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Competitor analysis
Summary
The competitor analysis segments provider types by Porter
generic competitive strategy: quality
differentiation, cost leadership, innovation focus,
business
model, for-profit
focus, geographic
niche; and discusses new entrants. Significant
flows across the value delivery system are detailed.
Introduction
The health care industry has a complex VDS is value delivery system. including cooperating and
competing payers, providers and physicians.
The health care provider analysis includes:
Provider business
analysis
US health care providers are increasingly affected by:
- Introduction of exotic diseases altering the hospital's infection
control works to prevent healthcare-associated infections. It monitors & supports associated hospital processes: Anti-microbial surfaces, Barrier clothing, Cleaning, Disinfection, Hand washing: North shore; Patient access during epidemics, Sterilization; to contain cross infection. The CDC provides support: Ebola process; and works closely with the primary biocontainment unit at Emory University Hospital.
strategies.
- Increasing specialization of doctors, driven by educational
debt burden, which results in shorter times with each
patient and increasing operational complexity.
- Antibiotics are compounds which kill bacteria, molds, etc. Sulfur dye stuffs were found to be effective antibiotics. The first evolved antibiotic discovered was penicillin. Antibiotics are central to modern health care supporting the processes of: Surgery, Wound management, Infection control; which makes the development of antibiotic resistance worrying. Antibiotics are:
- Economically problematic to develop and sell.
- Congress enacted GAIN to encourage development of new antibiotics. But it has not developed any market-entry award scheme, which seems necessary to encourage new antibiotic R&D.
- Medicare has required hospitals and SNFs to execute plans to ensure correct use of antibiotics & prevent the spread of drug-resistant infections.
- C.D.C. is acting to stop the spread of resistant infections and reduce unnecessary use of antibiotics.
- F.D.A. has simplified approval standards. It is working with industry to limit use of antibiotics in livestock.
- BARDA is promoting public-private partnerships to support promising research.
- Impacting the microbiome of the recipient. Stool banking is a solution (Sloan-Kettering stool banking).
- Associated with obesity, although evidence suggests childhood obesity relates to the infections not the antibiotic treatments (Nov 2016).
- Monitored globally by W.H.O.
- Regulated in the US by the F.D.A. who promote voluntary labeling by industry to discourage livestock fattening (Dec 2013).
- Customer demands have more effect - Perdue shifts to no antibiotics in premier chickens (Aug 2015).
dependent processes evolving resistant results from evolutionary pressure of antibiotics, supported by plasmids and R factors: NDN1; which encode resistance properties for otherwise lethal antibiotics. World leaders hope cooperation can preserve the power of last resort antibiotics: Carbapenems, Colistin (Oct 2016). Worrying trends include: C. auris resistance to medical antifungals: itraconazole; as well as azole agricultural fungicides (Apr 2019), CRE (May 2016), C. diff (May 2015), MDR & XDR TB; resulting in increased risk of sepsis and death. The World Bank estimates full resistance would reduce the global economy in 2050 by between 1.1 and 3.8%.
super bugs: C. diff usually competes with other bacteria in the human gut microbiome. But antibiotic treatments provide it with an advantage where it becomes the predominant gut bacteria causing diarrhea, abdominal pain, and toxic megacolon. Repeated treatments select for infections that are progressively more difficult to treat. C. difficile infections kill more than 25,000 people a year in the US. Fecal transplants, especially enabled by stool-banking, reintroduce competitive bacteria that limit the success of C. difficile and cure patients with previously recurrent infections. But the F.D.A. has not approved such transplants as a treatment and the procedure is not covered by insurance. ,
MRSA is methicillin-resistant Staphylococcus aureus , XDR tuberculosis is extensively drug-resistant tuberculosis. It requires very toxic and costly drugs to treat. Most patients die. ;
which undermine the treatment strategies: Surgery, Perioperative is the care of a patient prior to and after surgery. ;
that depend in effective antibiotics.
- Health care Value Delivery
System (VDS is value delivery system. ) is
being divided into islands by the vertical integration of large
insurers with pharmacists, PAC providers is a Post-Acute Care provider. A three-day hospital admission and discharge are prerequisite requirements to receiving Medicare PAC services. Acute care hospitals become portals to the PAC business. Referrals are key. PAC includes different types of facility focused on different severity of illness (high to low):
- Long term care Hospital (LTCH),
- Inpatient rehabilitation facility (IRF),
- Skilled nursing facility (SNF),
- Home health agency (HHA) - most acute care hospitals and EMR providers have strategies for integration with home based care,
- Outpatient rehabilitation. SNF and HHA represent 80% of discharges and expenditures. Assisted living is not part of federal Medicaid, but states often include it through a waiver.
,
urgent care is an efficient and less costly 'alternative' to the ER. There is no accepted standard. Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls. Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones. Unlike an ER they can not admit patients to a hospital. Some also offer services like pre-employment drug screening and summer camp physicals.
businesses, surgical
centers, physician groups and community health clinics:
- CVS Health, continues
its UHG
like diversified health services strategy:
merging with Aetna;
responding to Amazon's
potential disruption of pharmacy
market (Oct
2017)
- CVS Health purchases Aetna for $69 Billion - developing
community-based sites of care; a big deal argues Leerink
Partners' Gupte (Dec
2017)
- Assessments of the merger vary (Dec
2017)
- CVS +
Aetna merger is
allowed by regulators with the requirement that some Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
plans are
sold to WellCare
Health Plans. No discrete large PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. is left: UHG (OptumRx),
Cigna +
Express Scripts,
Anthem
building a PBM; limiting drug cost management for smaller
insurers and PBMs. PBMs have been criticised for secret deals
that have helped keep drug prices high. Health plan
control of where prescription drugs are purchased will limit Amazon's disruption of pharmacies,
and likely limit consumers opportunities to bargain. State
regulators will start to look at the operations of
PBMs. Large insurers are also entering health care
provision of low cost care for chronic conditions and chain care
in the community (Oct
2018)
- UnitedHealth
purchases standalone
surgery center Surgical
Care Affiliates for Optum's OptumCare (Jan
2017)
- UnitedHealth
purchases DaVita's
physician group for Optum
for $4.9 Billion. US is the United States of America.
needs a Value Delivery
System (VDS is value delivery system. ) for
chronic disease: asthma is inflammation of the airways resulting in their narrowing, swelling and generating additional mucus which inhibits breathing. Its prevalence doubled in the US between 1980 and 2000. Asthma is the most common chronic disease in childhood, the most common reason for being away from school and the most common reason for hospitalization. 10 to 13% of children's asthma cases are due to obesity. Among obese children 23 to 27% of asthma cases are due to obesity. Diagnosis: Propeller Health; Treatments include: Xolair;
,
and diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
.
Northwestern's
Garthwaite
asks: is Kaiser's
business model under threat? (Dec
2017)
- CMS is the centers for Medicare and Medicaid services. implements CHRONIC care
act of 2017 is Ron Wyden & Orrin Hatch's Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act signed into law by President Trump as title III of the BBA of 2018.
through Medicare
Advantage (MA) is a private provider administered health insurance plan providing access to Medicare benefits. It was originally enacted as part of BBA Medicare + Choice or Part C plans. The government funded the plan with an annual fee, based on age and severity of the subscriber's medical conditions, rather than FFS. When a Medicare eligible person enrolls in a MA plan the government pays the private provider a set amount each month. The participant pays the Medicare part B premium and if required a part C premium each month. The MA plans offer a PCP who coordinates care. And the plans have an annual limit on out-of-pocket expenses unlike traditional Medicare. When they obtain treatment they will have to pay a copayment which may be quite high for some specialists. It is the health plan's responsibility to contract the physician network that will provide the care, leaving the risk with the insurer. About 36% of Medicare beneficiaries are enrolled with Medicare Advantage by 2019. The ACA introduced quality outcome and patient satisfaction based differential payments into MA. To measure the performance it added a five-star quality rating scheme. MA plans report their quality and patient satisfaction data to CMS annually and based on the results are awarded one to five stars. The highest rated plans are provided with large additional payments. It was assumed that subscribers would shift to the highest rated plans and the other plans would improve or drop out of MA. And the ACA eliminated subsidies which the federal government used to establish Medicare Advantage. However, the Obama administration has used a $8.5 Billion demonstration project to maintain this funding. It is intended that it will eventually taper off so that the cost of Medicare Advantage coverage will be equivalent to standard Medicare. changes, affecting the costly half of Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
's
patients with multiple chronic conditions. The act offers
additional benefits for people suffering from chronic diseases
including: diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. ,
Alzheimer's is a dementia which correlates with deposition of amyloid plaques in the neurons. As of 2015 there are 5 million Alzheimer's patients in the USA. It was originally defined as starting in middle age which is rare, so it was a rare dementia. But in 1980s it was redefined as any dementia without another known cause. Early indications include mood and behavioral changes (MBI) and declarative memory and thinking problems (MCI). Specific cells within the hippocampal circuitry and its gateway, the entorhinal cortex, are damaged. The amygdala, cerebelum and other areas supporting implicit memory are not impacted during the early stages of the disease. Grid cell destruction results in a sense of being lost. The default mode network is disrupted. Variants include: late-onset sporadic; with risk factors - ApoE4 for late onset Alzheimer's, presenilin, androgen deprivation therapy (Dec 2015), type 2 diabetes. There are multiple theories of the mechanism of Alzheimer's during aging: Allen Roses argues that it is due to gene alleles that limit the capacity of mitochondria to support neuron operation, Neurons of sporadic Alzheimer's sufferers show greater APP gene diversity due to somatic recombination; It may be initiated by: stress induced HHV-6a, HHV7 herpes activation (Jun 2018) and or an increasingly leaky blood-brain barrier; and a subsequent innate immune response to the infections (May 2016). The Alzheimer's pathway follows: - Plaques form. These are seen in fMRIs 10 to 15 years prior to detecting memory and thinking changes. APP deployed in the cell membrane is cut into three parts. The external part becomes amyloid-beta peptide which aggregates into Amyloid plaques, external to the neurons, if too much is generated or it is not removed fast enough.
- Solanezumab aimed to inhibit plaque formation but clinical trials failed (Nov 2016).
- Encouraging the garbage collection of amyloid and tau with gamma rhythms stimulation retards Alzheimer's in mice studies (Mar 2019)
- BACE inhibitors block an enzyme needed to form amyloid.
- Mutation driven misfolded Tau proteins can form tangles within the cytoplasm of neurons. The Tau tangles kill nerve cells. LMTX is a drug treatment targeted at these tangles.
- The brain becomes inflamed resulting in the killing of many more nerve cells. The hippocampus disintegrates and the brain loses critical functions and memory loss becomes noticeable.
,
Parkinson's corresponds to the breakdown of certain interneurons in the brain. It is not fully understood why this occurs. Dopamine system neuron breakdown generates the classical symptoms of tremors and rigidity. In some instances an uncommon LRRK2 gene mutation confers a high risk of Parkinson's disease. In rare cases Italian and Greek families are impacted in their early forties and fifties resulting from a single letter mutation in alpha-synuclein which alters the alpha-synuclein protein causing degeneration in the substantia nigra, after a build up of Lewy bodies in the neurons. But poisoning from MPTP has also been shown to destroy dopamine system neurons. DeLong showed that MPTP poisoning results in overactivity in the subthalamic nucleus. People who have an appendectomy in their 20s are at lower risk of developing Parkinson's disease. The Alpha-synuclein protein is known to build up in the appendix in association with changes in the gut microbiome. This buildup may support the 'flow' of alpha-synuclein from the gut along neurons that route to the brain. Paraquat has also been linked to Parkinson's disease. Parkinson's disease does not directly kill many sufferers. But it impacts swallowing which encourages development of pneumonia through inhaling or aspirating food. And it undermines balance which can increase the possibility of falls. Dememtia can also develop. Treatment with deep-brain stimulation, after surgical implantation of electrodes in the subthalamic nucleus removes the symptoms of Parkinson's disease in some patients. ,
CHF is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands. There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). Treatments include: digoxin; , rheumatoid
Arthritis is an autoimmune disorder where the immune system attacks the joints and can generate inflammation around the lungs and heart. It can be treated with: Enbrel, Humira, Ilaris, Xeljanz; , and some cancers is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016). .
Combinations of social and medical services are funded.
