Sunday, October 26, 2008

What Does Baseball Teach Us About Healthcare - Not

Unusual things do happen. If the Oracle Alan Greenspan admits to making econometric mistakes and the elderly Cloris Leachman exceeds a dancing land-speed of two miles per hour, the Disease Management Care Blog will pay attention. That's why the improbable co-authorship of Newt Gingrich and John Kerry (with baseball expert Billy Beane) in this New York Times piece lauding the use of data-driven health care piqued its interest. If these opponents from either end of the political spectrum can actually agree on something, whatever it is must be good, right?

And agree they do on the notion that 'a health care system driven by robust comparative clinical evidence' will save lives and money. According to these well meaning politicos, physicians and hospitals need to learn from baseball's modern approach to outcomes data in day-to-day healthcare. Lives would be saved, walks and hits per healthcare encounter (WHHC) would increase, the on-base rate per insurance dollar claim (OBRpIDC) would go up and Frequency of Lowly Unwarranted Functionless Funnybusiness (FLUFF) would go down.

The DMCB likes the idea, but finds the baseball analogy a stretch. Here's why:

C0-morbitities: imagine at-bat statistics that involved different sized baseballs, multiple pitchers, shifting bat lengths and weights, changing distances and directions to first base and new rules about the numbers of balls and strikes allowed with each patient. Then multiply that times the number and types of docs and hospitals per region. Much of that variation is admittedly unexplained, but just because it's unexplained doesn't mean it's manageable by a Steinbrenneroid health czar. The statistical methodology necessary to account for the underlying variation is within reach (necessary) but hardly enough (not sufficient) to manage a health care system into a quality and cost World Series.

Incentives: in the rarified atmosphere of professional baseball, the pyramid single elimination winner-gets-all reward system is short-term (within a season) and extreme (huge pay out). When Newt and John suggest Intermoutain deserves to stand at the top of a heap, they lose sight of the fundamental intent of healthcare reform: to make all healthcare providers better and translate that improvement into a palpable difference for all patients - from Tampa Bay to Philadelphia to Los Angeles to Chicago to Boston.

Causality: Players clearly 'cause' runs, hits and errors. While this directionality is simple and appealing to denizens of the 'Beltway,' its not so simple in the clinical trenches of day-to-day medicine. For example, do physicians 'cause' better glucose control among persons with diabetes, or do persons with better glucose control see physicians more often? And while the brutal business of pursuing a Pennant affords owners the luxury of banishing players to the minors over the sin of being merely associated with a low ERA, it's not so simple with independently licensed physicians or local community hospitals.

Margins: The DMCB's spouse wishes it were a minority investor in one of the MLB professional franchises. If it were, she would invest in a robust information-technology based medical version of 'Sabermetrics,' because, let's face it, money would be no object and the ROI would be palpable. In contrast, money is an object in a 1-3% margin healthcare system dominated by a dysfunctional Medicare and Medicaid fee schedule in which the ticket prices have no relationship to their cost and the players are micro-managed on an unbundled system of payment (for each swing) and pre-determined cost-plus methodologies (pinstripe cost X .0028 RVUs, all subject to down coding).

Let's face it. The reason why healthcare has been resistant to change is because it truly is different with different rules and different statistical approaches, incentives, management styles and financing. Based on the overly simplistic nostrums demonstrated by the authors (and editors) in this New York Times piece, the DMCB wonders if we need different experts weighing in on how to fix things.

Sorry guys, you've struck out. And that, unfortunately, is not unusual.


Brady Augustine said...

The truth is somewhere in the middle. A wonderful recent book 'Overtreated' by Shannon Brownlee laid out the case very well that only about 30% of all treatments have a basis in evidence and that, for the quadrupling in diagnostics and imaging over the past 30 years, we are no better at diagnosing disease. Yes, people are not widgets and people do not live in the aggregate but we can not be afraid to let data help drive performance as long as the measures provide clinical flexibility for patient-centered care and large sample transparency for population-based care.

It is a delicate balancing act between art and science but the future of our health care system depends on the thoughful and appropriate use of data to drive continual improvements and build knowledge.

Jaan Sidorov said...

Brady Augustine is very correct. The DMCB didn't mean to imply that ALL measurement is useless. Rather, it's irritated that the otherwise smart Newt would be taken in by this simplistic baseball analogy. Brady has stepped to the plate and hit a home run.