In Liberia, the rate of maternal mortality rates is 725 deaths in every 100,000 live births. That's almost 50 times higher than it is in the US and among the highest rates in the world, even when compared to other developing countries. 

So communities, clinics, and medical providers in Liberia are scrambling for the right solution to get those rates down. According to a New York Times article this month, the consensus seems to be that safer births come from delivering in a clinic or hospital -- under the care of a trained midwife -- rather than at home with the support of a traditional birth attendant. 

That would surprise few people -- but the way they're going about it, as well as the results they are seeing -- are surprising indeed, and are very applicable to our conundrums about value based care, how to improve compliance, and whether care coordination and medical collaboration compliance can be of value in this new climate.

In the Liberian village of Zahmboyee, Evelyn Dolo is a birth attendant who traditionally supports women in giving birth at home. Recently, however, her village created a hugely steep punishment for doing just that. If Evelyn supports a village woman in giving birth at home, the fine is 5,000 Liberian dollars (about $50), a gallon of palm oil and a tub of cooked rice.

So Evelyn, like many traditional birth attendants in Liberia, is rushing patients to clinics rather than attending them at home. The fines vary from community to community -- sometimes the fine is in cattle, or dollar amounts, or rice, or food. But they are usually steep enough to be significant or even catastrophic for a birth attendant. 

Clinics say that they do indeed see more women giving birth in a clinic. And in Liberia, it's too soon to tell whether maternal mortality has shifted significantly. But in other countries, where similar programs are in place, the results simply aren't what people expected. For instance, in India, there has been a program in place to give poor women a cash incentive to give birth in a clinic or birthing facility. Like in Liberia, dramatically more births are happening in a facility -- the number went from 20% to 49% in 5 years -- but there has been no meaningful decrease in Indian maternal mortality rate. 

Lynn Freedman, director of Columbia University’s Averting Maternal Death and Disability program says of coercive punishment or incentive programs: “I don’t think it gets countries or their populations where they want to be.” 

I found this result discouraging when it comes to maternal mortality rates, but also interesting when compared to the pattern we have in the US of creating coercive reward and punishment programs for medical providers around things like care coordination and medical collaboration. Whether it is metrics like length of stay, rate of readmission, or specific patient satisfaction scores, providers are often punished or rewarded for particular indicators -- in the hopes that the hospital system will then experience an improved ROI.

When it comes to value based care, what can we learn from programs like these in Liberia and India?  And do rewards and punishments work in supporting better outcomes and better compliance?  Or is it possible that we can see results like India's, where the behavior we're rewarding increases, but value does not?

3 Reasons Rewards and Punishments Can Fail for Value Based Care:

1. Incentives don't always align with resources. 
   In Liberia's experience, hospitals are seeing more expectant mothers as patients but may not have more money or providers to care for them. As the New York Times points out, "If more women are coming into clinics, then those places need to have increased staffing and supplies to care for them." Similarly, providers are often told there is a new incentive for some aspect of care -- but the time to care for the patient and the support resources to make it happen remain scarce. In a value based care setting, extensive attention needs to be given to having incentives and resources align.
   
   
2. The right incentives have to be given for the right thing. 
   Sometimes the thing that's easy to measure isn't truly the thing of most value. For instance, in the case of maternal mortality rate in Liberia, it's easy to observe whether mothers are giving births in a clinic -- so that is what is being rewarded. But in truth, maternal mortality rate may be helped or hindered in either a home or clinic setting -- so ultimately, when it comes to the end "value" to the patient -- what needs to be measured may be something much more subtle. Similarly, here in the US, hospitals are all going to be on value based care payments. But if providers aren't equipped meaningfully to provide true value (rather than sent on a wild goose chase for metrics that don't really matter), then value for the patient won't really be achieved, even if the metric is met.
3. Providers may become disconnected from their deeper motivations and more important practices. 
   When medical providers, whether in Liberia or in the US, are incentivized for particular behaviors, they start to focus on those actions, rather than the natural things they do to care for the patient in the best way they know how. Not every provider is perfect, but almost every provider is deeply motivated by wanting to help and care for the patient in front of them. In many contexts, that means going above and beyond for the patient, collaborating creatively with other providers, and finding new and better ways to do care coordination because it can help the patient get a better result. Just as Liberian birth attendants may start to become disconnected with their own wisdom about what the patient needs, if there are too many restrictions on how they can care for the patient, the same thing is happening with US medical providers. So many of the incredible people who use iClickCare for care coordination and medical collaboration are doing so because they believe it will help their patients -- not because of any immediate reward or incentive. 

Ultimately, the simple act of trying to care for your patient to get the best possible outcome is the most true act of value based care that can exist. Certainly, hospital systems need to find ways to improve on the value dimensions that are dictating hospital funding. But we advocate for finding a way to do so that doesn't risk alienating medical providers from their most powerful outcome based approaches.

Why not incentivize through enrollment in true understanding of what works and what doesn't in the end outcome, rather than through sticks and carrots linked to simplistic actions? We tend to think that the US is different from a country like Liberia or India -- but we can ignore their learnings at our own risk.

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Photo by 149720488@N03 on Flickr, used under Creative Commons rights.