The act will encourage high tech remote capabilities to be
deployed (Jun
2018)
- The implementation is seen as undermining traditional Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
with part D is a federal program to subsidize the costs of outpatient prescription drugs for Medicare beneficiaries enacted as part of the MMA and delivered entirely by private companies. It is an evolved amplifier with MMA schematic rules ensuring catalytic tax subsidies: reinsurance; flow to a broad group of elderly voters and a small but influential group of payers: UnitedHealth, Humana, CVS Health; while pharmaceutical companies also benefited from increased sales of reimbursed drugs. It includes: - E-prescribing regulations. Health care providers that electronically prescribe Part D drugs for Part D eligible individuals under 42 CFR 423.160(a)(3)(iii) may use HL7 or NCPDP SCRIPT standard to transmit prescriptions & related information internally but must use NCPDP SCRIPT (or other adopted standard) to transmit information to another legal entity.
- Premium subsidy set by a market average. Medicare collects bids from all plans that reflect their costs of providing the minimum required level of drug coverage. It then sets the subsidy at 74.5% of the average bid.
- Premium coverage gap (doughnut hole) between the 74.5% premium subsidy and the catastrophic-coverage threshold. The BBA of 2018 required Part D insurers cover 5% of the beneficiaries coverage gap and drug companies provide discounts that reduce federal spending by a total of $7.7 billion through 2027.
& Medigap is additional private insurance purchased to cover health care costs not covered by Medicare: copayments, deductibles and foreign travel insurance. ,
and generating confusion in the Medicare
Advantage (MA) is a private provider administered health insurance plan providing access to Medicare benefits. It was originally enacted as part of BBA Medicare + Choice or Part C plans. The government funded the plan with an annual fee, based on age and severity of the subscriber's medical conditions, rather than FFS. When a Medicare eligible person enrolls in a MA plan the government pays the private provider a set amount each month. The participant pays the Medicare part B premium and if required a part C premium each month. The MA plans offer a PCP who coordinates care. And the plans have an annual limit on out-of-pocket expenses unlike traditional Medicare. When they obtain treatment they will have to pay a copayment which may be quite high for some specialists. It is the health plan's responsibility to contract the physician network that will provide the care, leaving the risk with the insurer. About 36% of Medicare beneficiaries are enrolled with Medicare Advantage by 2019. The ACA introduced quality outcome and patient satisfaction based differential payments into MA. To measure the performance it added a five-star quality rating scheme. MA plans report their quality and patient satisfaction data to CMS annually and based on the results are awarded one to five stars. The highest rated plans are provided with large additional payments. It was assumed that subscribers would shift to the highest rated plans and the other plans would improve or drop out of MA. And the ACA eliminated subsidies which the federal government used to establish Medicare Advantage. However, the Obama administration has used a $8.5 Billion demonstration project to maintain this funding. It is intended that it will eventually taper off so that the cost of Medicare Advantage coverage will be equivalent to standard Medicare. subscribers (Jul
2018)
- Medicare
Advantage (MA) is a private provider administered health insurance plan providing access to Medicare benefits. It was originally enacted as part of BBA Medicare + Choice or Part C plans. The government funded the plan with an annual fee, based on age and severity of the subscriber's medical conditions, rather than FFS. When a Medicare eligible person enrolls in a MA plan the government pays the private provider a set amount each month. The participant pays the Medicare part B premium and if required a part C premium each month. The MA plans offer a PCP who coordinates care. And the plans have an annual limit on out-of-pocket expenses unlike traditional Medicare. When they obtain treatment they will have to pay a copayment which may be quite high for some specialists. It is the health plan's responsibility to contract the physician network that will provide the care, leaving the risk with the insurer. About 36% of Medicare beneficiaries are enrolled with Medicare Advantage by 2019. The ACA introduced quality outcome and patient satisfaction based differential payments into MA. To measure the performance it added a five-star quality rating scheme. MA plans report their quality and patient satisfaction data to CMS annually and based on the results are awarded one to five stars. The highest rated plans are provided with large additional payments. It was assumed that subscribers would shift to the highest rated plans and the other plans would improve or drop out of MA. And the ACA eliminated subsidies which the federal government used to establish Medicare Advantage. However, the Obama administration has used a $8.5 Billion demonstration project to maintain this funding. It is intended that it will eventually taper off so that the cost of Medicare Advantage coverage will be equivalent to standard Medicare.
plans are being provided with more funds by
Congress, but even 5 star Star ratings are CMS quality ratings of health care domains. They reflect measures of outcomes including intermediate outcomes, patient experience, access and process. Care coordination (assessed by CAHPS survey) and quality improvement measures have been added. Data is sourced from health and drug plans, from CMS contractors, from surveys of enrollees, and from CMS administrative data. They reflect HEDIS data. The ACA established Star Ratings as the basis of QBPs. 5-star health plans benefit from being able to market all year round, and beneficiaries can join at any time via a SEP. Health plans with less than 3-star ratings can be terminated by CMS starting in 2015. Star ratings cover 9 domains: - Ratings of health plans (part C)
- Staying healthy: screening, tests, vaccines
- Managing chronic (long-term) conditions
- Member experience with the health plan
- Member complaints, problems getting services, and improvements in the health plans performance
- Health plan customer service
- Ratings of drug plans (part D)
- Drug plan customer service
- Member complaints, problems getting services, and improvements in the drug plan's performance
- Member experience with the drug plan
- Patient safety and accuracy of drug pricing
plans
are denying valid care, via prior
authorization is a constraint imposed by some insurance companies prior to their agreeing to cover some prescribed medications or medical procedures. The constraint may be due to: age, medical necessity, availability of a generic alternative, or to check drug interactions. After a healthcare provider orders a service for a patient, the provider's staff will contact the patient's insurer to determine if they require prior authorization. This should result in an exception process which may involve the provider's staff manual faxing a prior authorization form to the insurer. If the service is rejected, the healthcare provider may file an appeal based on the provider's medical review process. It may take 30 days for the insurer to approve the request. , and claims by providers and patients, to
improve FFV is fee-for-value payment. It may be a bundled payment for a set of services provided by a group of doctors and facilities, or full capitation. In each case the risk has shifted from the payer to the providers of care. profits,
the HHS is the U.S. Department of Health and Human Services. inspector
general reports. The abuse is widespread and
persistent. AHIP's
Matt Eyles defended the process. Few people appeal but 75%
of those who do succeed (Oct
2018)
- Humana partners
with private
equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors. Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges. Private equity companies were initially corporate raiders.
firms:
TPG, and Welsh,
Carson, Anderson & Stowe; to become the largest player
in hospice has the key goal of helping people with a fatal illness to have the fullest possible life right now. There are major hospice chains focused on providing palliative care. care,
by acquiring a Kindred
Healthcare hospice division and Curo Health
Services. UHG has
already entered & exited the market, in which the government
is enforcing quality measures (Jun
2018)
Driving hospital disintermediation is the shift of operations from one network provider to another lower cost connected network provider. The first network provider leverages the cost benefits of the shift to increase its profitability but becomes disrupted. The lower cost network provider gains revenue flows, expertise and increases its active agents. Over time this disruptive shift will leave the higher cost network as a highly profitable shell, but the agents that performed the operations that migrated to the low cost network will be ejected from the network. For a company that may imply the costs of layoffs. For a state the ejected workers imply increased cost impacts and reduced revenue potential which the state are trading off for improved operating efficiency. :
- Hedge fund is an investment fund that accepts investments from a limited number of accredited individual or institutional investors. Hedge funds are able to use investment methods that are not allowed for other types of fund.
Glenview
Capital sells off Hospital
Corporation of America & Health
Management Associates, but still suffers from investments
in hospitals: Tenet;
that have added debt from acquisitions but lost customers to
outpatient treatment and HDHP is a high-deductible health plan which has lower premiums and a higher deductable than traditional health insurance plan such as a HMO plan or PPO plan.
pressure (Sep
2017)
- Major hospital
systems is the owner of a set of hospitals and other owned infrastructure and employer of direct staff. : Dignity + Catholic
Health Initiatives, Ascension,
Advocate
+ Aurora;
plan mergers; Tenet
& Community
Health sell off poor performing hospitals & shift
further to outpatient services. All are hoping to capture
patient base before new entrents: UnitedHealth,
CVS Health, Amazon; can.
And scale may help with margin & HCIT is health care information technology. The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets. Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.;
costs.
UnitedHealth's Optum
purchases the Advisory
Board. Republican tax law suggests reduced funding
of: ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
, Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
& Medicaid is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; will all
be further impacting revenue to hospitals (Dec
2017)
- NYT/UC
Berkeley study finds prices rise after hospital mergers,
since these: reduce competition, raise price of admission,
undermine quality; with major groups: Baylor
Scott, CHI
Franciscan Health, Dignity, Hartford,
Memorial
Hermann, Phoebe
Putney Health System, Sutter Health,
West
Virginia University Medicine, Yale
New Haven Health; integrating other hospitals and
especially physician groups (Nov
2018)
- UnitedHealth
purchases standalone
surgery center Surgical
Care Affiliates for Optum's OptumCare (Jan
2017)
- Amazon, Berkshire
Hathaway, JPMorgan
Chase partnership aims to disrupt
health care; leveraging their combined consumer choice &
health insurance knowledge to enable technology to simplify
care. (Jan
2018)
- Comcast
keeps health care costs to 1% growth (instead of 3% average of
large employers) with an innovative go it alone approach to
health benefits, helped by Venrock and Comcast
ventures portfolio companies: Accolade health
benefit navigators, Grand Rounds
for second opinions, Doctors On
Demand for tele-health is the use of remote health care. It includes telepharmacy and clinical telehealth for stroke and psychiatry. It also includes sessions between primary care providers and patients and assisted caregiving such as medication reminders and DME usage monitors.
,
Brightside,
which helps employees manage their finances, is a startup which
Comcast Ventures created; for its 225,000 employees - although
many of its workers are contractors. NBGH
vets the startups for its members. Some large companies
cover the costs of health care for their employees, but most use
insurers to do paperwork, and contract with hospitals and
doctors. It can be hard for the partners to get data from
the insurers. Fidelity
Investments is large enough to make insurers
cooperate. Companies and employees are unhappy with the
regular service (Sep
2018)
- RWJ
funded RAND study, of 1,598 hospital treatment's insurance
claims, shows Parkwiew
Health, in Indiana, charges private
insurers 4 * its Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
prices. States paying the most are: Indiana, Wyoming,
Maine, Wisconsin, Montana, Colorado, Texas, Georgia, Ohio,
Washington; on average hospitals charge 2.4 * Medicare prices to
private health insurance patients. Outpatient care was 3 *
Medicare pricing; angering employers. Employers
say they must exert discipline on health care costs: will gather
data on prices and quality to decide on the best strategy: single-payer is a healthcare architecture in which there is a single financing organization. Significant aspects of single-payer include: - Strengths of single-payer:
- Removes the extensive replication of payer organizations and their different interfaces to the other healthcare entities and subscribers.
- One payment organization, removing the need to allow subscribers the yearly choice to change payer, encouraging payers to help subscribers remain healthy
- Single-payer instantiates a political monopoly on health insurance.
- Problematic implementation of single-payer in the US
- Undermines the alignment of the healthcare network, threatening profits, power structures and financial rewards. This limits the possibility of single-payer in the US: Lobbying juggernaut: Politicians, Providers, Doctors, Insurers; leveraging dislike of tax increases, The 9 out of 10 Americans who are employed or retired are satisfied with their situation, Current insurance costs are hidden from the insured: in lowered pay packages, spread over all tax payers reducing government revenues; Current private insurers would be forced to reduce costs;
- Alters one sixth of the US economy: Commercial health insurance replaced, investors impacted by transformation of business models; a huge change of high uncertainty, something evolution works to avoid by including mechanisms to force small incremental changes.
- A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations. Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016).
,
focus on best value hospitals; Insurers are not incented
to keep prices down when working for self-insured companies -
where insurers are spending the companies money and make more
revenue when the company spends more. Anthem
claims narrow
networks - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans. This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans. By limiting the number of providers/doctors offered in the plans the few that are included should get more business. Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers). In large cities narrow networks are even more common. Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills. There are problems induced by narrow network constraints: - Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts. Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running. If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016).
of hospitals is its direction to drive down
prices. One-third of all healthcare spending goes to
hospital care. Hospitals are buying physician practices is physician practice management. This consolidation of PCP practices was partly a response to Wall Street's capitalization of HMOs and hospitals in early 1990s. As Wall Street switched to financing PPMs, enabling Medpartners's purchase of Mullikin Inc., hospitals responded by buying up the PPMs. Most PPMs struggled to control costs in the capitated care framework of the 1990s. Some of these PPMs shifted to become PBMs. and
spending on new facilities. Hospitals (AHA is the American_hospital association. ) argue they lose
money on Medicare and Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. , so the
comparison is biased (May
2019)
Customer
segmentation analysis
Hospital agency can only be understood when viewed in terms of the political
constraints on cost growth, generation of jobs, reimbursement is the payment process for much of US health care. Reimbursement is the centralizing mechanism in the US Health care network. It associates reward flows with central planning requirements such as HITECH. Different payment methods apportion risk differently between the payer and the provider. The payment methods include: - Fee-for-service,
- Per Diem,
- Episode of Care Payment,
- Multi-provider bundled EPC,
- Condition-specific capitation,
- Full capitation.
and
pricing forces that dominate US health care.
