Thursday, May 7, 2009

The Age of Unthinkable Health Care

The Disease Management Care Blog read ‘The Age of the Unthinkable’ by geostrategist-economist Joshua Cooper Ramo. While written for foreign policy types, the DMCB thinks there may be lessons for healthcare.

Highly readable, this book draws on the deceptively simple intellectual model of a sand pile. When the cone of sand first develops, it’s very easy to predict its dimensions. However, as it becomes a progressively larger pile, it will eventually reach a critical mass at which a ‘sandslide’ will occur somewhere on the surface. It turns out that as the experiment is repeated, the sandslide varies in size and stage. What’s more, it is impossible to mathematically model just when and how each slide will develop. As it grows in size, a simple sand-castle phenomenon witnessed many times by the DMCB and its spawn is just too much for our largest supercomputers.

The point? We live in a sandpile world, where complex financial instruments, shifting military alliances, risk contracts, transnational movements, transborder pandemics, 24-7 media, currency exchange rates, global warming and countless other interactions involving billions of individuals can lead to tipping points of any size, any time and anywhere. Joshua Ramo points out that the linear calculations (input: ‘sanctions,’ output: ‘a compliant Iran’) is simply unable to manage, let alone predict any outcome with sufficient certainty. While it’s possible to retrospectively go back and calculate why or how something happened (! The shadow banking system and government sanctioned easy credit!), we have nothing to forewarn us about the next crisis.

So what are the lessons for healthcare? While translocations in the health and cost status of populations may not receive front page news, it still happens. For example, despite the best planning, health plans can experience big drops in their State and national NCQA rankings, incurred but not reported (IBNR) can gyrate up or down, COX II’s can kill, State Attorney Generals can sue, cost trends can spike and primary care appointments can vanish. New laws and new regulations may or may not help, but they will certainly make the sand pile even more complex. Inputs like: ‘electronic records,’ output: ‘health care savings’ or input: ‘cover all Americans,’ output ‘access to care’ in a world of genetic testing, possible insurance mandates, an insatiable appetite for technology, growing pharmacologic options, an aging population and H1N1 viruses (to name a few) are not only simplistic, they’re naïve and by no means assured.

Joshua Ramo has some ideas on how to manage this. How it might work in healthcare is for a future post.

No comments: