Golden Handcuffs
If you ask the head of HR at any healthcare organization what their biggest ongoing headache is, they’ll probably say: “Recruitment and retention.” But then, if you ask them what specific strategies they’re working on to address that problem, they’re likely to say: “Provider compensation.”
In the thirty-five years since I started practicing medicine, a lot has changed. Patient visits are shorter and more frequent. Clerical tasks and other “asynchronous work” have increased exponentially. There’s a nationwide shortage of providers, and physician salaries (when adjusted for inflation and actual hours of work) have been decreasing for years. For most systems, it’s an open question whether or not they can afford to pay their providers enough to do the work they’re asking them to do. No wonder recruitment and retention are causing migraines in HR.
Organizations have responded to this crisis in a number of ways. Many have added productivity standards or incentives, linking compensation to the generation of revenue. That usually improves the productivity metrics, but it can have unintended effects. Most of the time, providers are already working at nearly full capacity. Faced with a system that demands even more from them, they do everything they can, short of placing their patients in immediate danger, to game the system. Provider encounters may go up, but so do referrals, diagnostic tests and hospital admissions. Non-urgent care, such as cancer screening and immunizations will likely suffer as well. There’s only so much time in a day, and only so much blood you can squeeze from a stone.
Other organizations have tried to improve retention through something called a vested pension. Basically, providers are rewarded handsomely for staying on the job for a certain number of years. If they leave before then, they lose their pension. In the most extreme cases, they are paid the vesting income in advance, but sign a contract saying they agree to pay it back if they leave before the vesting date.
If this sounds suspiciously like sharecropping, it’s based on exactly the same principle. We don’t think about physicians “owing their souls to the company store,” but this kind of vested pension is just a high income form of indentured servitude. The handcuffs are made of gold, but they’re still handcuffs.
In general, monetary compensation is extremely limited as a motivating factor. It works for simple, transactional behaviors: you do this, and we’ll give you that. But medicine is a complex, emotional undertaking that relies on the engagement, commitment and focus of its providers. Golden handcuffs won’t enhance that kind of emotional labor, and in most cases they’ll undermine it.
If you want to hold on to providers the right way, the answer is both simple and incredibly difficult: you have to give them work that they love. That may mean surrounding them with a team that can take on the parts of their work they resent and hate. It may mean giving them more time to connect with their patients and their co-workers. It may mean giving them more say in how their work lives are structured and how policy decisions are made.
Alternatively, you can just slap on the golden handcuffs. That may buy retention but it won’t buy loyalty. Loyalty is something you have to earn.
