Monday, December 29, 2008

Threads of an ongoing discussion

It is the following issue that rightfully has most students of our health care system upset

For what it is worth, I am not sure one can take away as much from this graph as it initially suggests. At least you cannot if your initial reaction is similar to mine- we now spend so much money on health care in the US that the spending is starting to crowd out other spending such as smaller primary school classroom sizes or better road safety, etc... all of which MIGHT have a larger effect on our median national longevity per dollar of money spent than spending another dollar on health care might have- clearly some types of health care spending have diminishing returns. For there are many other explanations that are just as plausible and which I will not address here today.

Anyway, what this data does strongly suggest to me is that it
was no accident Massachusetts was the first state in our union to pass universal health coverage. The uninsured have a bigger problem there than in other areas of the country. Further, human nature what it is, the citizens of Massachusetts followed the same old rule: spoil the commons before they actually need to make painful personal choices. For while it may not be completely clear from this data, a clever reader should immediately recognize that universal coverage in Massachusetts did nothing to address their TOTAL SPENDING issue (and indeed, as many of you may already be aware, spending has actually increased since universal coverage was passed).

Another suggestion from these charts is America MAY be in the midst of the granddaddy of all health care spending bubbles. And IF this is true, it is likely that states like Massachusetts (and regions like Long Island), where far more money is spent per person than in (say) Arizona or Georgia, are likely at the greatest risk for a severe contraction should the bubble pop. For even if all states in the union equally spend 16% of their GDP on health care, Massachusetts' 16% would be on a much higher dollar per person. And while one could argue this must reflect Massachusetts larger wealth per person, one forgets the chicken and egg nature of economic bubbles- more health spending begets a stronger local economy which in turn begets more health spending, etc... So if the 16% were held constant, but there was a more equitable redistribution of the money spent per person between (say) Georgia and Massachusetts, the net effect would cause a MUCH greater contraction in Massachusetts' economy than in Georgia.

Further, were the 16% national GDP devoted to health spending to contracts to (say) 11%, which is much closer in line with other OECD countries, Boston and Long Island would be in very BIG trouble as they would face a reduction on both an absolute and a % basis. Under such a scenario, Boston or Long Island could easily see an economic contraction on the order of 8 to 9% (which would be a very nasty recession indeed).

Living under the aegis of big government spending can be very risky, in fact every bit as risky as living under the aegis of free market private corporations, as the residents of any town that has been downsized under BRAC realignment can attest.

Risk is always conserved and bubbles are inevitable.

Friday, December 26, 2008

A Primer on Fractals

A friend of mine sent me this link to a wonderful PBS series on fractals. If you are unfamiliar with fractals, I highly recommend you watch the program, it is not very long. If you have trouble watching it thru the last link then try this link where you can watch it chapter by chapter.

In particular, I recommend you pay attention to the section in part II on "The Monsters" by Georg Cantor; not only was it the first fractal Mandelbrot recognized when he studied noise in radio transmissions, it was the exact same pattern I first noticed when I started looking closely at health care spending data at multiple levels. And it is the same fractal pattern I have used in a power point I am creating to illustrate the fractal nature of health care spending.

And here is a wikipedia link on fractals

Tuesday, December 23, 2008

Health Care Spending Is Fractal

Sometimes a picture is worth a thousand words

Wednesday, November 12, 2008

For those interested in looking at the endless fractals of society as I do, I thought you might enjoy this latest one I came across tonight while running a work flow analysis of mid-level providers in a high volume emergency department. It basically shows that 20% of the conditions they treat represent 80% of the time they spend at work; a perfect Pareto distribution... In case you were curious, the data for physicians looks the same.

FYI- if you have no idea what I am talking about, and/or are having a hard time actually seeing the fractal this building block is a miniscule part of, try thinking about reiteratively combining this "building block" up and down the healthcare delivery food chain (and remember it is itself made of different "building blocks") with a similar Pareto spread of the work flow of other healthcare providers and patients.


Tuesday, September 30, 2008

September Madness- final four bracket picks due by Friday.

Who will you pick as your final four? Who will go the distance?

Winners to be paid in the fiat currency of my choosing...

When I choose...

For the amount I choose...

Awards as reliable as any Bear Sterns guarantee.

