health Policy and Medicine, Perelman School of Medicine, The Wharton School, University of Pennsylvania, 1120 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021.

Author Contributions: Conception and design: E.J. Emanuel, P.A. Ubel, J.B. Kessler, G. Meyer, P. Patel, R. Pearl, M.B. Rosenthal, K. Volpp.

Analysis and interpretation of the data: E.J. Emanuel, G. Meyer, R. Pearl, K. Volpp.

Drafting of the article: E.J. Emanuel, P.A. Ubel, G. Meyer, A.S. Navathe, P. Patel, R. Pearl, A.P. Sen, P. Sherman, K. Volpp.

Critical revision of the article for important intellectual content: E.J. Emanuel, P.A. Ubel, J.B. Kessler, G. Meyer, R.W. Muller, A.S. Navathe, P. Patel, R. Pearl, M.B. Rosenthal, L. Sacks, A.P. Sen, P. Sherman, K. Volpp.

Final approval of the article: E.J. Emanuel, P.A. Ubel, G. Meyer, R.W. Muller, A.S. Navathe, P. Patel, R. Pearl, M.B. Rosenthal, L. Sacks, P. Sherman, K. Volpp.

Statistical expertise: R. Pearl.

Obtaining of funding: K. Volpp.

Administrative, technical, or logistic support: A.P. Sen, K. Volpp.

Collection and assembly of data: G. Meyer, L. Sacks.


Ann Intern Med. 2016;164(2):114-119. doi:10.7326/M15-1330
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Behavioral economics provides insights about the development of effective incentives for physicians to deliver high-value care. It suggests that the structure and delivery of incentives can shape behavior, as can thoughtful design of the decision-making environment. This article discusses several principles of behavioral economics, including inertia, loss aversion, choice overload, and relative social ranking. Whereas these principles have been applied to motivate personal health decisions, retirement planning, and savings behavior, they have been largely ignored in the design of physician incentive programs. Applying these principles to physician incentives can improve their effectiveness through better alignment with performance goals. Anecdotal examples of successful incentive programs that apply behavioral economics principles are provided, even as the authors recognize that its application to the design of physician incentives is largely untested, and many outstanding questions exist. Application and rigorous evaluation of infrastructure changes and incentives are needed to design payment systems that incentivize high-quality, cost-conscious care.

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Motivation
Posted on January 25, 2016
Dave Weisman
Abington Neurological Associates
Conflict of Interest: None Declared
While the paper is an interesting run down how to incentivize physicians, one year ago the lead author, Dr. Emanuel, wrote perhaps the most demotivating article imaginable. He told NY Times readers not to go for annual physicals. Never mind that he's a professor with access to any doctor for any reason, he told the public that their one chance to meet a doctor under non-stressful circumstances is not useful. The argument given to not visit our primary care doctors: not enough data to support it. There was no mention of: the doctor/patient relationship, additional compliance, less cigarettes, more exercise, just checking BP.

I found that to be odd. There isn't a lot of data to support the utility of executive networking meetings over expensive steaks and wine, but I strongly suspect that isn't stopping anyone. One must sometimes be careful in life that position not blind us to privilege and metrics not blind us to value.

Now this article states "Physicians do not want to be viewed as a “low performer” relative to their peers." But he's already told all primary care doctors they are low performers for doing their job. Perhaps to best design physician incentives that deliver the best care, (which is redundant I think as the best value care is the best care), we should value physicians and the good work we do.
If it is money that interests you, go work on Wall Street!
Posted on February 9, 2016
Rebecca D. Elon, MD, MPH
FutureCare Health and Management Corporation
Conflict of Interest: None Declared

In 1994, I had the privilege of serving as a small group discussion facilitator for a second year medical student course, “Physician and Society.”  My co-facilitator was an emeritus professor of medicine who began his clinical practice at Johns Hopkins Hospital in 1954. Though he retired from clinical medicine in 1989, he continued to teach medical students for more than a decade thereafter.


One afternoon, as our discussion group was assembling, the students began spontaneously discussing among themselves how much money they might expect to earn in various medical and surgical specialties. In retrospect, they were discussing behavioral economics, exhibiting “an underlying pillar of economic theory…that rational individuals use information to make choices that optimize their well being.”


The elder professor was uncharacteristically quiet as this discussion unfolded, until he could no longer contain himself.  “In all of my decades teaching at Hopkins, I have never heard such a discussion of money! This is not at all what should concern you. You must devote yourselves to your studies and to your patients. If you are diligent in your profession, society will reward you amply. You should be interested in medicine, not money.  If it is money that interests you, go work on Wall Street.”  With that said, he left the room.  His rebuke stung sharply. Everyone, myself included, was speechless.


The professor practiced medicine in the era when the academic hospital was a temple of medical science.  Physicians were driven to their best effort by being true to their oath, valuing the doctor-patient relationship, and earning the respect of their peers. When the professor died in 2004, it seemed his era had preceded him in death. Times have changed. Students now must make rational financial choices about their careers.  If they want to understand the vast health care industry, they will need to read The Wall Street Journal, in addition to their medical journals.


As Dr. Emanuel points out, as physicians we are now expected to alter our clinical behavior when the payers place money before us to do so. Though times have changed, the professor’s main thesis, that it is medicine and our patients that should interest us, not money, still holds true.  If financial incentives are what drive our clinical behavior, then truly we have lost our profession and become a conquered people.


Rebecca D. Elon, MD, MPH



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