The dramatic pressures on health care providers are altering how
they are structured and make money.
The current US is the United States of America. health care
network is costly
and underperforming.
Providers are being pressured
by political actions to reduce medically driven unsustainable growth
in the national debt, to move away from
their low risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment. 'shop' business model. They
can restructure from a focus on acute care hospital
transactional services to leverage bundled payments is where the purchaser disburses a single predefined payment to cover certain combinations of hospital, physician, post-acute, or other services performed during an episode of care relating to a particular condition (unlike capitation). This bundling is assumed (Sep 2018) to allow the value delivery system to optimize around low cost high quality long term health care. With one bundled payment physicians & hospitals must coordinate care and reduce the unit costs to remain profitable. And to avoid taking on risk of expensive complications physicians & hospitals are incented to standardize and focus on quality. This optimization is dependent on quantifying the value of the outcome of the episode of care. Previously FFS payments induced excessive treatment activity. Bundled payment is included in CMS ACE demonstrations and BPCI initiatives. There are significant impacts on IT. - It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.
- Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments.
- Care delivery must be re-architected to reduce costs and improve quality.
- Monitoring sensors can be used to feed reports to ensure re-architected operations conform.
,
or by tightly integrating with a PAC is a Post-Acute Care provider. A three-day hospital admission and discharge are prerequisite requirements to receiving Medicare PAC services. Acute care hospitals become portals to the PAC business. Referrals are key. PAC includes different types of facility focused on different severity of illness (high to low): - Long term care Hospital (LTCH),
- Inpatient rehabilitation facility (IRF),
- Skilled nursing facility (SNF),
- Home health agency (HHA) - most acute care hospitals and EMR providers have strategies for integration with home based care,
- Outpatient rehabilitation. SNF and HHA represent 80% of discharges and expenditures. Assisted living is not part of federal Medicaid, but states often include it through a waiver.
network, or as
a PCMH is patient centered medical homes:
- Describes a reorganization of the health care delivery
system to focus on the patient and care giver supported by
EHR infrastructure and some form of
process management
which will be necessary to coordinate interventions by
each of the functional entities resources to treat
the patients specific problems. The
disadvantage of a PCMH is the administrative and
technology cost needed to support its complex
processes. The PCMH
- Was promoted as a way to incent more PCP
which had been seen as a low reward role by medical
students. HCI3 argues
this use of PCMH is flawed. PCMH is driven by
the medical home models
of the ACA. In this model the
PCMH is accountable for meeting the vast majority of each
patients physical and mental health care needs including
prevention and wellness, acute
care, and chronic care. It is focused on treating
the whole person. It is tasked with coordinating the
care across all elements of the health care system,
including transitions and building clear and open
communications. It must ensure extended access and
availability of its services and patients preferences
about access. It must continuously improve quality
by monitoring evidence-based medicine
and clinical decision support tools (NCQA).
Many argue that to be effective it must be connected to a
'medical neighborhood'.
The PCMH brings together the specialized resources and
infrastructure required to develop and iteratively
maintain the care plans and
population oriented system descriptions that are central
to ACA care coordination.
or an ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. - CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
. The increased
clinical and financial risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. /uncertainty is when a factor is hard to measure because it is dependent on many interconnected agents and may be affected by infrastructure and evolved amplifiers. This is different from risk, although the two are deliberately conflated by ERISA. Keynes argued that most aspects of the future are uncertain, at best represented by ordinal probabilities, and often only by capricious hope for future innovation, fear inducing expectations of limited confidence, which evolutionary psychology implies is based on the demands of our hunter gatherer past. Deacon notes reduced uncertainty equates to information. taken
on in this series of organizations must be managed. In the
limit we reach the total capitation is a global payment for all care for a patient during a specified time period. It forces the provider of care to take a high risk. Managing the risk implies successful population health management. (with an
alternative
quality contract (AQC) is: - A 2009 payment arrangement developed by Blue Cross Blue Shield of Massachusetts. It was developed to support change. It differs from capitation in including upside measures for patient safety, appropriateness of care and patient satisfaction. Its key components are:
- Integration across the care continuum
- Accountability for performance measures for ambulatory and inpatient care. Includes a 10% incentive for performing.
- Performance measures are selected that are: Nationally accepted, Vary across providers, Include sufficient data on provider being measured, measured at the level that can influence the outcome.
- Global payment for all medical services with health status adjustment and with margin retention.
- Five year contract to create a sustained partnership
) blended integrated
health systems. The progress of the Vivity joint venture will
demonstrate the opportunity and threat.
- Startup Aledade
demonstrates a way to integrate the PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
with the health
care network and lower costs (Aug
2017)
- Intelligence Squared U.S. Debate: Is the U.S. is the United States of America. Health care system
terminally broken? with Shannon
Brownlee, Ezekiel
Emanuel, Robert Pearl, David
Feinberg (Oct
2017)
- Trump administration, like Obama administration before it
& MedPac is the Medicare Payment Advisory Commission. It was established by the BBA. The mandate is to advise the U.S. Congress on payments to private health plans participating in Medicare and health providers with Medicare beneficiaries. It produces two major reports each year for Congress. ,
propose removing the Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
reimbursement is the payment process for much of US health care. Reimbursement is the centralizing mechanism in the US Health care network. It associates reward flows with central planning requirements such as HITECH. Different payment methods apportion risk differently between the payer and the provider. The payment methods include: - Fee-for-service,
- Per Diem,
- Episode of Care Payment,
- Multi-provider bundled EPC,
- Condition-specific capitation,
- Full capitation.
uplift for hospital based physicians (Mar
2019)
The risk is heightened by the continuing increase in chronic
illnesses with more than three interacting problems, described
by Lehigh
Valley health. This growth in chronic problems could
overwhelm the available number of bed and nurses and require
particularly sophisticated treatment management to cope with the
additional complexity. Many hospitals are exploring how to
counteract this trend in their patient base by improving
wellness as described by Cleveland Clinic's
CEO Toby Cosgrove.
Analysis of CAS
by Dorner
indicates complex problems require time to
observe and accurately model. While individual doctors
might agree: Laguna
Honda's Dr. Sweet;
the trend is to reduce the time spent with each patient and to
respond quickly.
Health care is a major component of the states' local job
strategy.
The merging
of payers is likely to increase the pressure for health care
providers to consolidate.
Network effects are exacerbated by the
development of narrow
networks - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans. This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans. By limiting the number of providers/doctors offered in the plans the few that are included should get more business. Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers). In large cities narrow networks are even more common. Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills. There are problems induced by narrow network constraints: - Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts. Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running. If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016).
.
The low cost of capital, from 2008 to 2016, makes acquisition a
highly attractive strategy to do any consolidation.
- NYT/UC
Berkeley study finds prices rise after hospital mergers,
since these: reduce competition, raise price of admission,
undermine quality; with major groups: Baylor
Scott, CHI
Franciscan Health, Dignity, Hartford,
Memorial
Hermann, Phoebe
Putney Health System, Sutter Health,
West
Virginia University Medicine, Yale
New Haven Health; integrating other hospitals and
especially physician groups (Nov
2018)
The bundled payments restructuring allows hospitals to separate
their 'diagnosis' oriented solution shop and value-added repair
based businesses. Cleveland clinic's
Cosgrove envisions
increased leverage of transportation to deliver patients to the
appropriate optimized hub for treatment. Interstate
licensing may facilitate this vision.
A core interest of the hospital group in extending back to 'employ
or link in' the PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. and
similarly out to the specialists is to capture patient referrals
while limiting financial
risk is composed of different aspects of the hospital systems overall risk. It includes: - Contractuals
- Patient accounting and collections
- Risk based reimbursement
.
Disruption is an increasing threat for
full service hospitals. Lower cost business models: Urgent care
centers is an efficient and less costly 'alternative' to the ER. There is no accepted standard. Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls. Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones. Unlike an ER they can not admit patients to a hospital. Some also offer services like pre-employment drug screening and summer camp physicals. , Standalone
surgery centers; are capturing business and investment.
Christensen
argues that
each business model can only be optimized once they are separated.
He sees diseases as typically intersecting more than one 'system'
within the body. Typical hospital organizations encourage
specialists to focus on one of the 'systems' and deal with both
diagnosis and treatment. But studying the disease from the
perspective of only one of those systems, therefore, can't develop
an integrated solution consonant with the integrated nature of the
disease. Christensen notes that Texas Heart
Institute, Cleveland
Clinic Institutes,
and Mayo
Clinic have separated out solution shops. For the
un-optimized hospitals Christensen argues they will find wrong
prescription drugs and devices that were the result of inaccurate,
incomplete diagnoses by a stream of individually operating
specialists. Steele &
Feinberg agree
with this assessment. 24 by 7 Branded Urgent Care (1,
2)
may ramp the disruption. CVS
and Wal-Mart intend
to enter the health care provider market offering
low cost alternatives to traditional
PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. etc. Personal
experience suggests that the situation is even worse than
Christensen describes:
- Specialists who aim to treat the whole problem, such as Dr. Jocelyn Dunn
who treats breasts, and are successful are in high demand seem
tied into only the hospital surgical and inpatient
infrastructure, since they gain little benefit from doing much
more. But they must still reflect their services in the
current reimbursement is the payment process for much of US health care. Reimbursement is the centralizing mechanism in the US Health care network. It associates reward flows with central planning requirements such as HITECH. Different payment methods apportion risk differently between the payer and the provider. The payment methods include:
- Fee-for-service,
- Per Diem,
- Episode of Care Payment,
- Multi-provider bundled EPC,
- Condition-specific capitation,
- Full capitation.
system. And providers wrap services around these 'whole
problem' strategies with cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016). specialists,
cosmetic surgeons, etc. for breast cancer is a variety of different cancerous conditions of the breast tissue. World wide it is the leading type of cancer in women and is 100 times more common in women than men. 260,000 new cases of breast cancer will occur in the US in 2018 causing 41,000 deaths. The varieties include: Hormone sensitive tumors that test negative for her2 (the most common type affecting three quarters of breast cancers in the US, BRCA1/2 positive, ductal carcinomas including DCIS, lobular carcinomas including LCIS. Receptor presence on the cancer cells is used as a classification: Her2+/-, estrogen (ER)+/-, progesterone (PR)+/-. Metastasis classes the cancer as stage 4. Genetic risk factors include: BRCA, p53, PTEN, STK11, CHEK2, ATM, GATA3, BRIP1 and PALB2. Treatments include: Tamoxifen, Raloxifene; where worrying racial disparities have been found (Dec 2013). International studies indicate early stage breast cancer typed by a genomic test: Oncotype DX, MammaPrint; can be treated without chemotherapy (Aug 2016, Jun 2018).
Eventually the 'whole problem' doctor moves on to other acute
patients and the focus of the center for the current patient
shifts further into the mixed hospital business model.
- Pharmaceutical treatments are not highly targeted and so start
affecting other aspects of the body, which have not been a focus
of even the 'whole problem' specialists.
In line with Christensen skilled
nursing facilities can
be seen to be seperating into short stay rehab facilities and long
term stay facilities.
But the U.S. government and U.S. health care have been part of a
single complex adaptive system (CAS)
for many years and the recent legislation
has solidified this integration. The core schematic
structures that shape the health care network are medical
school education, US federal and
state laws. The health care providers are phenotypic
instances of these schematic structures and the HIE a Health Information Exchange is responsible for the transmission of health care-related data among facilities, health information organizations and government agencies according to national standards. They are designed to address legal, organizational and technical challenges that would otherwise impede the sustainability of health information interchange. An HIE is a component of the HIT. It must enable reliable and secure transfer of data among diverse systems and facilitate access and retrieval. The two main types are private and public exchanges. Private exchanges may be able to leverage homogeneous IT infrastructure to facilitate data sharing. Public exchanges are likely to be heterogeneous. RHIO provide the regional organizations to support such HIE. They are there to ensure that infrastructure amplification initiates. The government will ensure that low healthcare density areas are served by public HIE infrastructure. Both centralized and federated technical solutions were initially considered for implementation by the RHIOs for deploying HIE as specified in the Markle Foundation's NHIN common framework. Common framework clients such as appropriately architected HIE use SOAP messaging to interact with their local SNO's ISB and RLS. The HIE SOAP query transactions follow the HL7 Query Model. Alternatively some HIE's are now using direct messaging to support interoperation. HIE deployment goals have been phased (1 - supporting care transitions, 2 - Quality and care management, 3 - Population health). Some HIEs will support "EHR-lite" as part of their functionality. HIE does not yet solve some difficult challenges: - Safeguarding the security of health information. Currently HIEs conforming to the common framework only provide locations of clinical data held remotely.
