Pay for Performance and a Glass Jar for Marbles

Throughout elementary school, middle school, and high school, the best term that would describe me would be, “teacher’s pet.” I was not trendy, funny, sporty, or rebellious. I was good at following the rules. And most importantly, I was recognized for following the rules both in a good way (by my teachers) and a bad way (by my classmates). I’m not entirely sure what motivated me to follow the rules, but thinking about my quest for good behavior through a “pay for performance” lens may provide some interesting insights.

Photograph by Sam Rosenbaum

“Pay for performance” or P4P is a hotly debated topic in health care. Many who see the perverse misalignment of incentives in the current “fee for service” or FFS payment schemes often suggest P4P as an alternative. P4P, as defined by Dr. Don Berwick, is “a contingent relationship, enforced, and implemented in an organizational hierarchy, in which supervisors judge the merit of the work of those below them in the hierarchy and, based on those judgments, give out variable and contingent financial rewards.”

In the second grade, the P4P system looked like this: Each student had a glass jar sitting in the corner of his or her desk. Ms. Gabso always carried with her a handful of marbles. Whenever she saw us behaving well, she would drop a marble in our jars. Good behavior meant not talking when she was talking; sitting quietly with our hands folded at the start of each day and as we waited for dismissal; having all of our books ready whenever we switched between subjects; and raising our hand to speak in class. Once our jar was filled with marbles, we got the chance to open the treasure chest on Ms. Gabso’s desk and pick out a trinket to take home with us.

Photograph by Sam Rosenbaum

In Ms. Gabso’s class merit was good behavior and our rewards were marbles. That sounds simple and fair, right?

Well, not exactly. True to being a “teacher’s pet” I probably racked up the greatest number of trips to the treasure chest. But, I don’t think I was the best behaved student in class. Even though I was just a second grader, I quickly picked up on my fortunate advantages. Consider the following important factors in being awarded marbles:

1) Location in classroom: Ms. Gabso dropped marbles into our jars as she walked around the classroom. The path she walked most often was between her desk and the front of the classroom. I happened to sit right along this path. That means poor Tommy who sat in the back corner of the classroom would never get marbles unless his extraordinary good behavior caught Ms. Gabso’s attention or she happened to walk by that corner of the classroom.

2) Material and appearance of the marbles: The marbles were identical and made of glass. Being slippery, they were not easy to maneuver in Ms. Gabso’s hands. This made it difficult for her to accurately control the number of marbles awarded. Sometimes one marble became three marbles because two would slip out. Because all of the marbles looked exactly the same, once you accumulated a good number of marbles, mistakes of awarding too many marbles or too little marbles could not be easily corrected.

3) Placement of marble jar: Glass jars in a second grade classroom is a recipe for accidents. However, our desks were grouped in clusters of six (a two by two square of desks flanked by one desk on opposite sides of the square). Those of us sitting in the square, had our jars grouped in the center. Again, because the marbles often slipped out of Ms. Gabso’s hands, a few marbles to my friend Lauren on my right could also mean one or two marbles into my jar by mistake. This meant that my friends sitting on the ends always seemed to have less marbles than those of us in the center.

Photograph by Sam Rosenbaum

4) Good posture: Though she never said so, Ms. Gabso was a fan of good posture. Rather than just having your hands folded on your desk at the beginning and end of each day, if you also sat up straight, you were more likely to get noticed and be awarded with marbles.

5) First impressions: After the first few weeks of school, Ms. Gabso had identified a handful of best behaved students and throughout the year it was these students that continually were rewarded with marbles. Ms. Gabso is human after all. So, only consistent exceptional behavior as demonstrated since the beginning of the school year and dramatic improvements in behavior were noticed. If you fell somewhere in between, you were rewarded less frequently.

These five points mentioned have absolutely nothing to do with good behavior and are arbitrary and uncontrollable characteristics of this P4P system for good behavior. From Tommy in the back corner’s point of view, Ms. Gabso’s marble system was not fair. More troublesome is the attitude that the class developed: we only had to behave when Ms. Gabso was watching. This change in attitude was reflected in the fact that Ms. Gabso never needed to send any of her students to be disciplined by the assistant principle, but our electives instructors did.

Now, if the students were health care providers, the merit clinical performance, and the reward a financial bonus, what could you get in return? A P4P system that encouraged health care providers to only perform well on what was being measured and only when being evaluated. Does that sound like an improved and reliable system to you?

Photograph by Sam Rosenbaum

I will have to admit that my “teacher’s pet” feathers have not completely been shed. Since Ms. Gabso was the only teacher to have such a P4P system in place, what continues to motivate me to follow the rules and always be on my best behavior? I think it must be the intrinsic satisfaction I must gain from following the rules and behaving well. For example, I don’t need a bouquet of flowers after every dance performance to enjoy dancing and performing.

In health care, there is natural satisfaction gained from relieving pain, answering questions, working in a team, and helping those in need. Personally, I’d want my doctor to give me medical advice and the correct prescriptions not because he’ll get an extra bonus at the end of the month, but because of the pride and joy he gains from caring for others.

Now, with that in mind, is P4P really a health reform panacea?



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