What are the problems?
What is the evidence the problems exist?
What is the quality of that evidence?
Who are the stakeholders in the problems and solutions?
What are the perspectives of those stakeholders?
What are the perspectives of the stakeholders with experience and expertise in the problems and solutions?
Who stands to gain personally, professionally, and financially from the problems and solutions?
In the pursuit of any sort of reform, the right questions are essential—as is credible evidence—before solutions can be identified as valid, useful, and potentially effective. The great failure of democracy is that it appears those elected to power have neither the ability to ask the right questions nor the propensity to seek credible solutions. Those leaders are, however, eager to claim problems and support solutions that benefit them.
“In a bold experiment in performance pay, complaints from patients at New York City’s public hospitals and other measures of their care — like how long before they are discharged and how they fare afterward — will be reflected in doctors’ paychecks under a plan being negotiated by the physicians and their hospitals,” announces the lede to “New York City Ties Doctors’ Income to Quality of Care.”
“Bold” apparently means “making decisions based on ideology and not a shred of evidence.”
The article makes no case that doctor pay currently poses any sort of genuine problem—just that doctor pay is “traditional.” Further, the article does acknowledge two important facts:
“Still, doctors are hesitant, saying they could be penalized for conditions they cannot control, including how clean the hospital floors are, the attentiveness of nurses and the availability of beds.
“And it is unclear whether performance incentives work in the medical world; studies of similar programs in other countries indicate that doctors learn to manipulate the system.”
For those of us struggling against a similar baseless current of teacher evaluation and pay reform, these details are all too familiar: (1) Concerns about accountability being linked to conditions over which a worker has no control (or autonomy), and (2) A complete disregard for the mountain of evidence that merit pay of all kinds proves to be ineffective and triggers for many negative unintended consequences:
“‘The consequences in a complex system like a hospital for giving an incentive for one little piece of behavior are virtually impossible to foresee,’ said Dr. David U. Himmelstein, professor of public health at the City University of New York and a visiting professor at Harvard Medical School, who has reviewed the literature on performance incentives. ‘There are ways of gaming it without even outright lying that distort the meaning of the measure.’ …
“Dr. Himmelstein also said doctors could try to avoid the sickest and poorest patients, who tend to have the worst outcomes and be the least satisfied. But physicians within the public hospital system have little ability to choose their patients, Mr. Aviles said. He added that he did not expect the doctors to act so cynically because, ‘in the main, physicians are here because they are attracted to that very mission of serving everybody equally.’”
The medical profession is poised to experience the complete failure of democracy that has been the fate of educators for at least three decades now. Democracy has spawned a legion of people with power but no expertise, and the result is a template for reform that ignores clearly identifying problems, fails to gather credible evidence, bypasses a wealth of experience and expertise, and imposes the mechanisms of inequity that brought those in power to that power.
As a result, buried late in this article on doctor pay reform is a cautionary tale:
“But Dr. Himmelstein said there were still hazards in the city’s plan. He said that when primary-care doctors in England were offered bonuses based on quality measures, they met virtually all of them in the first year, suggesting either that quality improved or — the more likely explanation, in his view — ‘they learned very quickly to teach to the test.’”
Educators, sound familiar?