Intricacies of Motivation: We Are Not Just Robots

Edward Deci stated, "Human beings have an inherent tendency to seek out novelty and challenges, to extend and expand their capacities, to explore, and to learn." Daniel Pink, in his book Drive, utilizes Deci argument as the basis for his theory of motivation in humans as it applies to business and education. For my purpose, however, I want to look at the dynamics of the ever changing motivational tendencies for us, humans.

 In Drive, Pink makes a comparison between Microsoft's profit driven encyclopedia , MSN Encarta, and the online free encyclopedia version, Wikipedia. After just nine years, Wikipedia had put MSN Encarta out of business and was the largest most popular encyclopedia in the World. Why did Wikipedia succeed where Microsoft the largest most powerful software company in the world could not? Because someone had a great idea to develop a website that allowed tens of thousands of people to write and edit articles for fun. What is amazing about Wikipedia is that all the work being accomplished along with the website is free for all to read and explore. Wikipedia took advantage of peoples self motivation and allowed them to accomplish great things within the website. No one was managed or given a deadline on what or how to write the information within the articles. No one sits around Wikipedia Headquarters trying to figure out how to motivate its free employees. Pink touts Wikipedia's success as the model system in which self motivation out performs all other business examples.

Recently, I read an article that describes Wikipedia's slow decline. (http://www.enterpriseirregulars.com/14301/wikipedia%E2%80%99s-decline-and-the-7-types-of-human-motivation/) The article by Niel Robertson, offers many hypothesis to Wikipedia's downfall. However, he focuses on one main reason why Wikipedia is suffering from what other mass collaboration (crowdsourcing) companies are learning to take advantage of: humans have different motivation systems and you have to cater to all of them.

Just because a person has reached self actualization does not mean they will always stay at that level. Eventually other forms of motivation will need to be brought into the picture in order for people to continue to perform. Humans are not robots once interest is lost in something new a plateau will be reached within ourselves as well as within any organization. It is up to the individual or organization to continually reinvent them self or itself.

The following is an awesome video of Daniel Pink explaining his motivational theory:

Illegal Immigration and Medicaid

Receiving something for nothing seems to be the way our nation is progressing today with regards to all the handouts being given to those who are in danger of failing, out of work, poor, or here illegally. This will ultimately destroy our nation once those who provide the funds through taxation end their quest for the American Dream and raise their hands instead for the free handouts. Once done chaos will ensue and only the strong will survive.

Today's discussion focuses on how illegal immigrants will receive health care with the passage of the Affordable Care Act in 2010. The recently enacted health reform law, in part, expands eligibility for the Medicaid program. Illegal aliens remain ineligible for Medicaid beyond emergency services. However, this could change if they are legalized. The costs associated with the new affordability credits for those with income above the Medicaid threshold are not included here, and would be in addition to the extra Medicaid costs.

Among the findings:

• It is estimated that 3.4 million uninsured illegal immigrants have incomes low enough (under 133 percent of poverty) to qualify for Medicaid under the expanded eligibility established by health reform.
• Based on the 1986 amnesty, we estimate that incomes for uninsured illegal aliens would rise modestly after legalization, leaving 3.1 million uninsured illegal immigrants qualified for Medicaid.
• The primary reason so many illegal immigrants have low incomes is that most have relatively few years of schooling, with more than half not having completed high school. Legalization would not change this fact.
• The estimated cost of providing Medicaid coverage to 3.1 million amnestied illegal immigrants would be $8.1 billion annually.
• It is estimated that taxpayer-provided health care for uninsured illegal immigrants costs $4.3 billion annually. About half of that goes to those with incomes below 133 percent of poverty.
• While the annual costs run into the billions, because of their relatively young age and generally good health, the average cost of Medicaid for illegal immigrants is about half of the average general cost of Medicaid per enrollee.
• During the budget period 2014-2019, in which Medicaid expansion takes effect, covering 3.1 million amnestied immigrants would conservatively cost taxpayers $48.6 billion.

The expansion of Medicaid under the new health reform law already adds significant costs to the system. The costs of providing Medicaid to legalized illegal immigrants would be substantial. Because illegal aliens are relatively young in age and in generally good health, the average cost of their Medicaid coverage is about half of the average cost of current Medicaid recipients, which includes the aged and disabled. Nonetheless, it is estimated that covering just 3.1 million uninsured illegal immigrants with the lowest incomes would cost $8.1 billion annually. This estimate does not include the extra costs of the illegal immigrants whose incomes would qualify them for the new affordability credits under health reform.

The following videos are from FoxNews, one with Bill O'Reilly and the other with Greta Van Susteren both discuss how the illegal immigrants will be impacted by the Affordable Care Act and what it means for us.

The Patient-Centered Medical and Nurse Practitioners

The Institute of Medicine, in 2001, declared that: “the American health care system is in need of a fundamental change.” Their report identified significant changes in health care requirements for our nation. For many decades, the focus of health care has been on the management of acute episodic illness. Now, the requirements of our population have changed to include health promotion/disease prevention and chronic disease management. This shift in the focus of health care argues for a change in health care service delivery. It has long been known that to achieve optimal patient outcomes, health care should be patient-centered.

Currently the most discussed patient-centered model is the Patient-Centered Medical Home (PCMH). The PCMH is an approach to providing comprehensive preventative and primary care for children, youth and adults. The PCMH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. With health reform passing in 2009, attention has now turned towards this model to provide the U.S. population with a regular source of primary care, which is associated with better health outcomes at lower costs.

There are two inherent problems facing the U.S. as a whole. The first deals with the premise of the Affordable Care Act bringing  an estimated 32 million people of those currently uninsured in to health care system by 2019.   But insured or not, they’re going to have trouble finding a doctor. Passage of national health reform elevated the problem of the primary care doctor shortage that must be solved if federal health care reform is going to work, says Dr. Lori Heim, president of the American Academy of Family Physicians. “If current trends continue, there will be a shortage of about 40,000 family doctors by 2020,” she says.

One of the hot topics occurring in the health care deals with figuring out appropriate leaders of the Patient Centered Medical Home (PCMH). With the recent report by the IOM advocating for independent practice by nurse practitioners via nurse-doctor substitution, many physician groups, including the AAFP and AMA, have come forth with strong statements advocating against the IOM report and independent practice by CRNPs. However, Jan Towers, director of health policy and professional affairs at the American Association of Nurse Practitioners says, “Nurse practitioners produce similar results when compared to physician-led primary care practices, but we continue to be a group of providers that are underutilized.”

Currently, Nurse practitioners are the fastest growing segment of primary caregivers. The number of primary care nurse practitioners is increasing at a rate of 9.44 percent per capita, compared to 1.17 percent for physicians. It is estimated that about 80 percent of the workforce is in a primary care setting (Tobler, 2010).  What is not discussed here is the impact being created on the nursing workforce as a whole due to this push for Nurse practitioners.  Numbers produced by the American Association of Colleges of Nursing (AACN) that the IOM, CRNP advocates, and the media fail to mention  that according to AACN’s report on 2010-2011 Enrollment and Graduations in baccalaureate and Graduate Programs in Nursing, nursing schools turned away 67,563 qualified applicants from baccalaureate and graduate nursing programs in 2010 due to insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints. Concurrently, In the July/August 2009 Health Affairs,  Dr. Peter Buerhaus et al found that despite the current easing of the nursing shortage due to the recession, the U.S. nursing shortage is projected to grow to 260,000 registered nurses by 2025.

Expanding the scope of practice for nursing without addressing the current shortage of nurses within the current scope of practice will only spread the nursing workforce even thinner – and in my opinion, will only compromise patient care further than it already does. Increasing advocacy efforts for independent practice and encouraging current nurses to pursue higher education to provide outpatient primary care in the PCMH without increasing the amount of resources and faculty to contribute to a larger nursing workforce will lead to adverse unintended consequences.

Below are two videos discussing the two different medical home models; the first is from the nurse practitioners perspective the second is from the physician perspective. Enjoy. Lee