Linking Performance Incentives to Ethical Practice

Health spending is a huge part of the United States economy as it is a large business. We all have seen increasing inclusion of corporate practices in health care. One such inclusion is the incentive programs which have at their core the goal of production of the desired behavioral outcomes directly related either to performance output or extraordinary achievement. However, management influence on the organization’s ethical environment and culture can inadvertently encourage or endorse unethical behavior despite the best intentions. One way would be failing to link performance incentives to ethical practice. When leaders create strong incentives to accomplish a goal without creating equally strong incentives to adhere to ethical practice in achieving the desired goal, they effectively set the stage for ethical malpractice. Incentivizing ethical practice is equally important as incentivizing other behaviors (1). In the health care industry, unlike in the sales industry, professionalism and patient care are not like sale numbers and the costs of not providing excellent care can be serious. When emphasis is more about good performance numbers than accurate performance numbers, hospital accreditation reviews may result in, issuance of orders that are impossible to fulfill, or finding scapegoats to blame in a crisis. This can have powerful effects in shaping the organization’s environment and how staff members perceive the organization, their place in it, and the behaviors that are valued. Ironically, it isn’t unusual for leaders to assume all is fine from an ethical perspective when in fact it may not be. Research has shown that the higher in the organizational level the healthier the perceptions of organizational ethics is perceived (2).

It takes a great deal more than high ideals and good intentions to have ethical authority. It requires commitment and a proactive effort to achieve high standards. If executives are to meet the challenge of fostering an ethical environment and culture, it’s essential that they cultivate the required specific knowledge, skills, and habits. More and more, the public expects its leaders to hold themselves and their employees accountable and high on that expectation is ethical practice.

A focused example is the current opioid crises. In 2004 Centers for Medicare & Medicaid Services added pain scale as the 5^th vital sign. Subsequently, both the Department of Veterans Affairs and The Joint Commission mandated a pain scale as the 5^th vital sign (3-8). These pain scales ask patients to rate their pain on a scale of 1-10. The Joint Commission mandated that "Pain is to be assessed in all patients” and would give hospitals "Requirements for Improvement" if they failed to meet this standard (8). The Joint Commission also published a book in 2000 for purchase as part of required continuing education seminar (8). The book, sponsored by the opiate manufacturer Purdue Pharma (maker of oxycodone), cited studies that claimed, "there is no evidence that addiction is a significant issue when persons are given opioids for pain control." It also called doctors' concerns about addictive side effects "inaccurate and exaggerated." The health organizations used patient satisfaction scores for Performance Incentives and some patients who were addicted or on their way to becoming addicted would complain to administrators when they did not get drugs they were seeking.

No one excuses the unethical practice of widespread prescription of opioids without sufficient medical oversight. However, intrusion by unqualified bureaucrats, administrators and politician’s incentivizing more pain medications and punishing appropriate care likely contributed to the current crisis. In November 2017 four cities in West Virginia teamed up to file suit against The Joint Commission over the organization’s handling of pain management standards (9). In healthcare, physicians must advocate for their patients, build trust, insist on high standards of care, and participate creatively in improving the health care system in a fiscally responsible way (10). We should hold firm to pressures from manufacturers, administrators, and medical boards s to do what is in the best interests of our patients. Preserving the standards of professionalism in medicine while maintaining the highest levels of ethical standards has the best chance of healing this opiate epidemic. Let's maintain the trust and professionalism of our discipline during this crisis. 

F. Brian Boudi, MD

Associate Editor, SWJPCC

References

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8. Moghe S. Opioid history: From 'wonder drug' to abuse epidemic. CNN. October 14, 2016. Available at: http://www.cnn.com/2016/05/12/health/opioid-addiction-history/ (accessed 2/22/18).
9. Sullivan W, Plaster L. Four West Virginia cities sue The Joint Commission. Emergency Physician Monthly. December 5, 2017. Available at: http://epmonthly.com/article/four-west-virginia-cities-sue-joint-commission/ (accessed 2/22/18).   
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Cite as: Boudi FB. Linking performance incentives to ethical practice. Southwest J Pulm Crit Care. 2018;16(2):96-8. doi: https://doi.org/10.13175/swjpcc036-18 PDF