- Providing effective life cycle management. The HIE is dependent on the local set of entities to provide updates that match the current state of the entity data.
, and interfaces,
provide them with controlled ways to expose some state, and present
signals, is an emergent capability which is used by cooperating agents to support coordination & rival agents to support control and dominance. In eukaryotic cells signalling is used extensively. A signal interacts with the exposed region of a receptor molecule inducing it to change shape to an activated form. Chains of enzymes interact with the activated receptor relaying, amplifying and responding to the signal to change the state of the cell. Many of the signalling pathways pass through the nuclear membrane and interact with the DNA to change its state. Enzymes sensitive to the changes induced in the DNA then start to operate generating actions including sending further signals. Cell signalling is reviewed by Helmreich. Signalling is a fundamental aspect of CAS theory and is discussed from the abstract CAS perspective in signals and sensors. In AWF the eukaryotic signalling architecture has been abstracted in a codelet based implementation. To be credible signals must be hard to fake. To be effective they must be easily detected by the target recipient. To be efficient they are low cost to produce and destroy. for
interactions with other CAS agents.
Fraud and billing errors are monitored within CMS is the centers for Medicare and Medicaid services. . Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
's CPIC
investigates fraud. RAC is recovery audit contractor program created by the MMA of 2003. It is intended to identify and recover invalid FFS Medicare claims payments.
recovery from billing errors is a significant issue to Hispitals in
2014.
Hospitals can use their platform is agent generated infrastructure that supports emergence of an entity through: leverage of an abundant energy source, reusable resources; attracting a phenotypically aligned network of agents.
structure, position and power within this unusual network to their
benefit. For example the regulatory effects, increasing costs
of drugs and hospitals scale and scope have driven independent
oncologists to affiliate with them.
- RWJ
funded RAND study, of 1,598 hospital treatment's insurance
claims, shows Parkwiew
Health, in Indiana, charges private
insurers 4 * its Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
prices. States paying the most are: Indiana, Wyoming,
Maine, Wisconsin, Montana, Colorado, Texas, Georgia, Ohio,
Washington; on average hospitals charge 2.4 * Medicare prices to
private health insurance patients. Outpatient care was 3 *
Medicare pricing; angering employers. Employers
say they must exert discipline on health care costs: will gather
data on prices and quality to decide on the best strategy: single-payer is a healthcare architecture in which there is a single financing organization. Significant aspects of single-payer include: - Strengths of single-payer:
- Removes the extensive replication of payer organizations and their different interfaces to the other healthcare entities and subscribers.
- One payment organization, removing the need to allow subscribers the yearly choice to change payer, encouraging payers to help subscribers remain healthy
- Single-payer instantiates a political monopoly on health insurance.
- Problematic implementation of single-payer in the US
- Undermines the alignment of the healthcare network, threatening profits, power structures and financial rewards. This limits the possibility of single-payer in the US: Lobbying juggernaut: Politicians, Providers, Doctors, Insurers; leveraging dislike of tax increases, The 9 out of 10 Americans who are employed or retired are satisfied with their situation, Current insurance costs are hidden from the insured: in lowered pay packages, spread over all tax payers reducing government revenues; Current private insurers would be forced to reduce costs;
- Alters one sixth of the US economy: Commercial health insurance replaced, investors impacted by transformation of business models; a huge change of high uncertainty, something evolution works to avoid by including mechanisms to force small incremental changes.
- A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations. Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016).
,
focus on best value hospitals; Insurers are not incented
to keep prices down when working for self-insured companies -
where insurers are spending the companies money and make more
revenue when the company spends more. Anthem
claims narrow
networks - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans. This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans. By limiting the number of providers/doctors offered in the plans the few that are included should get more business. Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers). In large cities narrow networks are even more common. Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills. There are problems induced by narrow network constraints: - Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts. Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running. If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016).
of hospitals is its direction to drive down
prices. One-third of all healthcare spending goes to
hospital care. Hospitals are buying physician practices is physician practice management. This consolidation of PCP practices was partly a response to Wall Street's capitalization of HMOs and hospitals in early 1990s. As Wall Street switched to financing PPMs, enabling Medpartners's purchase of Mullikin Inc., hospitals responded by buying up the PPMs. Most PPMs struggled to control costs in the capitated care framework of the 1990s. Some of these PPMs shifted to become PBMs. and
spending on new facilities. Hospitals (AHA is the American_hospital association. ) argue they lose
money on Medicare and Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. , so the
comparison is biased (May
2019)
Patient centered
hospitals
What makes a hospital experience great? The factors include:
- Pricing of care does not lead to financial ruin.
- Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
340B requires pharmaceutical manufacturers to provide outpatient drugs at significant price discounts to eligible health care providers and other covered entities. 340B was legislated by Congress as a section of the PHSA, as a strategy to drive federal resources to more eligible patients and to provide more comprehensive services. The eligible set of hospitals was expanded by the ACA. It is not clear that all eligible hospitals have used the discounts to extend and improve services to the poor (Aug 2018).
payments to hospitals to be reduced significantly, notes VA
Boston Health Care's Austin
Frakt. Seems clear that after the program expanded,
hospitals are misusing the discount drug margin, which was ment
to fund more services for the poor. Hospital lobbyists are
fighting the reduction in court, while pharmaceutical companies
are pushing for the reductions (Aug
2018)
- People
oriented approach - Auxiliary etc.
- Children oriented hospital services available.
- Approach to the elderly designed to minimize stress is a multi-faceted condition reflecting high cortisol levels. Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight. As these actions occur the levels of cortisol return to the baseline rate. A stressor is anything that disrupts the regular homeostatic balance. The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis.
- The short term response to the stressor
- activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response. The brain's acuity and cognition are stimulated. The immune system is stimulated with beta-endorphin and repair activities curtail. In order for the body to destroy bacteria in wounds, pro-inflammatory cytokines increase blood flow to the area. The induced inflammation signals the brain to activate the insula and through it the ACC. But when the stressor is
- long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues. Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in. Sustained stress provides an evolved amplifier of a position of dominance and status. It is a strategy in female aggression used to limit reproductive competition. Sustained stress:
- Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment!
- Activates the integration between the thalamus and amygdala.
- Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful.
- BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning.
- Makes it easier to learn a fear association and to consolidate it into long-term memory. Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala. And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces. Accuracy of assessing emotions from faces suffers. A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand. The activation of the amygdala seems to determine how the hippocampus responds.
- Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression.
- Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive. It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.
- Increases the risk of autoimmune disease (Jan 2017)
- During depression, stress inhibits dopamine signalling.
- Strategies for stress reduction include: Mindfulness.
:
- Impacts of hospital stays on the elderly: disrupted sleep facilitates salient memory formation and removal of non-salient memories. The five different stages of the nightly sleep cycles support different aspects of memory formation. The sleep stages follow Pre-sleep and include: Stage one characterized by light sleep and lasting 10 minutes, Stage two where theta waves and sleep spindles occur, Stage three and Stage four together represent deep slow-wave sleep (SWS) with delta waves, Stage five is REM sleep; sleep cycles last between 90-110 minutes each and as the night progresses SWS times reduce and REM times increase. Sleep includes the operation of synapse synthesis and maintenance through DNA based activity including membrane trafficking, synaptic vesicle recycling, myelin structural protein formation and cholesterol and protein synthesis. Sleep also controls inflammation (Jan 2019) Sleep deprivation undermines the thalamus & nucleus accumbens management of pain.
, unappetizing
meal impacts, reduced muscle mass, poor balance, additional
medicine complications, delirium, pain emerged as a mental experience, Damasio asserts, constructed by the mind using mapping structures and events provided by nervous systems. But feeling pain is supported by older biological functions that support homeostasis. These capabilities reflect the organism's underlying emotive processes that respond to wounds: antibacterial and analgesic chemical deployment, flinching and evading actions; that occur in organisms without nervous systems. Later in evolution, after organisms with nervous systems were able to map non-neural events, the components of this complex response were 'imageable'. Today, a wound induced by an internal disease is reported by old, unmyelinated C nerve fibers. A wound created by an external cut is signalled by evolutionarily recent myelinated fibers that result in a sharp well-localized report, that initially flows to the dorsal root ganglia, then to the spinal cord, where the signals are mixed within the dorsal and ventral horns, and then are transmitted to the brain stem nuclei, thalamus and cerebral cortex. The pain of a cut is located, but it is also felt through an emotive response that stops us in our tracks. Pain amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so. Fear of pain is a significant contributor to female anxiety. Pain is the main reason people visit the ED in the US. Pain is mediated by the thalamus and nucleus accumbens, unless undermined by sleep deprivation. , internal
bleeding, anemia is a decrease in the number of red blood cells or the amount of hemoglobin in the blood. There are various types: Fanconia anemia, Iron-deficiency anemia, Pernicious anemia, Sickle-cell anemia; ,
ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). crowding/chaos
induced PTSD is post-traumatic stress disorder, an induced level of stress that is so troubling to the brain that it avoids processing it, change that is necessary if the stress is to be dissipated by the normal brain processes. The hippocampus loses volume. The damage to the hippocampus results in: flashbacks, becoming emotionally numb and withdrawn from other people, irritability, jumpiness, being more aggressive, having trouble sleeping and avoidance of the sensory experiences associated with the initial event. The amygdala responds to overwhelming trauma by repeatedly grabbing attention to encourage response to the emergency, increases in volume and is hyperactive and anxious. As a result it remains in a heightened state, resulting in fear of recall and further stress. PTSD is often accompanied by depression and substance abuse. It is now being realized that PTSD can be introduced into patients by traumatic treatment regimens such as ICU procedures. Traumatic head injuries, seen in athletes and soldiers can be reflected in PTSD and can subsequently become associated with prion based dementia. Some people are genetically predisposed to PTSD, with identical twins responding similarly. Another risk factor for PTSD is childhood trauma which can induce epi-genetic changes to stress processing. PTSD can be managed with CBT, and it also responds to propranolol while recalling the traumatic event, where the drug undermines the memory reconsolidation process. , forced
to walk in hospital gowns; results in post-hospital syndrome,
after discharge - have costly handoff problems reviewed by project BOOST. When discharge takes too long it ties up acute bed space which can result in adding up to 30% more (unnecessary) capacity when improved discharge would translate into additional revenue. Various interventions aim to improve the execution of the process including: CTI, TCN and RED for discharge to outpatient; InterAct for discharge to SNFs and BPIP to HHAs. Discharge information can include: - Patient info
- Behavioral summary
- Treatment history
- Medical history
- Treatment objectives
- Insurance policy
- Discharge plans
,
Yale's
Harlam Krumholz concluded, based on readmission have become a source of increased revenue for hospitals. But with government interested in reducing the US health care cost curve ACA's HRRP (pay-for-performance), BPCI and CTI and Interact discharge initiative have all increased the focus on unnecessary readmissions. Now the end-to-end process is under scrutiny with hospitals reengineering discharge (RED) and PAC providers using RAI and TCN.
being for unrelated problems to the initial cause of
hospitalization (Aug
2018)
- Hospital is the care infrastructure for expert surgeons and
physicians. To ensure quality and patient convenience, a lean production is the application of the Toyota quality improvement process. This focuses on:
- Removing the seven critical wastes:
- Excessive motion
- Waiting time
- Over production
- Unnecessary processing time
- Defects
- Excessive resources
- Unnecessary/ineffective handoffs
- The result should be improved processes and outcomes, reduced cost and increasing patient and staff satisfaction.
- It is typical to use metric collection and analysis to understand where the issues are and if they are being corrected.
architecture should be used: Geisinger;
to overcome problems described by Glenn
Steele, David Feinberg & Robert
Pearl. The mass production value delivery system is
prioritized to ensure timely access to limited resources for
critical care (Heart
attacks is an AMI. It can induce cardiac arrest. Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI. Risk factors include: taking NSAID pain killers (May 2017). There is uncertainty about why AMI occur. Alternative hypotheses include: - Plaques started to gather in the coronary arteries and grew until no blood flow was possible. If this is true it makes sense to preventatively treat the buildup with angioplasty.
- Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot. If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors.
Jul
2015, Stroke is when brain cells are deprived of oxygen and begin to die. 750,000 patients a year suffer strokes in the US. 85% of those strokes are caused by clots. There are two structural types: Ischemic and hemorrhagic. Thrombectomy has been found to be a highly effective treatment for some stroke situations (Jan 2018). s
Jun
2015). It induces prophylactic over investment in
high demand resources.
