Friday, April 18, 2008

Health care, unpredictability - Health Care and the Butterfly Effect

Dr. Edward N. Lorenz, a meteorologist who tried to predict the weather with computers butinstead ended up fathering chaos theory, died at 90 on April 17 at his home in Cambridge, Massachusetts.

Lorenz was best known for describing the “butterfly effect,” the idea that a small disturbance like a butterfly flapping its wings in Brazil could cause a tornado in Texas. The flapping wings represents a small change in the initial condition of a system. This causes a chain of events leading to large-scale phenomena. Had the butterfly not flapped its wings, the final system migh have vastly differed.

Dr. Lorenz realized perfect weather forecasting was a fantasy. Perfect forecasting required perfect knowledge of wind, temperature, humidity, and other conditions everywhere around the world at one moment of time. Even a small descrepancy could lead to completely different weather.

The butterfly effect applies to all matters initiated by mankind – stock markets, epidemics, wars, global warming, forest management, mortgage crises, physician shortages, and health system costs and outcomes.

Itis also a fantasy that one can predict social consequences with computers. The variables are simply too many. As chaos theorists say, “Small variations of the initial condition of a nonlinear dynamical system may produce large variations in the long term behavior of the system.”

Health care examples are:

• Introduction of Medicare in 1965, originally estimated to cost no more than $9 billion, now consumes $400 billion, 25% of federal budget. The butterfly effects here were, given unfettered access to “free” health care, people would flock to it, and doctors would provide more of it than ever anticipated.

• Estimates of a physician glut in early 1980s by various authorative bodies, but now with a widely acknowledged physician shortfall of 30%. The butterfly effects here were unpredicted population surges, massive immigration influxes, unprecedented prosperity with more discrtionary spending,, demands for technogical access, and changes in physician behavior and health care workforce makeup.

• Technologic innovations, CTs scans and MRIs, leading to the fastest growing cost of U.S. health care segment, imaging.now 15%- 20% a year. The butterfly effect here was an unparalled technological advance, allowing doctors to look inside the brain, body cavities, and joints, and becoming thought as a routine standard of care by patients and doctors alike.

• The dread of malpractice suits and defensive medicine behavior by physicians, leading to chains of tests, procedures, and referrals. These chains may cost $200,000 or more for routine workups of chest pain and severe headache. The butterfly effects here, which is immeasurable by computers, are how patients, doctors, and lawyers react to thoughts of winning or losing the lawsuit lottery and how everyone along the chain profits.

• The endgame of information technologies, which promises perfect knowledge of all the variables – financial incentives, documented actions, disease outcomes, system costs, provider behaviors – with unknown butterfly effects at present.

There is no perfect model for predicting health care costs, human behavior, and market responses. In 1964 Dr. Lorenz published described “ how a small twiddling of various paramenters in a model could produce vastly different beahvior, transforming regular, periodic events into a seemingly random chaotic pattern.’

When I contemplate health care, I think first of Mark Twain’s remark, “Everybody talks about the weather, but nobody does anything about it.” Health care is different. When I ponder health care and the “butterfly effect,” I realize everybody talks about it, everybody does something about it, everybody thinks they can use computers to measure it, but nobody knows where the next tornado will land.

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