What does motivate doctors?
Doctors are indeed
motivated by financial incentives, and they do expect to achieve an income
commensurate with the rigors and expense of the training necessary to do what
they do. However, they are also motivated by professionalism: putting the needs
of their patients first, quality improvement, and individualizing care for
complex and difficult patients.
There are two broad ethical
paradigms in the world of economics: commercial ethics and "guardian"
ethics.11 The commercial paradigm assumes a seller and buyer of
goods or services, whose power and interests are balanced through the
marketplace and the laws of supply and demand, with financial incentives as a
primary motivator. Guardian ethics are applicable to socially necessary services
that require specialized training not available or achievable by the general
public, so that there is an inherent imbalance of power between the provider
and recipient of services. Classic examples are the military, medicine, and
other specialized professions. In these cases, the interests of the public are
protected by a tradition of professionalism and concern for the welfare of the
public, or patient, or client, which is held to be a higher ethical value than
financial considerations.
There has been a movement
in this country for the past 50 years to de-professionalize medicine, with an
underlying assumption that commercial ethics are the only valid and trustworthy
ethics. This justifies increasing interference in health care decisions by
insurance plans and government, and a reliance on financial incentives to
"fix" problems in health care, and especially its high cost. However,
if doctors are stripped of their professional autonomy and treated as if
financial considerations are paramount, they actually do start to abandon
professional ethics for commercial ones. They start responding to financial
considerations above patient needs; they select patients according to their
insurance status; and they look for ways to game the system and make more money
from things other than professional services. They begin to try to maximize
income by any available means, helping drive the cost of health care
higher. Sometimes this leads to outright fraud.
My opinion is that the real
cause of much of the physician-controlled unnecessary care in the U.S. is
abandonment of traditional professional ethics for commercial ethics -
"medicine as a business, patients as consumers" - that when
combined with fee-for-service leads to excessive and unnecessary care. If my
diagnosis is correct, then the further commercialization of medical
practices into competing corporate entities will only make the problem
worse.
On the other hand,
promotion of professionalism among doctors and harnessing it to make care
more cost effective through quality improvement programs is the antidote
to both the incentive to over-treat under fee-for-service and to under-treat
under salaried arrangements.
Quality Improvement
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