Thursday, April 3, 2008

"The most expensive thing of all is the loss of trust"...

As an administrative physician for a large group of physicians, I have come to the conclusion there are four main reasons healthcare costs are escalating in this country and they are fairly easy to understand-- I hope I am up to the task of explaining :)

1. The various players in the healthcare system (patients, government, physicians, hospitals, insurance companies) no longer trust each other. In a multiparty prisoner's dilemma games, the players are 'defecting'.

‘Defecting’ means various players in the system are increasing barriers to improve things (from their point of view), but in totality are making things far more worse than they would otherwise be.

In many ways, what we are witnessing in American healthcare is analogous to the financial credit crunch. Imagine a marriage with all kinds of written rules, regulations and procedures-- would it really ever work?

Yet husbands and wives in reality must behave according to rules, or things would fall apart between them for lack of trust. When it is necessary to behave outside the rulebook, trust and faith in one another is really the only thing that allows it. And they must allow it, or the marital rigidity would lead to divorce.

It is kind of a circular problem without answer, and yet it only works when couples trust one another.

2. Many well intentioned regulations, drafted a long time ago (many before you and I were born) designed to protect patient care, now dramatically increase barriers to competition. But these regulations are almost immodifiable today-- would any attempt to modify them, helath practitioners would recognize a reductin in barriers to entry for competition and begin raising fears of poor care (if you think on it, this is really no different than #1.

The biggest of these 'sacred cows' are the rules governing what a physician or healthcare practitioner should be, and what skills they should have before they can practice ANY form of medicine.

Yet the reality is we do not need physicians to read x-rays (I sometimes think art student would do just as well), we do not need physicians to perform most interventions like angioplasties or colonoscopies (think of the complex manual dexterity of many fine craftsmen), etc… these and many other skills do not require a full medical school training to perform.

And while the training to perform these skills might still be rigorous, still it does not need to be as lengthy, or broad, or expensive. Most of the other things medical students learn in medical school are completely unnecessary to practice these (and only these) skills. There are many other skills in medicine, where training for that one skill does not require the training of a entire modern medical education, with its tremendous investment and lengthy apprenticeship.

As medicine becomes more procedure oriented, this issue is becoming more significant.

And since all of these laws are passed at the state level, they are often ignored in national discussions.

I believe changing healthcare training from the very beginning into two camps-- one camp where people learn a narrow range of skills, and another where they continue to learn deep and broad knowledge, would be perhaps the greatest 'low hanging fruit' cost saver of them all.

And the 'deep and broad' camp should not perform many proceedures. The conflict of interest is just too great.

3. Most people do not understand the fractal nature of illness and healthcare spending (most people don't even understand fractals!). This leads many people to the wrong impressions regarding who is ill, what is 'bad medicine', and where our healthcare money is spent.

Further, as people don't understand fractals, they don't understand how to reconcile fractal issues such as scaleinvariance with issues like trust.

4. America continues to avoid a values discussion on when it is 'OK' for our healthcare system to ration care. It avoids the conversation: "can we, should we, will we, and who will do it?" Indeed the very notion of rationing or triage (so fundamental to medicine once upon a time), are completely anathema to most Americans today. But the reality is we must ration (we already do, we just don;t admit it). We must decide how we will do it. We must decide who to empower with rationing care, just as we have empowered judges to administer justice.

Further rationing SOMETIMES requires override the wishes of individual patients and families (like judges sometimes override plaintiffs and defendants), so that 'our collective finances' might be protected. And if we empower someone to ration care, we must empower them with the ability to be wrong, as judges are so privileged. Without the ability to be wrong, rationing can never work.

You may not have ever thought on how physicians in America once guarded our healthcare resources, but believe me, they did. They still do in countries like England and France, but in America, with its diminishing trust, SOME of the physicians who once guarded our resources have lost trust in their patients, and are now prescribing care without concern for the collective. And they are doing this quite independently from any financial benefit they may gain by providing additional healthcare. Physicians are human; they too fear publicizing errors and character assault.

Tuesday, January 29, 2008

Have you ever wondered what your moral periodic table might look like? Have you ever wondered if it predicts your political views and whether your brain's electrical wiring might heavily influence whether you are a liberal, conservative or libertarian? Jonathan Haidt, professor of psychology at the University of Virginia, has developed a tool to let you do just this: take the test.

