In the mid-1970s, Bill James was a night watchman at a factory in Lawrence, Kansas. During quiet nights, he began exploring baseball statistics in a novel way. He wanted to boil baseball down to its essentials and determine what statistic(s) most strongly correlated with winning games. But just as with most organizations, those in professional baseball were not impressed with the unique findings of this outsider, and were thus resistant to the change he prescribed. It has only been since the early 2000s that some general managers and managers have openly accepted many of his thoughts as potentially beneficial in winning baseball games.
One aspect of baseball that James and many other baseball-loving statisticians have tried to better measure is defense. Offense is easily quantified because it is easily understood: you either score runs or you don’t, and correlations can thus be made. But defense is inherently reactionary and inefficient, using nine players to defend against one offensive player. It is essentially preventing something from happening, thus complicating effective quantification. Yet because of its inefficiencies, any improvement in the understanding of defense could lead to dramatic changes in the way the game is played.
While perfect defensive statistics still elude us, many advances have taken place in the last few years and have begun to make their mark on the game. In no way is this more visible than in defensive shifts. “Defensive shifting” occurs when the majority of fielders are shifted to the side of the field where the ball is most likely to be hit, as opposed to having the defenders evenly distributed on the field. While this concept originated in the 1940s, it has not been used consistently until the last couple of years. After one or two teams showed success with its use, many other teams have begun employing the strategy against certain players. When this new data is appropriately utilized, it can turn into a strong weapon for the team to use against its opponent, and can dramatically improve a team’s probability of winning.
Health care is evolving in much the same way as baseball has. With few exceptions, medicine is handled in the same way it has been for decades. We are playing defense against disease, which is inherently reactionary and, thus, inefficient. We are forced to utilize trillions of dollars and countless hours responding to illnesses instead of proactively fighting against them. Not all diseases are preventable; “defense” in health care is not going away. To improve our approach to illness however, we need to take a new look at existing questions and use the information that we have to better structure and utilize the health care team.
The first and most important tool to use against illness is a strong primary care base. Much data exists to show that areas throughout the world and the United States that focus on primary care have lower costs and improved outcomes. [i] The US currently has more specialists than primary care physicians (PCPs), which is a significant contributor to our severely high health care costs.
Major ideas for increasing primary care providers have recently focused on lessening the payment gap between PCPs and specialists, a major factor in what area of medicine a student will choose. The use of physician extenders has also been used to increase primary care’s reach. These efforts have not been as fruitful as desired due to multiple factors, but payment reform is slowly starting to permeate the health care system.
As evidenced by the recent success of groups such as Primary Care Progress, as well as significant student interest in patient-centered medical home (PCMH) initiatives, it appears that finances and the lure of specialty prestige may not have been the biggest deterrents to students choosing primary care. It is likely more closely related to the way that primary care is currently practiced.
The PCMH has long been used for patients with disabilities, but has begun to be viewed as an answer to patients with other chronic health problems in the last decade. The PCMH combines population-based, integrated, coordinated, whole-person care through increased use of a health care team as opposed to an individual physician. Effective implementation of the concept has shown significant improvement in preventive health, chronic illness outcomes, and cost. [ii],[iii]
Numerous practices around the country have begun the process toward recognition as a full PCMH, even as payment reform for this model lags behind. The Veterans Administration system and large private payers, such as WellPoint and United HealthCare, have begun to encourage such redesign with payment incentives. Many states are adjusting their Medicaid programs to emphasize care in a PCMH. More organizations are in the process of doing the same.
Necessary redesign does not end at the PCMH. Accountable care organizations (ACOs) provide an essential mechanism to further spread coordination and combine responsibility for populations among PCPs and specialist physicians. ACOs help to close the gap in communication and coordination that often occurs when patients see multiple providers. ACOs also provide for a much larger emphasis on proactively managing chronic illness to prevent worsening of disease and unnecessary hospitalizations.
More coordination in the design of health care leads to increased importance in use of public health infrastructure and expertise. Physicians are not taught much, if anything, about population management, and find it difficult to implement.
Recent national reports have explored the collaboration of public health and clinical medical practice. [iv],[v] They underscore the improved outcomes and lower costs of coordination between health departments and health care providers. The partnerships have not only improved preventive infectious disease health measures, but also chronic disease management and prevention.
Baseball has shown that using new and existing data to answer old questions can lead to future improvement. Redesigning our health care system through increasing the proportion of PCPs, changing practice to the PCMH and ACOs, and the increased use of public health professionals as part of the health care team are the most effective ways to “shift” the health care team’s defense against disease. As we continue to overcome any remaining resistance to clinical reform, we can use the information that we have to turn our reactionary health care system into a positive for patients and providers alike.
[i] Starfield B et al. Contribution of primary care to health systems and health. Milbank Quarterly. Vol. 83, No. 3, 2005 (pp. 457–502).
[ii] Grumbach K, Bodenheimer T, Grundy P. The outcomes of implementing patient-centered medical home interventions: a review of the evidence from recent prospective studies in the United States. Updated November 16, 2010. Available at http://www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf. Accessed August 3, 2012.
[iii] Maeng DD, Graf TR, Davis DE, Tomcavage J, Bloom FJ. Can a patient-centered medical home lead to better patient outcomes? The quality implications of Geisinger’s ProvenHealth navigator. Am J Med Qual. May/June 2012;27:210-216.
[iv] Committee on Integrating Primary Care and Public Health. Primary Care and Public Health: Exploring Integration to Improve Population Health. Institute of Medicine; March 2012. http://www.iom.edu/Reports/2012/Primary-Care-and-Public-Health.aspx. Accessed August 3, 2012.
[v] Sloane PD, et al. Effective Clinical Partnerships Between Primary Care Medical Practices and Public Health Agencies. American Medical Association, 2009. http://www.ama-assn.org/ama1/pub/upload/mm/433/clinical-partnerships.pdf. Accessed August 3, 2012.