You are what you measure. What gets measured gets done. These and other phrases are taught in most business schools around the world -- if you want someone to do something, pay them based on getting it done.
In sales, it's commissions -- if you don’t sell, you don’t eat; outside sales, many use MBOs (management by objectives). The process is slightly different, but the effect is roughly the same. The key is designing the measurement to ensure the desired outcome.
When students are measured based on test scores, the skill created is not understanding the curriculum, but rather knowing how to pass tests (an unhelpful skill in the working world). More insidiously, if schools are paid based on standardized test scores, an easy was to improve is to expel the poor performers. Sure the numbers look good, but is that really the right outcome? Are we measuring the right thing?
You need money to live, you work to earn money; like students who learn test-passing but not curriculum, adults learn how to game their system, how to interpret and translate their MBOs into the greatest income at the lowest effort.
Health care is rife with “gaming,” and like any other player in this game, (some) doctors are no exception. I was listening to Marketplace recently, and their fascinating show on billing codes -- every patient-related activity has a code assigned to it, and doctors must map their work to these codes to then bill the insurance companies and get paid.
To “clamp down” on rising costs, the insurance companies are reducing the $/code - so if lancing a boil used to pay $100, it now only pays $90. The result? Increased payouts, and more sophisticated gaming. Not exactly the desired outcome.
According to the show, 2.2 people are employed to do billing for each doctor in America. They even have their own conference -- CodingCon, where they “equip medical coders, billers and related healthcare professionals with best practices and tools needed in correcting codes from the start, avoiding claim denials, maximizing productivity and increasing practice’s bottom-line.”
Or, “learn how to not only overcome the $10 cut on boil lancing, but also add $100s more to your bottom line.”
The Marketplace doctor’s codistas have increased his revenue by 70% ("hundreds of thousands of dollars per year”). A codista at a hospital discovered that instead of claiming knee surgery and rehabilitation under one code, they could discharge the patient from surgery and then readmit them to the physiotherapy clinic downstairs, thus billing against two codes, and making much more.
How big is this? An additional $360B (yes, BILLION) per year is spent on the whole coding process - a concept that was introduced to standardize care and lower costs... We reap what we sow.
Net -- the best way for a doctor, clinic, or hospital to dramatically grow revenues is not by providing better care, adding more doctors, or serving more patients; it is by hiring more coders, and sending them to CodingCon.
We are what we measure, and what we measure gets done.
What if instead of student test scores and attendance, schools were paid according to how well their graduates did after they left that school? (Click for more info.) Now principals, teachers, staff, unions, etc. have a common purpose: the more prepared their students are for the future, the more money they earn. You’d better believe they will work together to ensure that their students are prepared for elementary (if a pre-school), middle, high school; or college/university, and the workplace. Attendance and tests are a piece of the picture, but the key measure is student preparedness.
The (state of federal) secretary of education’s only concern is tracking how students do after they graduate (something they, and the census system already does). By eliminating tons of redundancy and complexity, we should be able to educate all public school students at half the cost of today, saving $2-300B/year.
What if instead of procedures, doctors were paid based on how healthy their patients were? (Click for more info.) The job of health care is not to perform procedures, it is to assure a healthy community. This measurement would save $2-300B/year in coding procedures and such.
It is possible to create centralized (federal) funding with autonomy at the point of execution. The key is to ensure that the recipient of funds does NOT control how their performance is assessed or reported. Create the right measures...
For both education and health care, we can accomplish this with existing measurement systems and existing funding mechanisms. Not only would we achieve better graduates and a healthier population, we would do it for as much as half a $trillion less.
These are but two examples - consider the 39-year long war on drugs (metrics: arrests and interdictions). The result is $billions spent jailing street corner dealers (3 years in jail @$33k/yr for a $200 transaction) and intercepting tons of easily and inexpensively replaced drugs, with NO corresponding drop in consumption (constant for the last decade). If instead the last 39 years had been spent helping addicts, the war might already be over.
To quote a man of immense wisdom: “Impossible is just a big word thrown around by small men who find it easier to live in the world they've been given than to explore the power they have to change it. Impossible is not a fact. It's an opinion. Impossible is not a declaration. It's a dare. Impossible is potential. Impossible is temporary. Impossible is nothing."