- Surgeons perform enough of the required procedure to be an
artist. But some must end up being the vehicle of
trainees' skill development?
- Time of day, month during the year, and type of hospital,
affect the uncertainty is when a factor is hard to measure because it is dependent on many interconnected agents and may be affected by infrastructure and evolved amplifiers. This is different from risk, although the two are deliberately conflated by ERISA. Keynes argued that most aspects of the future are uncertain, at best represented by ordinal probabilities, and often only by capricious hope for future innovation, fear inducing expectations of limited confidence, which evolutionary psychology implies is based on the demands of our hunter gatherer past. Deacon notes reduced uncertainty equates to information.
of complications from giving birth. 12,000 of two million
births included: severe perineal laceration, ruptured uterus,
unplanned hysterectomy, admission to ICU is intensive care unit. It is now being realized that the procedures and environment of the ICU is highly stressful for the patients. In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD. Intubation and catheterization are also traumatic. Sometimes seperated into MICU and SICU. eICU skill centralization may bring down costs. , unplanned
follow-on operation; with night shift risk 21% higher, weekends
9% higher, holidays 29% higher. Teaching hospitals is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017); , at
the start of new residencies, are 28% higher - with risk droping
to normal by June. All these factors increase the costs of
a hospital birth (Mar
2019)
- Hospital provides access to matched
organs.
- Hospital architecture is matched to patient and treatment
trends: Designed to help
healing, support medical processes (2)
and for bigger people (Aug
2015).
- Most rooms are single occupancy
- All rooms are wifi networked allowing effective monitoring
of patients vital information from any room.
- Hospital provides access to leading edge treatments and trials
where appropriate.
- Avoid the typical lag between best practice guidelines and
median treatment approach: Statins,
Ovarian
cancer;
- Helipad links available at primary nodes to support rural
needs
- Local community & physical resources of the neighborhood
attract vibrant group of resident skilled doctors.
- Hospital clinicians treat the whole patient relating complex
interactions of acute and chronic problems and treatment
regimens to quality of life and implications of strategic
decisions. Approaches that leverage the patient's problems
to focus their inner resources to undermine stress is a multi-faceted condition reflecting high cortisol levels. Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight. As these actions occur the levels of cortisol return to the baseline rate. A stressor is anything that disrupts the regular homeostatic balance. The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis.
- The short term response to the stressor
- activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response. The brain's acuity and cognition are stimulated. The immune system is stimulated with beta-endorphin and repair activities curtail. In order for the body to destroy bacteria in wounds, pro-inflammatory cytokines increase blood flow to the area. The induced inflammation signals the brain to activate the insula and through it the ACC. But when the stressor is
- long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues. Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in. Sustained stress provides an evolved amplifier of a position of dominance and status. It is a strategy in female aggression used to limit reproductive competition. Sustained stress:
- Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment!
- Activates the integration between the thalamus and amygdala.
- Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful.
- BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning.
- Makes it easier to learn a fear association and to consolidate it into long-term memory. Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala. And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces. Accuracy of assessing emotions from faces suffers. A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand. The activation of the amygdala seems to determine how the hippocampus responds.
- Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression.
- Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive. It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.
- Increases the risk of autoimmune disease (Jan 2017)
- During depression, stress inhibits dopamine signalling.
- Strategies for stress reduction include: Mindfulness.
, such as MBSR is mindfulness-based stress reduction. Jon Kabat-Zinn developed the stress reduction clinic where techniques are taught to develop mindfulness and integrate it and a personal vision of success into every day experience. In Kabat-Zinn's book Full Catastrophe Living a model of stress is described that allows stressful events to be coped with effectively. Strategies are described for a wide variety of specific situations including medical symptoms, physical and emotional pain, anxiety and panic, time pressures, relationships, work, food, and external events. developed at UMASS
medical center's CFM,
are developing but still limited. End of life treatment and palliative care aims to relieve and prevent the suffering (symptoms, pain and stress of serious illness) of patients what ever their prognosis.
balance effective (Fix heart
failure issues)
- Hospital minimizes potential for infections: Hand washing (North
Shore), Checklists are signals which remind the reader of highly significant aspects of a process. They are designed to be consulted at a point in the process where forgetting about the aspect will have a significantly detrimental effect. Often the processes are being used to respond to failures in the regular operation. Atul Gawande argues that effective use of checklists is vital to coping with situations that are complex.
(Johns
Hopkins), Minimal use of Swan-Ganz
lines is the deployment of a catheter into the right side of the heart and the arteries leading to the lungs so as to monitor the heart's function and blood flow. (El
Camino), Copper equipment (Oct
2016);
- Hospital does not abandon patients with medical error induced
complications.
- Nursing has the capacity to cope with significant number of
emergencies and still accurately perform required checks and
treatment applications.
- Doctors provide kin with likely implication analysis.
- Visitor car parks are free and of sufficient capacity.
Just because there is one connected network does not limit the types
of agents that operate the network. Indeed the wide variety of
environments across different states and rich and sparse regions
allows different forms of agent to compete effectively. But
some trends like people getting larger has resulted in a general
need for flexible rooms that accomodate all sizes (Aug
2015).
Some providers, notably Geisinger,
have been exploring
their CAS structure. Geisinger
used a Boem quality process to introduce
and leverage schematic
structure allowing them to increase the robustness of clinical
processes. Geisinger are now using extended
phenotypic alignment through their PNH (PCMH is patient centered medical homes:
- Describes a reorganization of the health care delivery
system to focus on the patient and care giver supported by
EHR infrastructure and some form of
process management
which will be necessary to coordinate interventions by
each of the functional entities resources to treat
the patients specific problems. The
disadvantage of a PCMH is the administrative and
technology cost needed to support its complex
processes. The PCMH
- Was promoted as a way to incent more PCP
which had been seen as a low reward role by medical
students. HCI3 argues
this use of PCMH is flawed. PCMH is driven by
the medical home models
of the ACA. In this model the
PCMH is accountable for meeting the vast majority of each
patients physical and mental health care needs including
prevention and wellness, acute
care, and chronic care. It is focused on treating
the whole person. It is tasked with coordinating the
care across all elements of the health care system,
including transitions and building clear and open
communications. It must ensure extended access and
availability of its services and patients preferences
about access. It must continuously improve quality
by monitoring evidence-based medicine
and clinical decision support tools (NCQA).
Many argue that to be effective it must be connected to a
'medical neighborhood'.
The PCMH brings together the specialized resources and
infrastructure required to develop and iteratively
maintain the care plans and
population oriented system descriptions that are central
to ACA care coordination.
) and xG
strategies to transform PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. s.
It does not seem too much of a stretch to expect them to support
their Pennsylvania geographic
cluster's revenue base developments and public health is the proactive planning, coordination and execution of strategies to improve and safeguard the wellbeing of the public. Its global situation is discussed in The Great Escape by Deaton. Public health in the US is coordinated by the PHS federally but is mainly executed at the state and local levels. Public health includes: - Awareness campaigns about health threatening activities including: Smoking, Over-eating, Alcohol consumption, Contamination with poisons: lead; Joint damage from over-exercise;
- Research, monitoring and control of: disease agents, reservoir and amplifier hosts, spillover and other processes, and vectors; by agencies including the CDC.
- Monitoring of the public's health by institutes including the NIH. This includes screening for cancer & heart disease.
- Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.
- Development, deployment and maintenance of vaccination strategies.
- Development, deployment and maintenance of fluoridation.
- Development, deployment and maintenance of family planning services.
- Regulation and constraint of foods, drugs and devices by agencies including the FDA.
activities. Currently their population base is older, poorer,
sicker, more rural, and less transient than the national
median. Geisinger's integrated
approach does not seem to be affecting that according to the Clayton
Christensen Institute. As of 2013 Philadelphia's
economic troubles are impacting its school system. In
comparison Stanford
Hospital clearly benefits from feedback such as environmental
enhancements created by the radio cluster build out of Stanford
University (Medical
Center), Silicon Valley and biotech.
Internally the representation of EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
and other state within
proprietary data base applications constrains the ability of the
health care network to instantiate new phenotypic combinations since
some of the agents have incompatible infrastructure. If such
constraints become significant to the legislators and regulators
they can adjust the schemata, or introduce constraints and flows to
encourage the standardization of these representations. But
that is not a current focus of government.
Externally the effective interaction of agents that make up the extended
phenotypic network appears to have sufficient representation
and signalling mechanisms (HIE
analysis) available to support adaptive in evolutionary biology is a trait that increased the number of surviving offspring in an organism's ancestral lineage. Holland argues: complex adaptive systems (CAS) adapt due to the influence of schematic strings on agents. Evolution indicates fitness when an organism survives and reproduces. For his genetic algorithm, Holland separated the adaptive process into credit assignment and rule discovery. He assigned a strength to each of the rules (alternate hypothesis) used by his artificial agents, by credit assignment - each accepted message being paid for by the recipient, increasing the sender agent's rule's strength (implicit modeling) and reducing the recipient's. When an agent achieved an explicit goal they obtained a final reward. Rule discovery used the genetic algorithm to select strong rule schemas from a pair of agents to be included in the next generation, with crossing over and mutation applied, and the resulting schematic strategies used to replace weaker schemas. The crossing over genetic operator is unlikely to break up a short schematic sequence that provides a building block retained because of its 'fitness'; In Deacon's conception of evolution, an adaptation is the realization of a set of constraints on candidate mechanisms, and so long as these constraints are maintained, other features are arbitrary.
interactions.
There are differing ways the providers can be deployed: Cost leadership, For profit differentiation,
Quality
differentiation, Business model
focus, Medical
innovation focus;
Medical
system quality differentiation strategies
Geisinger
is an example of a differentiated superorganism
integrated health plan and care delivery network. Similar
businesses include: Intermountain
Healthcare, VA - Department of Veterans Affairs. Includes the Veterans Health Administration. Health
System. Mayo
Clinic, Virginia
Mason, and Cleveland
Clinic are alternative business structures that
integrate the care delivery network but cooperate & compete with
independent health plan businesses.
Notable events involving these hospital networks include:
- Broad
Institute finds glioblastomas are a fast growing form of glioma which usually strike older people and have an average survival time of 18 months in 2015. The reason for the aggressive growth of glioblastomas is due to collapse of the barriers between two DNA islands which integrates a highly active loop with a low activation loop containing a growth promotor (Dec 2015). Researched by the TCGA project.
grow fast because DNA (DNA), a polymer composed of a chain of deoxy ribose sugars with purine or pyrimidine side chains. DNA naturally forms into helical pairs with the side chains stacked in the center of the helix. It is a natural form of schematic string. The purines and pyrimidines couple so that AT and GC pairs make up the stackable items. A code of triplets of base pairs (enabling 64 separate items to be named) has evolved which now redundantly represents each of the 20 amino-acids that are deployed into proteins, along with triplets representing the termination sequence. Chemical modifications and histone binding (chromatin) allow cells to represent state directly on the DNA schema. To cope with inconsistencies in the cell wide state second messenger and evolved amplification strategies are used.
islands become linked due to methylation; Cleveland
Clinic's Rich sees this discovery as rule changing (Dec
2015)
- Robert Califf nominated by President Obama for FDA Food and Drug Administration. commissioner's
research praised: Cleveland
Clinic (Sep
2015)
- Valeant's
pledge to give hospitals drug discounts seems hollow: Cleveland
Clinic and other hospitals found (May
2017)
- ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
and competitive
pressures encourage payer include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
-delivery
integration across the health care spectrum: UnitedHealth,
Anthem
CVS: IngenioRX PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. , Aetna: Inova, Banner
Health; Cleveland
clinic: Oscar;
(Nov
2017)
- Doug Lenat's Cyc - common sense rule engine used by Cleveland
Clinic, Goldman
Sachs; features of interest to Allen
Institute & needed by Deepmind
AlphaGo's deep
learning is an artificial intelligence approach where engineers deploy data into deep neural networks.
