Measuring Outcomes in Medical Service – Paired with Merit Pay?

Dear Readers!

First, a description of merit pay: from Wikipedia (see ‘merit pay’ for more information, including objections raised to the concept).

  • Merit pay is a term describing performance-related pay, most frequently in the context of educational reform. It provides bonuses for workers who perform their jobs better, according to measurable criteria. In the United States, policy makers are divided on whether merit pay should be offered to public school teachers, as is commonly the case in the United Kingdom.
  • Barack Obama is in support of Merit pay for teachers. …” (source cited).

I have heard wisps of references to merit pay for teachers from President Obama and have convinced myself it was a ‘trial balloon’ that has hopefully turned to lead. But I’ve also heard merit pay mentioned in connection with health care reform. I have strong commitment to single-payer, or at best an American Public Plan, and the leader best positioned to make it happen is interested in a strategy that I oppose!

It’s irrelevant to my main objection, (to provide “bonuses for workers who perform … better … according to measurable criteria”), whether payment for services in the social arena (education in the Wikipedia article, medicine in this essay) be called ‘merit pay’ or ‘performance related pay’.

The real point is: Why does a human being want to provide any service to another, and how is she/he motivated to do it with intelligence, heart, and quality training? This question would apply to medical practitioners and also to teachers.

There was clear irony at work whenever ‘merit pay’ discussions came up in my school district. One of our other lively topics was “how can children be guided toward the experience of intrinsic reward for their progress and social contributions!

On the one hand it was seriously proposed that adults (teachers) were inclined to ‘perform better’ if the carrot of increased pay was held before them. On the other it was seriously proposed the children would become more “mature in their future citizenship” if they were coached gradually away from responding to material reward! The underlying belief (as far as child development is concerned) was that there is innate desire within the individual to contribute, and satisfaction of contribution is a valued experience.

If response to material reward was viewed (in child development) as “less mature”, what, I wondered, did a merit pay proposal suggest of adults?

I agree with a premise that says, theoretically at least, the ‘best we can be’ as humans, is to feel internal motivation to service, in and outside our careers. I believe in our capacity for intrinsic, inner, satisfaction when offering service. My deep objection to the concept of ‘merit pay’ is that it betrays this capacity. It ignores it. It tries to manipulate desire and commitment to service.

Many years ago there was a novel, Magnificent Obsession, (Lloyd C Douglas, pub. 1929). As a child I was a voracious reader. My parents did not have a large library, but they did have a copy of this book and I read it a few times. The magnificent obsession was, in fact, to practice “serving without reward”. The principle behind the obsession went even deeper, the practice of service was to be done with so much modesty that it would ideally have no possibility of recognition. A whole new meaning to phrase ‘secret service’!

I am not proposing we develop a society in which intrinsic reward for service is the primary ‘reward’. Those who dedicate themselves to acquiring quality training, and to providing quality service, are reasonable to expect income that reflects this.

But not each and every individual who goes into education or medicine is primed strictly by monetary gain. Equally dedicated in training and service are some who do not focus on personal wealth. They expect, need, and want good income, but it is not their primary motivation. They have a different orientation – a different life-goal – a little bit of a magnificent obsession.

I want my physician and specialists to be highly trained; and I certainly want them to be well paid. But I also want the second type of motivation to be strongly present. I want a physician who gains significant intrinsic satisfaction from her/his chosen career.

What I most especially do not want, is a physician who studies and practices medicine as if she/he is a factory worker producing widgets, with motivation that these may be measured as ‘best widgets’ in order to get extra pay. I do not want a system that manipulates physicians to view themselves as production workers.

Measurement in fields of education and health bring us valuable information. Such measurement serves best when used to monitor progress and success or not of an intended goal. As a teacher I welcomed a wide range of measurement strategies, valued ‘hard data feedback’. With it, for instance, I was able to judge student readiness for the next level, or to notice weakness that might require a shift in learning experience.

It is a perversion to use this valuable information as a stick with which to beat a practitioner who ‘falls short’ and a flip side of the same perversion to use it to determine whom to reward.

I do not want my physician to experience a carrot/stick aspect to her/his practice. If the measurement is intended to inform – great. If upon consultation my physician recommends a treatment, and we follow it, and we take additional tests part way through to check success – great! The best use of measurement in medicine is to gain information about patient health.

My physician’s pay should not depend on whether or not recommended treatment brings hoped for results. A human body has many, many variables. And each body is unique. I do not want my physician to feel her/his practice, and income for same, is on the line if outcome is less than stellar. I want the concept of measurement to be “user friendly”!

There is something inappropriate about the concept of merit pay in service careers – particularly careers related to nurturing living, breathing, human beings – cognitive nurturing (education, psychology), and physical nurturing (medicine).

I have mentioned subtle cynicism before. I think it is found in the concept of merit pay in medicine. I think anything along a carrot/stick approach to medicine fails to recognize and understand innate (to be fostered) higher aspects of human nature.  It reveals a lack of faith in human nature, a fear that we cannot be trusted.

I’ve also mentioned before that children demonstrate these higher potentials spontaneously – they love to give, serve, share. They enjoy themselves when they do. They also love to experience the “thrill of skill”at their achievements. 

Imagine a physician practicing medicine because she/he truly enjoys practicing medicine!  Imagine pressure removed so she/he can bring full talent to the table!

To Health and Enjoyment! –MaggieAnn
(See also: Merit Pay Problem – a page under 21st Century Essential Practice;  Merit Pay Research Links (page) and Merit Pay Fundamental Problems (post).


About maggieannthoeni

A description once given of me was "rooted in the earth while roaming the stars" - and this has felt 'right'. I believe in something akin to this for each of us. I am a passionate supporter of discovering the autonomous self while serving the whole as primary intent. I believe in discovery of innate principles, clearing the overlay of socialization that obscures this from us. I believe it is our responsibility to leave no one behind - most particularly to respond to suffering as best we can whereever we find it, whenever we are made aware. I believe in this for the insect as well as the most magnificent form of humanity. I believe in brother/sisterhood without boundary. I believe in righteous indignation when it is appropriate, but do not believe in an enemy. I believe in consciousness, in intelligence, in logic, in rationality, in emotion, in transcendence - and am convinced until we generally practice explore and honor all this in ourselves, we remain profoundly immature. (I believe real maturity is known and practiced by many young children, and not enough adults!)
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One Response to Measuring Outcomes in Medical Service – Paired with Merit Pay?

  1. Isadore says:

    Teaching and doctoring are professions that are truly their own reward, unless that is, they are pursued for ulterior motives like money or fame or power etc. which then become the base rewards for a debased profession. The offer of performance pay* will appeal to those who are primarily in it for the money and will make no difference to those who are motivated by zeal. As to whether or not performance will actually be improved by this crass ploy* is debatable.

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