Bountiful health care and a beautiful mind. (Next).

Raise your hand if you saw the Oscar-winning film A Beautiful Mind.

Okay, keep your hand up if you understood exactly what the main character, John Nash, did to earn the Nobel prize.

Few people understood, so I'll provide a quick primer here.

What does John Nash have to do with health care? Just this: We who care about health care and its future desperately need a way to think about the whole system. We do not have it. We lack the language.

When we speak about health care, we talk about pieces of the system:

* Medical quality

* The insurance mess

* Government financing

* The problems of creating new drugs

When we try to think about the whole thing, we quickly fall into confusion. While we speak of "the health care system," most of us would be hard put to define its structure, name its chief executive or describe its checks and balances.

If we understand its structure, we might be able to see why health care contains such revolutionary future possibilities, at the same time that the adjective that springs most to mind when we think about it is "stuck."

John Nash provided something -- an insight into dynamic structure -- that will, in time, come to be seen as profound and revolutionary for economics and the social sciences as the discovery of DNA is for the biological sciences.

This discussion is most directly about that morass we in the United States euphemistically call our health care "system." But the thinking behind it applies to any system.

Looking for a leader

The core of the problem in the U.S. and elsewhere, to varying degrees, is that no one is in charge.

Think of Microsoft. There was a moment that Bill Gates suddenly "got" the Internet. All along, he had assumed that the battle was for control of the personal computer, the desktop.

He suddenly realized that the real battle was over control of the business of the Internet, the web servers and browsers, the email clients, all those things that stitch the desktops together. And he realized that control could be extended in new directions, onto televisions cell phones, pagers and whatever kind of device might arise in the future.

Within months of that epiphany, every Microsoft product was advertised as "Internet-ready."

For instance, in Microsoft Word, if I type in the address of a Web site, the letters turn blue. I can click on them and the computer will open the browser and go on the Web. The entire corporation shifted directions.

So here's the question: Who could do that in health care?

Could any person or organization at any level in health care, dictate a rapid change like that, even in the part of health care that they might be thought to control?

Could the CEO of a hospital, on her own, say, "We are dropping the oncology business and starting a birthing center?"

Could the National Institutes of Health command all doctors to give Warfarin after a heart attack?

Could you imagine a body in the United States that could do what the Restructuring Commission did in Ontario, Canada, in recent years, telling this hospital to close and that one to take over another?

Even in Canada, the Restructuring Commission did its job amid a roiling mass of public input, editorializing, lawsuits and resistance from physicians, local boards, towns, church groups, women's organizations and unions.

Health care is both a public and an intensely private concern. It can never be simple.

Searching for order

No one is in charge, but the mind looks for order.

We scan for simple hierarchy where there is none. So many conversations about the reform of health care revolve exclusively around the question of what the government should do, what legislation Congress should pass, what regulations the Department of Health and Human Services should change.

How can we begin to think more realistically about the whole thing?

Let's start where Nash started, with games.

Early mathematical game theorists like John Von Neuman restricted the definition of games in order to talk about them. They dealt with two-player games that are finite -- they have a definite ending. The rules are consensual and known.

Their games were competitive -- you play to win. They were zero-sum -- you win by making the other guy lose. They had a transferable payoff -- you played for things (chips, money, the championship) that has the same value for both sides.

Nash started from a question posed in an undergraduate class on world trade: Can two countries trade if they have no mutually convertible currency?

He began to take game theory apart. He showed that you could mathematically describe multi-player, infinite games (like, say, the stock market), games where negotiating the rules is one of the moves, games which were not necessarily competitive (nor cooperative), which were not zero-sum -- whether you win may or may not have anything to do with whether the other guy loses.

He described games where the payoff is not transferable, like countries bartering lumber for furs.

In short, he came up with something far beyond traditional game theory, something more like a general mathematical description of human transactions.

Playing a new game

Imagine a game with a number of players -- not only different players, but different types of players, with different types of relationships.

Some have a coercive relationship over others. Some have dependent relationships. Some have long-term, equal, mutual transactional relationships.

Others might have "loading dock" relationships -- you buy something, it's delivered, you pay for it, that's it. Still others have relationships of influence, sometimes known and acknowledged, sometimes covert.

Health care is just such an infinite, multi-player, non-cooperative, non-zero-sum game.

Nash and other theorists discovered some fascinating facts about such multi-player games. They found that any such game, starting with a given set of players with given resources, has multiple possible solutions. There are many ways you can make it work.

Yet each game tends to veer toward a solution and stay there. When it reaches the dynamic stasis called the "Nash Equilibrium," each player in the game is at what chaos theory calls a "local optimum." That is, if they were to unilaterally act differently, they would lose out.

In health care, for instance, if pharmaceutical companies were to charge less for their new drugs, or doctors were to spend more time with each patient, without any other change to the system, they would suffer for it.

So, while many solutions are possible, each real solution is highly stable. Any major perturbation will likely be resisted by the system.

In health care, this was vividly demonstrated by the rejection of the Clinton Plan in the 1990s. One major player attempted to change the rules and other players fought back vigorously.

Whatever the wisdom of the change for the system as a whole, any change discomfits major players who have the power to resist the change.

What can we learn from this? That health care is irrevocably stuck?

Actually, we can take away two important things:

1. We cannot expect major change to spring from any one player, even the government.

2. Major change will not come from intentional moves on the part of individual players, but from large-scale changes in the resources available to the players, the capabilities of the players or the appearance of new players.

Today, the most likely source of large-scale novelty in this system is emergent behaviors fueled by technological change, whether biological or digital. Technology is not the answer, but technology poses new questions.

Disruptive technologies -- such as pharmaceuticals that may wipe Out whole categories of disease, genomic tests that will obviate that need for many types of diagnostics and information systems that can bring physicians what they need to know when they need to know it (or give much of the power of physician into the hands of non-physicians) -- will change the relationships among players and introduce new ones, shift the flows of cash and influence, and provide entire new fields of play.

What do we need to do?

As individuals, as institutions, as an industry, we need to track new technologies (in depth, not just scanning what is arriving on the market now). We need to continually assess their disruptive potential and the opportunities that disruption presents.

We need to conduct a continual conversation among all the players in this game about what the next health care might be and how we might use the new technologies to get there.

Joe Flower is an internationally recognized health care futurist. He can be reached by calling 415/601-5036 or by e-mail at [e-mail].