& IBM's Watson (Mar
2016)
- MS-KCC
sets policy that all outside compensation driven by hospital
research must flow to the hospital. Vice president Dr. Gregory
Raskin: Office
of Technology Development - including hospital ventures
with for-profit companies, formerly of AllianceBernstein
VC is venture capital, venture companies invest in startups with intangable assets
arm vice president
focused on biotechnology; identifies two such cases of
compensation: Y-mAbs
developing MAB as a terminator in medication names indicates the drug is a monoclonal antibody biologic. s: naxitamab is a humanized anti-GD2 3F8 MAB (IgG1) developed by Memorial Sloan-Kettering cancer center, and commercialized by Y-mAbs Therapeutics, for treatment of high risk neuroblastoma. (F.D.A. Food and Drug Administration. breakthrough is used to speed the development and review of drugs that may demonstrate substantial improvement compared to current therapies.
status) & omburtamab is a is a humanized B7-H3 targeting MAB, developed by Memorial Sloan-Kettering cancer center, and commercialized by Y-mAbs Therapeutics, for treatment of human solid tumors: embryonal tumors, carcinomas, sarcomas and brain tumors. ;
based on MS-KCC pediatric oncologist Dr. Cheung's research
treatments, Sellas Life
Sciences Group - cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
vaccine are a core strategy of public health and have significantly extended global wellbeing over 200 years. Smallpox & polio were virtually eradicated. Recent successes include: HPV vaccine: Gardasil. They induce active acquired immunity to a particular disease. But the development and deployment of vaccines is complex: - The business model for vaccine development has been failing (Aug 2015):
- No Zika vaccine was available as the epidemic grew (Mar 2016). No vaccine for: CMV;
- Major foundations: Michael J. Fox, Gates, Wellcome; are working to improve the situation including sponsorship of the GAVI alliance. A geographic cluster is forming in Seattle including PATH (Apr 2016).
- Commercial developers include: Affiris, Cell Genesis, Chiron, CSL, Sanofi, Valeant;
- Vaccine deployment traditionally benefited from centrally managed vertical health programs. But political issues are now constraining success with less than 95-99% coverage required for herd immunity (Aug 2015, Sep 2015, Nov 2015, Nov 2016, Jul 2018).
- Where clinics have been driven into local neighborhoods health improves (Apr 2016).
- Retail clinics (Mar 2016): CVS Minute Clinics focus on vaccination.
- NNT is a useful metric for vaccine benefit. Influenza vaccine has an NNT of between 37 and 77, is cheap and causes little harm, so it is very beneficial.
- Key vaccines include: BCG, C. difficile (May 2015), Cholera (El Tor), Cervical Cancer (Gardasil HPV Jun 2018, Oct 2018), Dengvaxia (Mexico Dec 2015), Gvax, Influenza, Malaria vaccine, Provenge, Typbar-TCV (XDR typhoid Pakistan Apr 2018);
- Regulation involves: FDA (CBER), with CMS monitoring (star ratings, PACE (Aug 2016), Report cards (Sep 2015)) & CDC promoting vaccines: as a sepsis measure, To control C. difficile (May 2015);
- Research on vaccines includes:
- NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.
- NCI:
- Roswell Park clinical trial of immuno-oncology vaccine cimavax.
- Geisinger: effective process leverage in treatment.
- Stanford Edge immuno-oncology for cancer vaccines.
- P53-driven-cancer focused, gene therapy (Jun 2015).
; board
representation policies varies at Integrated systems: Cleveland
Clinic allow; AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017); s:
University
of Utah do not allow; and cancer centers: MD
Anderson allows; (Sep
2018)
- Insurers: Cigna (Express Scripts),
Harvard
Pilgrim, Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births.
;
worried at the high price and lifelong commitment of Amgen's Repatha
& Regeneron/Sanofi's Praluent, PCSK9 is proprotein convertase subtilisin/kexin type 9 an enzyme activator. It is encoded as zymogen and autocatalysed in the ER. It plays a major role in cholesterol homeostasis. It binds EGF-A domain of LDLR inducing LDLR degradation. Academic researchers Dr. Helen Hobbs and Jonathan Cohen, studying large populations found reduced LDLR results in reduced metabolism of LDL which can lead to hypercholesterolemia. Drugs that can inhibit PCSK9 can lower cholesterol much more than first generation cholesterol inhibitors. inhibitors, are
limiting their use by prior-authorization is a constraint imposed by some insurance companies prior to their agreeing to cover some prescribed medications or medical procedures. The constraint may be due to: age, medical necessity, availability of a generic alternative, or to check drug interactions. After a healthcare provider orders a service for a patient, the provider's staff will contact the patient's insurer to determine if they require prior authorization. This should result in an exception process which may involve the provider's staff manual faxing a prior authorization form to the insurer. If the service is rejected, the healthcare provider may file an appeal based on the provider's medical review process. It may take 30 days for the insurer to approve the request.
constraints, even to the one million heterozygous F.H. is Familial Hypercholesterolemia, which causes heart attacks at a young age with symptoms of very high cholesterol levels. A mutation in chromosome 19 inhibits removal of low density lipoprotein. sufferers in the US is the United States of America. where the F.D.A. Food and Drug Administration. has allowed
their use, causing problems for the patients and their
providers: Cleveland
Clinic; (Oct
2018)
- Weill Cornell
healthcare policy researcher & New
York-Presbyterian physician Dhruv Khullar
notes: Anthem's
CareMore,
Geisinger;
aim to support potential hot spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community. patients
in their homes with full support team deployed into the
neighborhoods (Sep
2017)
- Helix sets up network of direct-to-consumer
genomic
testing uses genomic analysis to diagnose genetic disorders - for example Genomic Health's Oncotype DX & Agendia's MammaPrint. The desire to see the genetic risk factors identified by such tests should depend on the risk * burden * Possibility of intervention. Early tests look at only single gene mutations, but big data research tools are showing promise with large gene algorithms (Aug 2018). Genomic testing can be performed direct-to-consumer. Data is being collated on the genetic components of most diseases to enable more sophisticated diagnosis in the future such as the OPHG (EGAPP initiative), USPSTF recommendations and NCBI (Genetic test registry). While there is only limited identification of the significant mutations and limited patient bases misdiagnosis is a problem (Aug 2016).
including Geisinger
(Oct
2017)
- Regeneron
studies clinical collection of DNA (DNA), a polymer composed of a chain of deoxy ribose sugars with purine or pyrimidine side chains. DNA naturally forms into helical pairs with the side chains stacked in the center of the helix. It is a natural form of schematic string. The purines and pyrimidines couple so that AT and GC pairs make up the stackable items. A code of triplets of base pairs (enabling 64 separate items to be named) has evolved which now redundantly represents each of the 20 amino-acids that are deployed into proteins, along with triplets representing the termination sequence. Chemical modifications and histone binding (chromatin) allow cells to represent state directly on the DNA schema. To cope with inconsistencies in the cell wide state second messenger and evolved amplification strategies are used. exomes is the 1 ot 2 percent of the genome which codes for the proteins.
with Geisinger
- stored in EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
; NHGRI is the NIH's national human genome research institute which aims to advance human health through genomics research. argues the
approach is significant (Jan
2014)
- NIH is the National Institute of Health, Bethesda Maryland. It is the primary federal agency for the support and conduct of biomedical and behavioral research. It is also one of the four US special containment units of the CDC. 's million person
precision
medicine is the integration of molecular research: genomics, proteomics, transcriptomics, metabolomics, cell signalling; and clinical data through a taxonomy based on CAS modeling overlaid on an information commons. It aims to support treatment of disease and remove the organ and symptom based methodological flaws in the ICD. Supporters of the D.S.M. note the aggressive shift to precision medicine at the NIMH under Dr. Insel, constrained useful clinical research (Nov 2015).
program All of US makes slow & costly
progress - relative to smaller biobanks: UK, Iceland (deCode), VA - Department of Veterans Affairs. Includes the Veterans Health Administration. , Kaiser, Geisinger;
causing some participants to back out: Kaiser, Geisinger (Regeneron); but Francis
Collins asserts its scope is essential & Verily
is still participating (Mar
2018)
- J&J's
Sylvant MAB as a terminator in medication names indicates the drug is a monoclonal antibody biologic. , Pfizer's Rapamune
used in treatment of Mayo Clinic
diagnosed Castleman
disease is a rare condition with symptoms of: Enlarged lymph nodes, hyperactivation of the immune system, excessive releases of cytokines, proliferation of lymphocytes and organ disfuction. It can affect subcomponents of the body or be multicentric when it is severe and deadly. Its cause is not defined: some argue it is viral, others an inherited genetic disorder or a cancer. It has been treated with: steroids, chemotherapy, J&J's targeted neoplastic disease therapy Sylvant (siltuximab) & Pfizer's Rapamune (sirolimus). . CDCN
at University
of Pennsylvania formed by Dr. Fajgenbaum to improve
research coordination; Everylife
advocates to F.D.A. Food and Drug Administration. (Feb
2017)
- Overdiagnosis is identification of disease when no symptoms or impacts will occur. It typically results from false positives during screening (Aug 2016). It can result in unnecessary and problematic treatment.
of hypothyroidism is under production of thyroxine by the thyroid.
is resulting in overtreatment is the application of unnecessary health care. It is a complex problem: - Overtreatment needs to be adaptive. As people age their medicine levels typically need to be changed. Often, as in the case of blood pressure, and blood sugar reduction, they should be reduced to avoid inducing falls (Nov 2015).
- Patients with chronic diseases, such as type 2 diabetes, often require different treatment settings. And again these vary with age.
- Patients who have learned a regime, and been told it was successful, may resist instructions to change it. Some worry that they will impact their health care provider's treatment performance measures.
with synthroid
(Apr
2017)
- Wal-mart
contracts directly with health care centers of excellence: Cleveland
Clinic, Geisinger,
Mayo Clinic; for
employee care (2012)
- NIH is the National Institute of Health, Bethesda Maryland. It is the primary federal agency for the support and conduct of biomedical and behavioral research. It is also one of the four US special containment units of the CDC. finances million-person
cohort is a precision medicine activity funded through the NIH with $130 million in December 2015 by Congress (Jul 2016).
with participants: Community
health centers, Harlem Hospital,
Mayo clinic, New
York Presbyterian, Northwestern
University, University
of Pittsburgh, Vanderbilt
University, Weill
Cornell; (Jul
2016)
- VA - Department of Veterans Affairs. Includes the Veterans Health Administration.
uses a 5 star rating Star ratings are CMS quality ratings of health care domains. They reflect measures of outcomes including intermediate outcomes, patient experience, access and process. Care coordination (assessed by CAHPS survey) and quality improvement measures have been added. Data is sourced from health and drug plans, from CMS contractors, from surveys of enrollees, and from CMS administrative data. They reflect HEDIS data. The ACA established Star Ratings as the basis of QBPs. 5-star health plans benefit from being able to market all year round, and beneficiaries can join at any time via a SEP. Health plans with less than 3-star ratings can be terminated by CMS starting in 2015. Star ratings cover 9 domains: - Ratings of health plans (part C)
- Staying healthy: screening, tests, vaccines
- Managing chronic (long-term) conditions
- Member experience with the health plan
- Member complaints, problems getting services, and improvements in the health plans performance
- Health plan customer service
- Ratings of drug plans (part D)
- Drug plan customer service
- Member complaints, problems getting services, and improvements in the drug plan's performance
- Member experience with the drug plan
- Patient safety and accuracy of drug pricing
system, SAIL is Strategic Analytics for Improvement and Learning, the VA's 5 star rating system that rolls up various metrics into a single number.
initially developed to monitor and enhance patient care, but
subsequently used, to rate and punish hospital administrators: Atlanta,
and West
Haven. Dr. Ken Kizer notes that punishing people
instead of fixing the system architecture, causes hospitals to
hide errors and distort statistics (Nov
2018)
Porter
describes the risks of differentiation:
- The cost differential between low-cost competitors and the
differentiated firm becomes too great for differentiation to
hold brand loyalty. Buyers thus sacrifice some of the
features, services, or image possessed by the differentiated
firm for larger cost savings;.
- Buyers' need for the differentiating factor fails. This
can occur as buyers become more sophisticated.
- Imitation narrows perceived differentiation, a common
occurrence as industries mature.
Of course the unusual
nature of health care transactions means that Porter's
strategic mechanisms are obscured at best.
Hospitals have been encouraged to deploy conforming EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
systems through HITECH the Health Information Technology and Economic and Clinical Health Act 2009. Central to the act is the establishment of the Medicare and Medicaid EHR incentive programs which make available $27 Billion over 10 years to encourage eligible professionals and hospitals to adopt and meaningfully use certified EHR technology. It is assumed that over time use of the new infrastructure will grow exponentially. HITECH established a formal mechanism for public input into HIT policy - the HITPC and HITSC. Hitech is a key evolved amplifier driving the migration to and installation of Epic and Cerner EHR systems. financial
incentives and meaningful
use is the set of standards defined by CMS Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria. It aims to ensure that ARRA subsidies for HIS are used to generate health improvements. It is staged: - 2011-2012 Data capture and sharing - Criteria focus on electronically capturing health information in a standardized format. Using that information to track key clinical conditions. Communicating that information for care coordination processes. Initiating the reporting of clinical quality measures and public health information. Using information to engage patients and their families in their care. Achieving meaningful use stage 1 requires meeting all core and selected menu objectives.
- 2014 Advance clinical processes - More rigorous health information exchange requirements. Increased requirements for e-prescribing and incorporating lab results. Electronic transmission of patient care summaries across multiple settings. More patient-controlled data. A patient portal is required. CMS hospital core measures, CMS hospital menu set measures, NPRMs of stage 2 meaningful use and certification criteria have been announced (2013).
- MU2 requires EHR systems to support direct messaging to send PHI to registered users.
- 2016 Improved outcomes - Improving quality, safety, and efficiency, leading to improved health outcomes. Decision support for national high-priority conditions. Patient access to self-managed tools. Access to comprehensive patient data through patient-centered HIE. Improving population health.
requirements.
The EHR systems help hospitals:
- Shift away from paper records
- Centralize most of their former data silos within the EHR data
store.
- Automate medical process work flows. This aspect
developed by Geisinger,
in collaboration with Epic,
is described in detail by Dr.
Glenn Steele and Dr. David Feinberg. They show how
process quality improvements are enabled when physicians,
hospital and insurer are part of one business.
- Kaiser,
which also has its own physicians, hospitals and insurer, enthusiastically adopted the strategy.
- AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017);
s and
geographic niche hospitals, who partner with independent
physicians, must cope with anti-trust and Stark law The Stark law constrains certain physician referrals. It prohibits physician referrals of designated health services for Medicare and Medicaid patients if the physician or a family member has a financial relationship with the entity. It was written by Californian congressman Peter Stark.
constraints before they can share EHR infrastructure and
workflows. The ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
& MACRA is Medicare Access and CHIP Reauthorization Act of 2015 is designed to encourage physicians to move to FFV and to link Medicare payment to quality & value. It alters the way Medicare pays for part B physician services encouraging physicians and other ECs to conform to one of two value based payment schemes: Advanced APMs (where the EC can become a QP) or MIPS. MACRA does not apply to hospitals which have their own meaningful use. MACRA is designed to promote transformation and includes: Data reporting by ECs, New practice models, Changing clinical standards, and Physician evaluations; with hundreds of millions of dollars in penalties and bonuses. It authorizes CMS to develop and deploy new rules. It provides for PCPs in PCMHs to qualify as advanced APMs via a special lower risk pathway. It replaced the problematic physician SGR formula.
provide encouragement to independent physicians to participate
in ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. - CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
s that can
develop end-to-end quality
workflows with hospitals.
Geisinger
notes the powerful synergies between
its stable population, health plan (GHP), EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
and the medical
organization's structure. But this integration with GHP
places Geisinger's business in conflict with the major
health plans.
Geisinger demonstrates
how Deming/JIT
principles can be applied to the delivery of health care.
Geisinger's reengineering
resulted in technology supported PCMH is patient centered medical homes:
- Describes a reorganization of the health care delivery
system to focus on the patient and care giver supported by
EHR infrastructure and some form of
process management
which will be necessary to coordinate interventions by
each of the functional entities resources to treat
the patients specific problems. The
disadvantage of a PCMH is the administrative and
technology cost needed to support its complex
processes. The PCMH
- Was promoted as a way to incent more PCP
which had been seen as a low reward role by medical
students. HCI3 argues
this use of PCMH is flawed. PCMH is driven by
the medical home models
of the ACA. In this model the
PCMH is accountable for meeting the vast majority of each
patients physical and mental health care needs including
prevention and wellness, acute
care, and chronic care. It is focused on treating
the whole person. It is tasked with coordinating the
care across all elements of the health care system,
including transitions and building clear and open
communications. It must ensure extended access and
availability of its services and patients preferences
about access. It must continuously improve quality
by monitoring evidence-based medicine
and clinical decision support tools (NCQA).
Many argue that to be effective it must be connected to a
'medical neighborhood'.
The PCMH brings together the specialized resources and
infrastructure required to develop and iteratively
maintain the care plans and
population oriented system descriptions that are central
to ACA care coordination.
based ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. - CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
with All-or-nothing
bundled offers. The lack of success of 2012 pioneer ACO pilots
can differentiate Geisinger's strategy if it is successful.
With its hiring of David Feinberg they are aiming to expand
the value of their health plan.
Geisinger funds two direct research
organizations to ensure some germ-line, a master copy of the schematic structures is maintained for reproduction of offspring. There will also be somatic copies which are modified by the operational agents so that they can represent their current state. 'mutation'
medical processes are present.
Mayo Clinic sold Mayo Clinic Health Solutions to Medica in 2017.
Cleveland clinic 2015 is
reticent to offer a health plan but is reluctantly deploying an
ACO.
The costs of medical errors, increasingly focused by the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
's pay-for-performance represents a number of programs: - Value-Based Purchasing Program which includes mandatory pay-for-performance where a percentage of hospital inpatient payments are withheld and then earned back based on achieving quality metrics. Withholds begin at 1% in 2013 and rise to 2% by 2017.
- HRRP which penalizes Hospitals with a readmission rate that is greater than expected. Penalties capped at 1% of total DRG in 2013, 2% in 2014 and 3% in 2015.
- CMS is also using a high HAC percentage as a penalty - 1% penalty deducted from DRG payment (HACRP) starting in 2015 to encourage reduction of HACs.
- MCMP EHR deployment in physician practices.
penalties, onto hospital's Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
& Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. business,
provide a significant opportunity for JIT based error removal as
well as complexity management with integrated clinical teams
supported by checklists. With
Geisinger's integration
of physician and hospital staff this should be relatively
simple to organize and execute. For the majority of hospitals
with MSO is either a physician's management services organization or a hospital's medical staff organization. based power
structures it may be more challenging.
The PCMH (PCMH) The Patient-centered medical home - Describes a reorganization of the health care delivery system to focus on the patient and care giver supported by EHR infrastructure and some form of process management which will be necessary to coordinate interventions by each of the functional entities resources to treat the patients specific problems. The disadvantage of a PCMH is the administrative and technology cost needed to support its complex processes. The PCMH
- Was promoted as a way to incent more PCP which had been seen as a low reward role by medical students. HCI3 argues this use of PCMH is flawed. PCMH is driven by the medical home models of the ACA. In this model the PCMH is accountable for meeting the vast majority of each patients physical and mental health care needs including prevention and wellness, acute care, and chronic care. It is focused on treating the whole person. It is tasked with coordinating the care across all elements of the health care system, including transitions and building clear and open communications. It must ensure extended access and availability of its services and patients preferences about access. It must continuously improve quality by monitoring evidence-based medicine and clinical decision support tools (NCQA). Many argue that to be effective it must be connected to a 'medical neighborhood'. The PCMH brings together the specialized resources and infrastructure required to develop and iteratively maintain the care plans and population oriented system descriptions that are central to ACA care coordination.
integration (ProvenHealth
Navigator (PHN) with xG) is
particularly important because it provides a capture point for
integrating the patient population. Through differentiated
reputation Geisinger can bring potential patients and better
processes and infrastructure to PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. s who can offer
referrals to Geisinger's treatment regimes. Geisinger must
resolve conflicts between its Epic
investments
and its xG
strategy.
Mayo Clinic has spun
out Ambient
Clinical Analytics.
This is driving the organizations to seek more information about
their patient population, and techniques to manage the patients
approach to staying healthy (PHM is population health management. It aims to use big data to extend the EHR infrastructure to provide cost effective personal treatment. This implies reengineering the health care payment and delivery process. - IT tools must be developed.
- Administrative structures must be updated.
- Clinical processes must be redesigned and accepted. Successful workflow process reengineering will depend on integration with existing workflows and presence of added value!
- Payment mechanisms must be overhauled ensuring that the physicians get incented to move on from FFS.
- It must be financed. It is not obvious where this will come from! Providers like fixed costs. ROI seems limited atleast initially. Subscriptions may work for both vendors and providers.
)
where Geisinger (or Kaiser) can
apply their relatively large pool of talented resources to implement
an effective vision.
Tools that help incent the patient population to make healthy
choices will become valuable. But that will mean understanding
what healthy choices are? See How UPMC similarly and visibly focuses on IT
and its
health plan is using predictive
health analytics aims to improve patients' healthcare outcomes and contain costs by using modeling technology integrating lifestyle information with patient data and modeling healthcare outcomes. At the population level the hope is to create a total view by combining and structuring big data. Then by segmenting the data at the cohort and patient level by risk, interventions and programs tailored to each person can be designed, supported by integrated care coordination. A Shewhart cycle is then used to iteratively learn and optimize the process. . Currently most extended networks do not
integrate across the care continuum.
The totally integrated 'blend' when viewed as a Porter generic
strategy appears conflicted. But superorganism
shared schematic
planning, signal
based cooperation, differentiated forms (of clinical
microsystems is a small group of people who work together on a regular basis to provide care to discrete subpopulations including the patients. It has clinical and business aims, linked processes, shared information environment and produces performance outcomes. They evolve overtime and are often embedded in larger organizations. They are viewed by the Microsystem academy as a Complex Adaptive System. They are the building blocks which form hospitals. ), and networked
effects is highly competitive in a rich environment.
Geisinger's behavioral
transformation processes focus on this. The capitation is a global payment for all care for a patient during a specified time period. It forces the provider of care to take a high risk. Managing the risk implies successful population health management. based reimbursement is the payment process for much of US health care. Reimbursement is the centralizing mechanism in the US Health care network. It associates reward flows with central planning requirements such as HITECH. Different payment methods apportion risk differently between the payer and the provider. The payment methods include: - Fee-for-service,
- Per Diem,
- Episode of Care Payment,
- Multi-provider bundled EPC,
- Condition-specific capitation,
- Full capitation.
allows the internal business models to be separated as at Cleveland
Clinic and Mayo
Clinic. Multiple profit oriented businesses within the
overall group structure can explore niches at the edge of chaos such
as Cleveland's Lerner
collage of medicine work
with IBM's Watson,
but it is a compromise compared to a VC plus startups system. These
superorgamisms can leverage the low cost of transportation to
optimize and compete widely with less efficiently organized
providers as
explained by Cleveland Clinic's Cosgrove
and at UCLA Health (1,
2,
3).
While the idea of transporting patients to the optimal center seems
important its ramifications must be understood:
- How does a family, or friends, get to visit the patient?
Who pays for their transport, lodging, loss of revenue
etc.? UCLA
Health describes
their solution to Joseph Mitchelli.
- How is the transport organized?
Cleveland Clinic's "centers of excellence" network
connect strategy is leveraged by employers aiming to provide
high quality compeititive care with reference priced constrains a policy holder to a reimbursement for the reference price of a treatment rather than the specific hospitals billed price. Patients have to pay the difference. It can allow subscribers broader access to different health care providers than narrow networks. It is only applicable for elective procedures where the patient can shop around (Aug 2016).
cost control (Aug
2016).
The Vivity joint
venture (Sep
2014) aims to build a regional HMO is a health maintenance organization. Originally HMOs were fashioned after Dr. Paul Ellwood's admiration for group practices such as: Kaiser Permanente, Mayo Clinic; which employed salaried physicians and charged fixed fees rather than FFS. Ellwood argued that this architecture helped keep subscribers healthy which he termed a health maintenance organization. President Nixon was convinced by Ellwood signing the HMO Act. But the legislated HMO did not have to conform to Ellwood's group practice architecture. Instead by 1997 for-profit commercial insurance companies operated two-thirds of the HMO business. The legislated HMO: - Provides or arranges managed care for:
- Health insurance
- Self-funded health care benefit plans
- Individuals
- Acts as a liaison with health care providers
- Covers care rendered by those doctors and others who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in return for access to patients. Treatment choices were often driven by insurance company rules. Financial incentives often based the contracted physician income on success in reducing expenses rather than health outcomes. There are a variety of contracts with physicians:
- Closed panel plan
- Open panel plan
- Network model plan
- Covers emergency care regardless of the providers contracted status.
/ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. - CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
comparable to
Geisinger's offerings.
Medical system cost
leadership strategies
Kaiser is an
example of 'cost leadership' superorganism
business strategies that assume all the risk.
Since 1944, [Kaiser] Permanente health system, a group practice is an integrated health care organization with salaried physicians and bundled pricing. Early examples included Kaiser Permanente and the Mayo Clinic. ,
has been composed of three associated operations:
- A health plan, which initially contracted with insurers.
It is nonprofit is a tax strategy selected by many hospitals in the US. These hospitals, which include: Cleveland Clinic, Johns Hopkins, Massachusetts General, Mayo Clinic; are exempt from federal and local taxes because they provide a level of community benefit. They are considered charitable institutions and benefit from tax-free contributions from donors and tax-free bonds for capital projects, explains Bellevue Hospital's Dr. Danielle Ofri. Prior to 1969, community benefit had to include charity medical care, but then the tax code was altered to allow many expenses to qualify as community benefits including: Accepting Medicaid insurance at a hospital estimated loss; and charitable care became optional. The ACA encouraged hospital networks to consolidate and with this additional pricing power, revenue at the top seven nonprofits has increased 15%, while charitable care decreased 35%.
