By John Miner and Brad Stulberg
Students in the Masters in Health Services Administration program at the University of Michigan
With baseball season over and "Moneyball" exiting the box-office, we cannot help but wonder: When will American medicine have its Moneyball moment? The story of the Oakland A’s and their “do more with less” approach to baseball can serve as a model for American health care: Health care should start measuring and paying for value instead of simply paying for quantity.
Moneyball tells the fascinating story of how the Oakland A’s management team drastically departed from conventional wisdom in building a top baseball team. Rather than continue in the ways of an inefficient baseball marketplace — where value was neither appropriately measured nor paid for — the A’s developed a system that prioritized data-driven insights along with human judgment to construct their lineup.
While teams like the New York Yankees paid tens of millions for star players that “looked great” or had “beautiful swings,” the Oakland A’s fashioned a method to figure out what player attributes really drove outcomes (in this case, winning baseball games) and then paid players based on those attributes: value-based purchasing, if you will.
[module align="right" width="half" type="pull-quote"]When compared to other developed countries, America is like the Yankees in terms of payroll — only without the 27 championships.[/module]
The A’s philosophy was in stark contrast to prevailing baseball culture. The franchise’s unconventional success rested upon a restricted budget (A’s ownership capped management spending at a hard amount), transformational leadership, and a change in mindsets and behaviors across the A’s clubhouse. The end result? Oakland, with a payroll two to three times smaller than top contenders, was able to compete with traditional powerhouses.
The analogy to health care is striking. Too often, health care dollars are disconnected from value; decisions are made based on precedent, anecdote, and preference rather than evidence; and new statistics and evidence-based measures are confronted with overwhelming disdain. (In fact, Billy Beane of the A's has himself written about this parallel, in an op-ed piece with Newt Gingrich and John Kerry.)
Value is rarely measured appropriately and even more rarely paid for in health care. Despite having the highest per-capita expenditures in the world by a sizeable margin, the United States ranks in the middle of the pack across most quality metrics. When compared to other developed countries, America is like the Yankees in terms of payroll — only without the 27 championships. Many books and entire careers have focused on this, and have converged around overarching themes. Costs must be understood and measured more accurately and quality must be assessed more robustly and made transparent. Only then can payments more directly reflect value.
Positive trends in this direction include activity-based cost accounting (within data-driven hospitals), bundled payments and other capitation methods, public quality measures, and CMS’ support of value-based purchasing. The emerging momentum behind these and similar concepts could act as a foundation for reforming United States health care in a way that ensures the flow of dollars rewards endeavors that lead to better health.
This change in paradigm will not be easy. America’s health care environment caters too often to physician preferences and patient perceptions instead of evidence-based practices. The healthcare community could benefit from watching a poignant scene in Moneyball, in which Billy Beane, the A’s visionary general manager, talks with old-school scouts about whom the team should recruit given its loss of big-name players. Billy flips conventional wisdom on its head, suggesting that players that “don’t look like great baseball players” are often under-appreciated. The scouts cannot accept this, and an argument ensues. While the scouts eventually come around after viewing compelling data, they remain bitter and doubtful.
Much like the tenured scouts, clinical practice frequently relies too much on outdated and narrow training and not on current evidence. This readily manifests itself in data showing enormous variations in care based on geography.
For the most complex conditions where treatment approaches are highly uncertain, this sort of variation is plausible, and to a large extent, necessary and positive as a driver of innovation. That said, the amount of variation surrounding more common conditions and routine processes of care is much less appealing. The fact that knee-replacements are done differently all over the country, or that some operating-rooms implement a "time-out" or "team huddle" process and others do not, is a bit bewildering, since for these things, there is generally an approach that is proven to work best.
A notable antidote to this problem is Atul Gawande’s call for medicine to utilize checklists like the airline industry (“The Checklist Manifesto”) which serves as an example of medicine moving towards evidence-based care. Additionally, clinical decision support systems built into a health system’s IT can, if done well, help bring a wealth of continuously changing evidence to the point-of-care.
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'The Oakland A’s proved that against the backdrop of a market where dollars were not chasing value, a limited payroll could go a long way.'
At a more macro level, comparative effectiveness research has the potential to serve as the foundation that moves health care from a world of implicit rationing to a world where limited resources are spent in the best way possible. Just as Billy Beane was able to make better managerial decisions when he had more and enhanced data on players, the medical community can improve by using comparative effectiveness research to encourage, prescribe, and perform those things that will best improve patients’ health.
By no means are clinicians the only ones at fault. In what has become known as a “Medical Arms Race,” hospitals around the country are quick to invest in and propagate the latest and greatest technology, often without proof that these expensive solutions are any better at improving health outcomes than their predecessors. In baseball, this is no different than teams chasing after heavy home-run hitters, even though the big-bats may not help achieve the end goal of wins.
The current approach is ineffective and inefficient at best and harmful to patients at worst.
Fighting conventional wisdom is like swimming upstream. It will take strong Billy Beane-like leaders and a change in the mindsets of clinicians and hospital administrators alike to implement a value-driven, evidence-based approach to medicine. While this approach has critics, the fact that America needs to do more with less, given our current health care, fiscal, and economic landscape, is indisputable. Like it or not, American healthcare may soon be given its “capped budget.”
The Oakland A’s proved that against the backdrop of a market where dollars were not chasing value, a limited payroll could go a long way. United States health care could benefit greatly from moving forward with a similar approach.
The authors are reachable at Johndminer@gmail.com and email@example.com.
This program aired on December 14, 2011. The audio for this program is not available.