Still early in a long game of delivery system transformation, the United States is already experiencing some of the negative consequences of pursuing quality and value measurement on professionalism in health care, specifically in the form of provider burnout. Other countries have struggled with similar endeavors, including the United Kingdom, which in 2004 launched an important experiment in value-base payment called the Quality and Outcomes Framework, or the QOF (“Qwaf”). The QOF increased primary care payments by up to 25% depending on how physicians did on more than 120 measures. The QOF was associated with improvements in several measures similar to those used currently in the United States such as smoking status, blood pressure control, and cholesterol management for patients with coronary heart disease or prior stroke. Improvement was directly aligned with incentives for when 12 measures were removed from the incentive list, there was significant erosion of previous improvement. The QOF was also associated with reductions in patient-centered outcomes, like continuity, and with increased physician burnout. In fact, one of the lessons from the QOF is that, “aligning financial incentives with professional values may reduce the risk of unintended consequences.” Scotland abandoned the QOF in 2016 and England reduced the number of QOF measures by one-third while also substantially reducing its role in physician income. As the United Kingdom was backing away from its pay-for-performance scheme, the United States launched the Quality Payment Program, without attending or adapting to the valuable lessons that the United Kingdom offered. Specifically, the United States failed to align these potent drivers of behavior with clinicians’ intrinsic motivations to deliver good care. Below, we review how such alignment might galvanize a new era of practical professionalism, by using policies that purposefully harness lessons from behavioral economics and principals derived from systems engineering. In doing so, we propose the creation of a built environment for health care in which delivering good, cost-effective care is not only the easy choice but one that supports professionalism and joy.
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