Presentation by Mikel Berdud at iHEA conference held in Milan in July 2015

1. Mikel Berdud1 • Juan M. Cabasés2 • Jorge Nieto2
1 Office of Health Economics (OHE)
2 Universidad Publica de Navarra (UPNA)
11th iHEA World Congress in Health Economics
Milan (Italy) • 11-15 July
Incentives and Intrinsic Motivation in Health
care Organizations: a Case Study from Servicio
Navarro de Salud-Osasunbidea (SNS-O)

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Table of Contents
1.Introduction
2.Methods
3.Findings
4.Discussion
5.Concluding Remarks

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Introduction (1)
How much do you expect to earn by
attending this presentation?

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Introduction (1)
How much do you expect to earn by
attending this presentation?
People don’t act just because they expect monetary
gains
• They often engage in low-individual-benefit or costly
activities
• Behavioral Economics: economic decisions are often
driven by motivations beyond the economic rationality
 Social preferences, fairness, altruism, reciprocity, intrinsic
motivation…
 Biases, beliefs, culture, social norms, ethical values, identity…
 Reputational and image concerns, self-view, self-esteem…

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Introduction (2)
Individuals are intrinsically motivated when they get
satisfaction (utility) from the very act of doing an activity or
performing in a task
Intrinsic Motivation: doing something because is inherently
interesting or enjoyable rather than for some separable
consequence.
Crowding effects: rewards or incentives might substitute
(crowding-out) or complement (crowding-in) individuals’ intrinsic
motivation
 Intrinsic motivation in psychology: Self Determination Theory (SDT)
[Deci and Ryan 1985, 2000a, 2000b]
 Crowding effects in economics: Motivation Crowding Theory (MCT)
[Frey 1997; Frey and Jegen 2001; Bowles and Polanía-Reyes 2012]

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Introduction (3)
It is plausible to assume that doctors in public health systems
are intrinsically motivated or have altruistic preferences
[Berdud, Cabasés and Nieto 2014; Makris and Siciliani 2013; Kolstad 2013;
Siciliani 2009; Delfgaauw 2007]
With the exception of Kolstad (2013) works exploring the interplay
between incentives and intrinsically motivated doctors are mainly
theoretical
 There is a necessity to find evidence about doctors’ intrinsic
motivation and crowding effects in health organisations
 Useful to inform policy makers and health managers about optimal
design of incentives within health organisations

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Methods (1)
We perform a Qualitative Analysis in Servicio Navarro de
Salud-Osasunbidea (SNS-O)
 Method: Semi-structured open interviews á-la-Bewley
[Bewley 1999, 2002]
 Questions used to conduct interviews were designed
grounded on:
 Self-Determination theory (SDT)
[Deci and Ryan 2000a, 2000b; Deci, Koestner and Ryan (1999); AFW survey SDT]
 Motivation Crowding Theory (MCT)
[Frey 1997; Frey and Jegen 2001; Bowles and Polanía-Reyes 2012]

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Methods (2)
 Sample: random purposive and emergent sampling criteria
 Interviews duration range: 57 to 104 minutes
 Interviews were recorded: mp4 recorder
 We have analysed 16 interviews: we draw the relevant evidence
of IM, CO and CI using the saturation criterion
 Saturation: the point in the data collection when no new or
relevant information emerges
 Work objectives:
i. Study the determinants of doctors’ intrinsic motivation
ii. Obtain evidence about crowding effects in Servicio Navarro de Salud-
Osasunbidea (SNS-O)
iii. Explore potential ways of designing crowding-in incentives that might
be useful for health managers

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Methods (3)
Analysis stacks the information within categories and codes
Categories: the relevant phenomena under which
data coming from the field or qualitative concepts,
are grouped
 Intrinsic Motivation (IM)
 Crowding-out (CO)
 Crowding-in (CI)

