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Dr. Thomas Lee

Dr. Thomas Lee had a wonderful editorial trying to contrast baseball to public health care option.

Dr. Thomas Lee says the better way of understanding the appropriate role of government and regulation in health care is to take a closer look at a completely different industry — such as, say, baseball. To many, baseball represents an American ideal for free-market opportunity. Player and team performance can be measured objectively and comprehensively with a wide array of statistics such as RBI, HR, ERA, and OBP. And the best players advance to the major leagues and garner the highest salaries. Regulation and centralized intervention play a minimal role in major league baseball. Or do they?

A closer look reveals that something as simple as baseball has more than 220 pages of rules and regulations. The 2009 Official MLB Rulebook has 17 pages alone devoted to the objectives of the game.

In that rulebook, it’s stated that “the infield shall be a 90-foot square.” The bat “shall be a smooth, round stick not more than 2 3/4 inches in diameter at the thickest part and not more than 42 inches in length.” And the ball “shall be a sphere formed by yarn wound around a small core of cork, rubber or similar material, covered with two stripes of white horsehide or cowhide, tightly stitched together. It shall weigh not less than five nor more than 5 1/4 ounces avoirdupois and measure not less than nine nor more than 9 1/4 inches in circumference.” Avoirdupois? And we thought health care IT standards harmonization was obscure?

The point is that all competitive markets have some form of central regulation and control. Whether you call them rules, laws or regulations, they allow competitive markets to work better. And a central body needs to define those rules, whether they be a baseball commissioner or Congress.

If you accept the baseball analogy, then it’s easy to concede that government (or some central body) should have a significant role in shaping how health care is “played.” This is true of almost all industries big or small and should apply to health care as well. The bigger question then is: What role should that be?

For those in the Obama administration, it appears that the government should not only provide the regulatory framework for how health care is financed and delivered in this country. But it should also offer a health insurance option that competes with private insurers. And to carry the metaphor into the health IT market, should government offer a competing electronic health record?

The analog in baseball would be for Major League Baseball — the corporate entity that oversees the game — to field a team that competed with other MLB teams. And that this MLB-owned team could play by a different set of rules (didn’t need to support its expenses, could have losses subsidized by taxpayers, etc).

One can imagine that such a team could hire the best players, charge less for tickets and potentially win the most games while running huge deficits. Even if the MLB-owned team was forced to play by the same financial rules, it would nevertheless send a strong message to others that it doesn’t believe that the other MLB teams were playing to their potential, and that it could do better. 

Granted, it’s fair to say that many employers, patients and physicians are not happy with their current private insurance options. But is creating a public insurance option really the best solution? If baseball were played with a 50-pound lead ball, would adding an MLB-owned team to the mix solve the underlying problem? Of course not. The fundamental rules for playing the game need to be changed, not the number or types of teams.

Which Game Are We Playing?

Unfortunately, the “game” of health care today is much more complicated than baseball. And certainly more important. Birth, health, illness and death are more profoundly intertwined with our humanity than bases, bats or balls. But it’s possible that the simple principles that make baseball such a successful, competitive sport could apply to the health care industry as well.

Such principles could include:

• Design the playground, not the players. As tempting as it might be to say that health care should be delivered in a certain way by specific types of people or organizations, that stifles any form of creativity and is only likely to drive labor costs up. Defining the landscape with simple constraints and fair play in mind will foster better competition in the long run.
• Foster a single competitive arena with uniform standards of competition. It rarely does a sport any good if there are two separate leagues playing with slightly different rules and teams. No victory is ever complete. And competition is never as vigorous. This certainly could be no truer than in the health insurance market where it’s more cost-advantageous to have everyone sharing from a single, large risk insurance pool. Risk-adjusted payments could level the playing field to avoid cherry-picking.
• Empower, don’t patronize, the consumer. If consumers are spending their own money directly, they are much more likely to seek value-based outputs. Yes, health care quality is more difficult to understand and not everything should be a consumable. But providing consumers with the right incentives will allow them to find and select better solutions in the long run.
• All teams should play by the same rules. This should go without saying, but it sometimes can get lost that the government may not need to play by the same rules as the private sector. If that happens, then the concept of true competition is lost.

There are plenty of other principles that could likely be applied but the key point is the health care industry, unintentionally or not, has been designed in a fundamentally flawed way. We’ve been playing in a health care system with 50-pound lead balls, balsa bats and free admission. And blaming or competing against the team owners or players will not solve the primary problem. The rulebook simply needs to be rewritten.

(Article source: ihealthbeat.org)