Sunday, January 27, 2008

Frame of Reference

My family and I recently rented a condo. Upon entering I was disappointed to discover that the condo was a 'pit’. Still ruminating on the unit’s ‘grubbiness’ while I brushed my teeth in the Jack and Jill bathroom dividing two of the unit's bedrooms, my six year old, James, burst in. He paused, looked up at me and smiled from ear to ear saying “Daddy, you found a secret room!” In one moment of childhood innocence, I was reminded yet again how often I forget ‘frame of reference’, and how much of this wondrous world I miss when I do.

‘Frame of reference’ is often analogized by
Positive Psychology’s proverbial ‘half empty-half full’ glass. Yet my own tendency towards pessimism always rejects that particular analogy outright: the stark image of a glass always seems so limiting. As if deliberately highlighting the zero-sum nature of the situation the proverb is usually raised in, my pessimistic tendency pushes back: “as it makes no difference, I will stick with my with the glass half empty thank you very much!”

Yet understanding the truth of frame of reference is really far more powerful than the proverbial glass, as understanding frame of reference often allows one to change a zero-sum problem to non-zero sum. And while an image of a glass is limiting to me, even the most pessimistic parts of me cannot resist the idea of entirely new universes.

To explain what I mean, I will use an analogy: your mind as a ‘biological’ computer. Your mind, like any good computer, must perform calculations in order to ‘solve’ equations such as A=pi r squared (which is the area of a circle). In the language of those who study information science: “your mind manipulates information in order to make it useful”.

As you probably already aware there are three types of information: ‘operations’, ‘variables’, and ‘constants’. Operations are the action in an equation-- addition, subtraction, multiplication. Operations tell equations what our brain is to do with variables and constants. Variables on the other hand, are the changing part of an equation: “what if I buy 4 feet of cloth instead of 3”?

As operations imply action and variables are, well, variable, most people have some kind of intuitive sense that operations and variables are changeable. Constants on the other hand, by definition do not change. Constants are the fixed part of a mathematical equation (in the formula for the area of a circle, the constant is the letter π or ‘Pi’, or is 3.1415926…). Without ‘constants’ such as π, our brain could not possibly calculate equations. Indeed, almost all our knowledge would be ‘meaningless’ or ‘useless’ without constants. We rightly hold them in high regard.

So the idea that constants such as π might be anything other than 3.1415926… is completely ‘foreign’ to many of us; to even suggest π could be 6 or 4 or 1.786 (which it indeed might be in other universes) is just too bizarre to accept… to some the idea is even threatening.

Yet the simple fact of the matter is that most things our mind understands as ‘constants’ are in fact not constant at all. They are only constant to us personally, because our brain was designed to treat them that way. And what is more, while many constants my brain accepts as constant are also constants to you, many others I accept as constant you do not. In truth, I see only my own personal universe, and you see only yours. And I will certainly never see yours if I do not learn where your constants and mine differ.

If this all seems a little bizarre to you, or if it seems as if I may be ‘playing on words’, I hope, as you continue to read, you will see this is neither bizarre, nor any word play. For if you miss what I am saying, that would be a shame, as you will miss out on the simply beauty of one of the most powerful ideas philosophers have ever know. To add to that sentiment, I truly believe, if we are ever to ‘move on’ as a species from our current predicament, we must all recognize the fundamental truth of frame of reference: a truth I actually see as the core of most religions in the world today. And though I am a lifelong atheist, as anyone who knows me will surely attest, yet I too recognize frame of reference commands me to have faith in you, as I will never learn all your constants.

Jean Piaget, the self described ‘genetic epistemologist’, was perhaps the first to recognize the process by which the human primate mind learns its constants. His findings were developed into a theory of childhood cognitive development still widely influential today in educational/behavioral circles. Piaget would say that we were born with a very few constants, and then learned the rest of our constants or π’s early in life. Interestingly, he would point out we do not learn most of our constants first. Constants come after we learn ‘operations’. But that is for another essay.