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Methods (4)
Analysis stacks the information within categories and codes
Codes: labels used to conceptualize and homogenise
interviewees’ statements or quotes
 Deductive: codes grounded in existing theories (SDT & MCT)
 Like/Enjoy, Control, Autonomy, Financial Incentives…
 Inductive: codes emerged in the course of the interviews while
information gathering
 Research, Service, Peonada-FFS, Empathy…

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Methods (5)

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Findings (1): IM codes

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Findings (2): IM summary
Intrinsic Motivation:
 Doctors are intrinsically motivated toward medical practice
 Like/Enjoy
 Vocation
 We can identify two clear dimensions of doctors’ IM:
 Scientific or technical dimension: scientific knowledge,
research, further education
 Pro-social or human dimension: help/empathy, service…
 Doctors’ answers showing IM are perfectly coherent with
classical definitions of IM provided by SDT
[Deci and Ryan 1985, 2000, 2001]

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Findings (3): CO codes

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Findings (4): CO summary
Crowding-out:
Doctors perceive as demotivating the current incentive schemes
implemented in SNS-O
 Peonada-FFS
 Changes in doctors’ perception of the meaning of the medical practice
 Market transaction context for health services provision
 Source of opportunistic behaviour
 Professional Career-1
 Perceived as a financial incentive: it fails to recognize excellence, merits or
quality of service provided
 Non effort or merit based promotional system: tenure based incentive
 Source of opportunistic behaviour
 Control: managerial actions harming doctors’ autonomy were also reported as
demotivating

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Findings (5): CI Codes

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Findings (6): CI Summary
Crowding-in:
 Doctors reported only two real experiences of CI
incentives characterised by:
 More autonomy and self-management of work
 Participative processes of agreeing objectives with
management
 Doctors made a lot of proposals of CI incentives:
 Support and funding for research activities, further education
and teaching
 The development of collaborative links and networking with
the academy: basic research and teaching
 More autonomy and self-management of work
 The development of a new professional career scheme based
in objective quality of work and excellence criteria

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Discussion (1)
1. Results confirm our three hypotheses:
 Doctors are intrinsically motivated agents
 Incentives and control policies may crowd-out doctors’ IM
 Designed properly, incentives potentially may crowd-in doctors’ IM
2. Results agree with those obtained in economics and psychology
 Results and classical definitions of IM (SDT)
 Financial incentives FFS and PC-1 lead to a change in the perceived nature
of the medical practice (BE)
 As reported by doctors control and lack of autonomy causes CO (SDT)
3. Results from the study suggest the need to start a serious debate on the
design of a new Professional Career scheme including:
 Objective rewarding criteria based on: merits and recognition, records of
quality in provision and degree of achievement in agreed objectives and
goals
 Rewarding schemes for research activities, further education or teaching
 Rewarding schemes for management specific goals: waiting lists, budget
impact

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Discussion (2)
4. Interview studies are subject to limitiations: design, questions,
interviewers or sampling
 Two interviewers: an expert in health care system management and
an expert in IM and incentives
 Physicians: science sensitive and familiar with the scientific method
5. Machlup (1946) criticism: ‘people do not know their own
motives’
 What agents involved in a particular phenomenon say about their
motives is a kind of informative evidence about its true nature
6. Hypothetical orientation of the study: suggestions of policy are
based mainly on opinions and not in real designs of schemes
already implemented
 Only two real cases reported for CI
 Although coming from the most recognized stakeholders of the
gamePolicy implications should be taken just as suggestions,

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Concluding Remarks
I. Findings from interviews in SNS-O show that it is
crucial to inform policy makers and health
managers about the need of taking into account
doctors’ intrinsic motivation in the design of
incentive schemes
II. Findings of this qualitative research in SNS-O could
contribute to generate a fruitful debate on
potential ways of designing crowding-in
incentives
III. As long as health managers expect better
performance and outcomes from intrinsically
motivated physicians, the design of Crowding in
incentives could be understood as an investment
in a asset called ‘Motivational Capital’

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References
References:
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