Health Care and the Bowl Championship Series…
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Oh boy - what could health care and the so-called “BCS” possibly have in common? I pondered this question as I read, watched and listened to the discussion going on across every major sports news outlet throughout the week-end about how the Bowl Championship Series is simply a bad way to pick a national champion. This year, there are at least 10 teams that all have a legitimate shot at #1 - Oklahoma, Texas (my favorite), Florida, Alabama, Texas Tech, Penn State, Utah, Boise State, USC and Ohio State. And if I was a big-time college football coach and you asked me who I’d least like to play in a Bowl Game (a pretty good indicator of who’s downright scary this time of year), it would be at least six of them (Oklahoma, Texas, Florida, Penn State, USC and Utah). Every one of these teams could win a national championship if Division I college football operated the same way every other major college sport - and every other division of college football outside of “D-1″ - operates, and offered a national play-off. Under this scenario, the Top Eight teams play a quarterfinal round, the four winners play a semifinal round, and then the two winners play each other - for all the marbles. Then you have a winner. That’s the way it works for everyone else at every level, because selecting a national champion any other way makes no sense.
But in college football, a computer piles up points all year long for each team - based on wins, losses, strength of schedules, and the like - and the two teams with the most points at the end of the season play each other. That determines the national champion. This year, when there are still two undefeated teams, and a host of teams with one loss (most of which occurred against one another), the idea of a two-team showdown based on computational statistics seems simply nuts. But the keepers of the BCS flame have their reasons for retaining the status quo, and they have the power and the juice to keep things just the way they are.
Their rationale - to anyone looking at this from the outside in - seems pretty skimpy. The list goes something like this: too much time away from school for the kids, too complicated to schedule around the holidays, not enough interest in such a prolonged play-off, too confusing given the existing set of Major Bowl commitments and the existing Bowl schedules, and too much damage done to the Conferences that have Conference play-offs of their own.
But maybe there’s another answer - the folks who participate in and benefit from the current arrangement don’t want to change it, and as long as the fans, the alumni, the TV networks, and the schools themselves continue to show up and participate every year, moving away from the status quo is simply not going to happen.
Which brings me to health care. Anyone looking at health care from the outside in would have to conclude that it needs to be reformed. And the commentary from the various analysts, experts and overseers on this question is quite familiar. There is too much utilization and service variation, too much focus on volume, not enough attention to outcome, too much administrative complexity, too much high technology, not enough personal attention, etc. The system, to anyone who’s studied it seriously, needs to be reformed.
And yet here we are, twenty years or so into this conversation, and it still works under more or less the same terms it’s always worked under. Why? Well, in some ways, it’s a lot like the BCS. As long as everyone who pays for, manages and participates in the current system likes it better than something they either don’t know or don’t understand, it’s unlikely that major change will occur.
Maybe major health care reform will happen at about the same time Division I college football moves away from the BCS and into a national play-off model. Seems if we can do one, we can simply apply the lessons learned from that to do the other.
Charlie,
I like your creative thought.
I recently heard David Hefner at the University of Chicago discuss the absolute necessity of shared sacrifice among all market participants. Even better was his suggestion that those of us who are participants in 1/7 of the economy should be working feverishly on “market” solutions before the other 6/7 of the economy makes changes for us.
As for the BCS, the answer is pretty simple: at the end of the year, after all the numbers are crunched and the games are played, odds are that the National Champion will be a member of the Southeastern Conference.
Hal - Let’s see how it goes. While the SEC certainly looks like the toughest conference year in and year out - and the SEC did produce the national champion under the existing system in 2007 (LSU) and 2006 (Florida) - I would have loved to have seen USC play LSU in 2003 when they were both ranked #1 by different polls at the end of the year. And of course, Texas was #1 in 2005 and USC won it outright in 2004. I like your 1/7 // 6/7 analogy.
Twenty years into this conversation? At one level, yes. But at a popular level, I think not. For years now “the plight of the uninsured” has been much discussed. But it’s only recently, I believe, that the cost of health care, per se, has begun to be a legitimate issue, except in connection with the uninsured, or insurance companies,
in the popular press.