Once our mind has locked onto its constants or π’s, describing a constant or π as anything than what we know it as becomes very bizarre or foreign to us—this tends to happen quite early in a child’s life. It is therefore perhaps fortunate that all human primates have nearly identical genetic code (our individual DNA’s unique sequences represent an infinitesimally small % variation of the total DNA we share with our primate cousins— we are most definitely all cousins). It is further fortunate that without minimizing how each of us sees our lives as highly unique, still a visiting anthropologist from another planet who knew nothing about human primates might describe our lives as possessing less variation than we often realize: we all come from our mother’s womb, all grow up in a social communities, all obtain calories from a very narrow dietary menu, all live life spans on the same planet which can be easily be described using Gaussian (or small variation) tools, etc… Indeed we are all very similar.

Our minds are so similar that for all ‘practical purposes’, most of us agree on most constants. A very exciting field of science known as evolutionary psychology, is based entirely on just this: the fact that we share so many ‘constants’.

Yet the simple fact of the matter is that not ALL my mind’s constants are your mind’s constants. ‘For all practical purposes’ is not the same as ‘identical’ and the proverbial “never judge a man until you have walked in his shoes” still holds true. My experiences will occasionally lead my brain to conclude certain things are constant which your experiences lead your brain to conclude are not. In fact, researches are showing we human primates do not even hear the world the same way.

Our brains were never designed to ‘see’ the entire fabric of the universe; instead they only see our own private universes; I see mine, you see yours. The fact that our universes may be nearly identical (say compared with the universe of an octopus-- a very intelligent animal if you were unaware of this truth) is comforting, yet they will never be 100% identical.

A recent article in the New York Times Sunday Magazine by Steven Pinker reminded me of just how important it is that the scientists who study our brains remember this. For clearly science is narrowing in on what the evolutionary psychologists call a ‘periodic table’ of human morality: the ‘constants’ within the structure of our brain which our mind uses to make moral calculations. And as we human primates share so much in common, it should not be too hard to reach significant agreement around what these major constants are, assuming there are not too many.

Just how this knowledge will ever become ‘practical’ is hard for me to say. There are still almost 6.8 billion people on this planet, each with their own similar but never identical private universes, and each with their own frame of reference. No matter how much we recognize the similarities of our own private universes, still yours will never be identical to mine.

Where I do see understanding frame of reference as ‘practical’ is where it gives us a road map to solve problems. And one problem it clearly gives a solution to is perhaps one of our biggest problems of all, how we ‘open our minds’ and solve problems in the first place. I at least see the road frame of reference suggests as it reminds me that my constants are just mine, but they are not universal and are probably not constant at all. If I am having trouble ‘solving a problem’, my trouble may arise just as much from fixing constant I never should have fixed, as it comes from failure applying logic on constants I ‘knew to be true’. Framing problems is really half the problem-- for many of us, it is more than half the mental work.

Researchers at the University of London recently came to similar conclusions when they set out to understand how our brain solves new problems to reach “Eureka” or mental pay dirt moments. Their key discovery should have been obvious all along, that in order to reach “Eureka” moments; the mind must be ‘open’. Translated, something the brain believed was constant was in fact not constant at all. The mind needed to turn something constant into something variable to reach “Eureka”. Solution did not follow by applying more logic on ‘what was known’; solution followed recognizing something you thought was true, was wrong in the first place. In fact, this seems to be the very function of sleeping.

Another example of how this has practical applications is in the sphere of solving interpersonal conflict. If you ever have the privilege (misfortune?) of working with a group of people sidelined through interpersonal conflict and a facilitator is called in to mediate, I suggest you watch the facilitator work closely. They work by focusing on what each individual team member holds as ‘truth’ or constant and through their explorations of everyone’s constants; they give other team members the chance to view each other’s private universes and frames of reference. Facilitators expose how the constants of one person’s private universes are really variables of another. And once trust is reestablished, teamwork usually rapidly follows. Facilitators can do this even if they often do not understand many of the technical details of the project the team is working on.

Next time you surf the internet for fun, I suggest that you do it from the following frame of reference: look at each web page as a place where one person (one biologic computer) is sharing their constants and their own private universe with every other biological computer out there. You may see, as I do, layers of parallel universes, where people of similar mental constants aggregate in ‘safety zones’ (places where people find their personal mental constants hold true).

You may then notice the web is really just a network of places where similar minds seek the safety of similar minds. You will find sites where people hold Christianity, Islam, Judaism or even science as their guiding constant. At each of site human minds seek safety and dialogue with minds of similar constant. Liberals share constants with liberals, conservatives with conservatives, etc...

Yet on each of these websites, if you read in the comments sections, you will see both agreement and conflict as the minds recognize they shared some, but not all, of the same constants.

We live in a fractal world indeed.

Thursday, January 24, 2008

I left this as a 'comment' on another (economics) blog the other day whose readers I have high regard for, and was shocked at the degree of misunderstanding/animostiy it generated. Yet as one who never seems to shirk from controversy from what I see as injustice, I thought I would add it to my own blog (please trust I am not schizophrenic) as I see the issues/controversies/misunderstandings it generated with other readers as being in fact the very same issues causing escalating health care costs in this country (a subject dear to my own heart). The issue is and always has been about trust...

As another addendum, I pretend to be nothing more than an 'amature' in the philosophy of science. Yet I see that philosophy as having very 'practical' implications to my own interests, so I thought I would add this here...

Are you familiar with Benoit Mandelbrot? He is a mathematician at Yale who wrote a non math book for us 'lay readers' called The Misbehavior of Markets.

As a way of legitimizing the book/author, another author you may have heard of-- Nassim Nicholas Taleb-- famous for Fooled by Randomness and The Black Swan, dedicated The Black Swan to Mandelbrot-- "A Greek among Romans".

Anyway, The Misbehavior of Markets tries to explain to us 'lay' (i.e. non-math) readers the difference between the two major types of risk/statistics that mathematicians use to describe the world:
1. Gaussian risk/statistics (which give 'The Bell Shaped Curve')
2. Cauchy or Lorentz risk/statistics (which give Fractals, Chaos Theory and Power Laws

Most people understand Gaussian statistics intutively-- we use them everyday to analyze things like casino gambling, coin tossing, etc...

Most people DO NOT understand Cauchy statistics intuitively at all. Most people therefore incorrectly misapply Gaussian statistics to problems that are fundamentally Cauchy and they end up with incorrect results (Daniel Kahneman, a psychologist, who won the 2002 Nobel Prize in economics, for his work on heuristics, would call this an example of a flawed heuristic for those who understand me)

Gaussian analysis/statistics work fine for things of 'small variation'-- height, IQ, weight, 'Six Sigma' manufacaturing quality control programs, etc...(just like Newtonian physics 'works fine' when applied at 'slow speeds').

However Gaussian analysis is fundamentally incorrectly applied to things of 'tremendous variation'-- things like wealth, knowledge, names, language, the internet, the stock market, etc...

... and interestingly enough, things of tremendous variation just happen to be most of the things people find meaningful/willing to go to war over-- wealth, love, hapiness, social justice, fairness and income distributions, etc...

When you get into talking about economic issues like 'fairness' and 'social cooperation' AND you apply Gaussian analysis, you will come up with inaccurate results. You are using the wrong statistical tool. If you built a home with simmilarly incorrect math, the home would fall apart.

It was just these issues that Joshua Epstein and Robert Axtell of The Brookings Institution accidentally stumbled upon when they started working on a project called SugarScape.

Sugarscape has profound implications to almost every single article you have written. Sugarscape clearly proves how most economists try to 'solve' issues using the wrong (i.e. Gaussian) mathematics.

In particular, Sugarscape shows how most economists beliefs on 'what is fair' and what is 'socially just' (which by the way have been my own until I learned this) are based on Gaussian logic and reasoning (since most of our minds work this way). Yet these problems are not Gaussian probabilities.

Re-ask every one of the question you have asked your readers but next time use Cauchy/Lorentz logic... you have been trying to 'solve' problems with the wrong tool.

You are using an evolutionary relic of how your own mind developed (no foul, we all do this).

The basic point I am trying to make here is that the entire logic of this very discussion is based ON FAULTY ASSUMPTIONS.

The following is a wonderful website to review some of the basic computer simulations researchers in the field of complex adaptive systems have developed. The site was created by by Ankur Teredesai , assistant professor in the department of computer science at the Rochester Institute of Technology