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Driven to Care: Aligning External Motivators with Intrinsic Motivation

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What motivates physicians to behave the way they do and make the decisions they make in the course of caring for patients? Given that a physician's proverbial pen dictates much of health care spending, possible answers to this question have serious implications not only for patients and their physicians, but also for payers, providers at large, policy makers, and the public.

Few would deny that external motivators like money influence human behavior. In the health care context, pay-for-volume incentives have contributed to wide variations in care and fueled the development of alternative ways of reimbursement, including most prominently pay-for-performance (P4P). Therefore, the issue is not whether financial incentives influence physician behavior, but whether they achieve their intended outcomes (e.g., high-value care) and, probably just as importantly, whether they lead to unintended and unwelcomed outcomes (e.g., avoiding caring for sicker patients; disproportionately focusing on care processes that are being evaluated). One of these adverse outcomes is the potential for external motivators to undercut intrinsic motivation, commonly referred to as the “undermining” (Deci, Koestner, and Ryan 1999) or “crowding-out” (Frey and Jegen 2001) effect. This phenomenon (referred to as the crowding-out effect for the remainder of the commentary) has been observed in a variety of professionals from public school teachers (Fryer 2011) to West Point military cadets (Wrzesniewski et al. 2014), but it has not been well studied among physicians.

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