Moreover we are still neck-deep in mythology about those high costs. Brownlee and Emanuel tried to debunk some myths, but at the cost of installing a few myths (in my opinion) of their own.
In fact, the popular press is so bad, that I begin to suspect that it we want quality discussion of health costs, we should try to persuade some sports analysts to do it.
Charlie - Are U.S. citizens really ready to “reform” healthcare? People think they are ready but let’s face it, when it comes to be “their turn” in the system they want everything done for them and their family (and I would probably be the same way). Let’s take beginning and end of life issues. If we really want to control costs do we continue to save premature babies at any cost resulting in millions of dollars in care in NICUs and learning disabilities? Do we provide expensive cardiac surgery and implanted defibrilators to patients over age 65? How about over age 70 or 75? How about a cancer regimen that extends life for a year but costs millions to provide? The amount we spend on beginning and end of life here in the U.S. is not what happens in nationalized healthcare systems that have far lower costs than us. I know there are other ways to streamline episodes of care and treatment patterns for existing diseases but there has been very little debate about beginning and end of life care and I really don’t think people are willing to live with the realities of these issues when it involves them or their family members. I think people put up with healthcare as it is because they know when it comes to be “their turn” they will have access to anything and everything.
To be explicit, there’s the issue of the substantial increase of monopoly power that’s gone on in health care in the last decade or so. But it seems too much ignored in the discussion. True, it’s not so big an issue in Massachusetts. But I was just looking at Bob Kuttner’s piece on health care inflation in NEJM, a national journal. Kuttner certainly knows what’s happened on the oligopoly front. Yet he did not seem to wish to discuss it as an inflationary factor. Very disappointing.
Susan - your point is a good one on several fronts - but I wonder if you and I would see the oligopoly question the same way. You see, I think the biggest oligopoly is Medicare - and it drives the decision-making and behavior of virtually everyone else in the system. When Kuttner talks in his article about the disparity in payments between primary care and cardiology, he implicitly blames that on managed care and private insurance. I’ve got bad news for him. Medicare payment policy - which drives all other payment policy - is responsible for that particular problem - and a host of others just like it. Yes, the Blues in most states are big and powerful, but they are nowhere near as big and as powerful as Medicare. And none of the National Carriers have the clout Medicare - or Medicaid, for that matter - has.
There are market oligopolies on the provider side as well - which tend to bid up the cost of services for most payors. While I share your concern about market makers not exactly making a market that makes sense, I wonder if we’d see eye-to-eye on where the problems rest. I would, of course, be interested in your response.
Sean - there’s a great comment underneath the NEJM article from last February by Bob Kuttner that Susan L references that you’d find interesting. The author says that until there’s some agreement among clinicians about what is “best practice” across a wide range services - including end of life care - the variation in care delivery that drives up cost and mitigates quality efforts will go on. Pretty good insight.
Charlie,
While sports fans will debate the merits of various systems for determining championships for the coming decades, we have to admit that they have an advantage here - they have a system to measure performance. Healthcare has no such system. It seems that all the players in the healthcare market agree that an optimal system will promote value. Substantive discussions about improving value fall short when we get to the need to express the value of health services in a way that all can agree with. If value is the outcomes delivered per unit of costs, then we don’t have a way of understanding whether value is improving or declining over time. All we have now is the denominator in that equation. The large number of unrelated outcome measures we have now (HEDIS, patient satisfaction surveys, etc.) can’t be combined in a meaningful way. Maybe the best next step is for payers and providers to focus on developing the numerator - a consistent way to express the health outcomes attributable to health services over time. At least then we’ll be able to see how we’re doing from one season to the next.
Greg - I share your view about the “what” we’re measuring as a missing part of the picture. I’d like to see the feds far more interested in health care services research than they’ve been to date. If they viewed knowing more about how we apply what we already know with the same intensity as pursuing the next new thing, we’d all be a lot better off.
And by the way, now that Utah has finished its season undefeated with a total beat-down on Alabama, and USC completely crushed Penn State - doesn’t this whole BCS thing look as foolish as ever?