- Permanente, hospital infrastructure owner and operator.
It is nonprofit, but generates large revenues and margins
- Permanente Medical Group is a for-profit partnership that
employs the doctors. Such a managed care contracts together its subscribing patients with particular groups of doctors and hospitals who agree to provide contracted care for a particular price which the managed care organization reimburses. It was based on the group practice organizations: Kaiser, Mayo Clinic; operations. The initial HMOs, supported by the HMO act and PPOs has subsequently been joined by other forms of managed care. Original capitation based implementations were problematic with only Kaiser succeeding. Managed care is now enhanced by inclusion of upside measures as in alternative quality contracts.
operation, in contrast with the ubiquitous FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment. operations of 1944,
was anathema to the AMA is the American Medical Association.
;
with all three operations tied together by Eugene Trefethen with
a contract in 1955.
The for-profit medical group drives Kaiser Permanente's business
model to seek margin. This encourages behaviors that limit
care, a characteristic that was noted by Nixon aid, John Ehrlichman,
when they were focused on the HMO act is the Health Maintenance Organization Act of 1973 which amended the PHSA to provide assistance for the creation of HMOs including: - Money for development
- An override of specific restrictive state laws
- A mandate offered to specific employers to offer an optional HMO plan as part of their employee benefits package.
. Kaiser
had 6 HMO is a health maintenance organization. Originally HMOs were fashioned after Dr. Paul Ellwood's admiration for group practices such as: Kaiser Permanente, Mayo Clinic; which employed salaried physicians and charged fixed fees rather than FFS. Ellwood argued that this architecture helped keep subscribers healthy which he termed a health maintenance organization. President Nixon was convinced by Ellwood signing the HMO Act. But the legislated HMO did not have to conform to Ellwood's group practice architecture. Instead by 1997 for-profit commercial insurance companies operated two-thirds of the HMO business. The legislated HMO: - Provides or arranges managed care for:
- Health insurance
- Self-funded health care benefit plans
- Individuals
- Acts as a liaison with health care providers
- Covers care rendered by those doctors and others who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in return for access to patients. Treatment choices were often driven by insurance company rules. Financial incentives often based the contracted physician income on success in reducing expenses rather than health outcomes. There are a variety of contracts with physicians:
- Closed panel plan
- Open panel plan
- Network model plan
- Covers emergency care regardless of the providers contracted status.
qualified
regions by 1977, and subsequently added: Mid-Atlantic,
District of Columbia, Maryland, Georgia. But during the 1990s
Kaiser abandoned aspects of its business in: Texas (total business)
in 1998, North Carolina (health plan) in 2002 and a health plan in
the Northeast in 2000. And It was growing more slowly than
other managed care groups: DaVita
HealthCare Partners.
Adopting Geisinger's
Epic integration strategy in 2003, Kaiser
transformed its quality model and expanded the strategic value of
its health plan.
It formed as a series of regional operations and this is still
reflected in its structures. Like global telcos such as
Vodafone the operations are power centers which resist doing
anything company wide that might reduce their power. Hence
about the only IT infrastructure that is truly global across Kaiser
is the Epic EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
branded HealthConnect
by Kaiser.
Notable events involving these hospital networks include:
- Hypertension is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers.
is a high risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty.
factor for later dementia is a classification of memory impairment, constrained feelings and enfeebled or extinct intellect. The most common form for people under 60 is FTD. Dementia has multiple causes including: vascular disease (inducing VCI) including strokes, head trauma, syphilis and mercury poisoning for treating syphilis, alcoholism, B12 deficiency (Sep 2016), privation, Androgen deprivation therapy (Oct 2016), stress, Parkinson's disease, Alzheimer's disease, and prion infections such as CJD and kuru. The condition is typically chronic and treatment long term (Laguna Honda ward) and is predicted by Stanley Prusiner to become a major burden on the health system. It may be possible to constrain the development some forms of dementia by: physical activity, hypertension management, and ongoing cognitive training. Dementia appears to develop faster in women than men. ,
Kaiser
researchers find (Oct
2017)
- UnitedHealth
purchases DaVita's
physician group for Optum
for $4.9 Billion. US is the United States of America.
needs a Value Delivery
System (VDS is value delivery system. ) for
chronic disease: asthma is inflammation of the airways resulting in their narrowing, swelling and generating additional mucus which inhibits breathing. Its prevalence doubled in the US between 1980 and 2000. Asthma is the most common chronic disease in childhood, the most common reason for being away from school and the most common reason for hospitalization. 10 to 13% of children's asthma cases are due to obesity. Among obese children 23 to 27% of asthma cases are due to obesity. Diagnosis: Propeller Health; Treatments include: Xolair;
,
and diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
.
Northwestern's
Garthwaite
asks: is Kaiser's
business model under threat? (Dec
2017)
- NIH is the National Institute of Health, Bethesda Maryland. It is the primary federal agency for the support and conduct of biomedical and behavioral research. It is also one of the four US special containment units of the CDC. 's million person
precision
medicine is the integration of molecular research: genomics, proteomics, transcriptomics, metabolomics, cell signalling; and clinical data through a taxonomy based on CAS modeling overlaid on an information commons. It aims to support treatment of disease and remove the organ and symptom based methodological flaws in the ICD. Supporters of the D.S.M. note the aggressive shift to precision medicine at the NIMH under Dr. Insel, constrained useful clinical research (Nov 2015).
program All of US makes slow & costly
progress - relative to smaller biobanks: UK, Iceland (deCode), VA - Department of Veterans Affairs. Includes the Veterans Health Administration. , Kaiser, Geisinger;
causing some participants to back out: Kaiser, Geisinger (Regeneron); but Francis
Collins asserts its scope is essential & Verily
is still participating (Mar
2018)
- Business
model for individual PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
collapses under
pressure from various large organizations executing acquisitions
and mergers: Apple
running own clinics for employees, Large hospitals setting up
urgent care: HCA,
Dignity Health,
Northwell
Health (GoHealth);
CVS Health & Aetna, Wal-Mart & Humana, United Health
employs 30,000 physicians and owns one of the largest urgent care is an efficient and less costly 'alternative' to the ER. There is no accepted standard. Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls. Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones. Unlike an ER they can not admit patients to a hospital. Some also offer services like pre-employment drug screening and summer camp physicals.
groups
(MedExpress);
who can leverage employed PCP prescriptions for their PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. s, driving some PCPs
to compete with urgent care: Healthy Now; and or leverage nurse
practitioners, and others to explore One Medical
& Aledade (Apr
2018)
- Hospitals required to display chargemaster is a hospital specific mapping of chargeable ICD procedure codes to the description and list price set by the hospital.
and DRG is a diagnosis-related group. It transformed the health care operating model, when 467 DRGs with standard payments were introduced by Medicare in the 1980s, enabling for-profit business strategies to seek ways to cut expenses and hence increase profits. The DRG is a classification, designed by Yale's Robert Fetter and John Thompson, intended to define the products that a hospital provides. It assumes patients within a grouping are clinically similar. Grouping is based on ICDs adjusted for age, sex, discharge status and comorbidities. For Medicare hospital inpatient claims the DRG is used to select the fee that will be reimbursed. charges for
common procedures by CMS is the centers for Medicare and Medicaid services. .
Listings: Highland
Hospital, Kaiser, Santa
Clara Valley Medical Center, Seton,
Stanford,
UCSF MC;
provide little insight into patient bills (Jan
2019)
Porter
describes the risks in overall cost leadership:
- To maintain its position a cost leader must reinvest in modern
equipment;
- Ruthlessly scrap obsolete assets; This is seen in the IT
drive to consolidate onto a common platform.
- Avoid product line proliferation;
- Remain alert for technological improvements. Kaiser is
supporting Epic by joining Healtheway;
- It must sustain cost declines based on scale by effective PDCAs;
- Technological change can nullify its past investments and
learning;
- Low-cost learning by new entrants and followers imitating can
reduce their cost advantage;
- Inability to see required product or marketing change because
of attention placed on cost;
- Inflation in costs that narrow the firm's ability to maintain
enough of a price differential to offset competitors' brand
image and other approaches to differentiation.
Hence Kaiser must ensure it benefits from
total integration (which is a challenge with its regional
based power structure). This focus allows Kaiser to invest in
infrastructure amplifiers, including IT and salaried physicians; so
that it can PDCA end-to-end processes, and identify best practices
from amongst its operations.
Hospitals have been encouraged to deploy conforming EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
systems through HITECH the Health Information Technology and Economic and Clinical Health Act 2009. Central to the act is the establishment of the Medicare and Medicaid EHR incentive programs which make available $27 Billion over 10 years to encourage eligible professionals and hospitals to adopt and meaningfully use certified EHR technology. It is assumed that over time use of the new infrastructure will grow exponentially. HITECH established a formal mechanism for public input into HIT policy - the HITPC and HITSC. Hitech is a key evolved amplifier driving the migration to and installation of Epic and Cerner EHR systems. financial
incentives and meaningful
use is the set of standards defined by CMS Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria. It aims to ensure that ARRA subsidies for HIS are used to generate health improvements. It is staged: - 2011-2012 Data capture and sharing - Criteria focus on electronically capturing health information in a standardized format. Using that information to track key clinical conditions. Communicating that information for care coordination processes. Initiating the reporting of clinical quality measures and public health information. Using information to engage patients and their families in their care. Achieving meaningful use stage 1 requires meeting all core and selected menu objectives.
- 2014 Advance clinical processes - More rigorous health information exchange requirements. Increased requirements for e-prescribing and incorporating lab results. Electronic transmission of patient care summaries across multiple settings. More patient-controlled data. A patient portal is required. CMS hospital core measures, CMS hospital menu set measures, NPRMs of stage 2 meaningful use and certification criteria have been announced (2013).
- MU2 requires EHR systems to support direct messaging to send PHI to registered users.
- 2016 Improved outcomes - Improving quality, safety, and efficiency, leading to improved health outcomes. Decision support for national high-priority conditions. Patient access to self-managed tools. Access to comprehensive patient data through patient-centered HIE. Improving population health.
requirements.
The EHR systems help hospitals:
- Shift away from paper records
- Centralize most of their former data silos within the EHR data
store.
- Automate medical process work flows. This aspect
developed by Geisinger,
in collaboration with Epic,
is described in detail by Dr.
Glenn Steele and Dr. David Feinberg. They show how
process quality improvements are enabled when physicians,
hospital and insurer are part of one business.
- Kaiser,
which also has its own physicians, hospitals and insurer, enthusiastically adopted the strategy.
- AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017);
s and
geographic niche hospitals, who partner with independent
physicians, must cope with anti-trust and Stark law The Stark law constrains certain physician referrals. It prohibits physician referrals of designated health services for Medicare and Medicaid patients if the physician or a family member has a financial relationship with the entity. It was written by Californian congressman Peter Stark.
constraints before they can share EHR infrastructure and
workflows. The ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
& MACRA is Medicare Access and CHIP Reauthorization Act of 2015 is designed to encourage physicians to move to FFV and to link Medicare payment to quality & value. It alters the way Medicare pays for part B physician services encouraging physicians and other ECs to conform to one of two value based payment schemes: Advanced APMs (where the EC can become a QP) or MIPS. MACRA does not apply to hospitals which have their own meaningful use. MACRA is designed to promote transformation and includes: Data reporting by ECs, New practice models, Changing clinical standards, and Physician evaluations; with hundreds of millions of dollars in penalties and bonuses. It authorizes CMS to develop and deploy new rules. It provides for PCPs in PCMHs to qualify as advanced APMs via a special lower risk pathway. It replaced the problematic physician SGR formula.
provide encouragement to independent physicians to participate
in ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. - CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
s that can
develop end-to-end quality
workflows with hospitals.
They are still seeking to limit costs and treatments where they
cannot influence patient performance. Kaiser argues that healthcare
must be practiced in far lower cost reengineered environments such
as at home via Tele-health. It seems likely that Kaiser
will suffer from the centralized planning
problem that will undermine its process oriented quality
strategy.
Sovaldi (sofosbuvir) is Gilead Sciences hepatitis-C drug. It is the first effective cure with acceptable side effects. Sofosbuvir was originally developed by Pharmasset which sold the rights to Gilead for $11 billion. In 2014 Sovaldi costs $84,000 for a typical course of treatment. treatment
pricing has highlighted that even Kaiser's Insurance policies with
their yearly membership and premiums are misaligned
with treatments that cure rapidly and benefit long term health
of the patient and nation.
Kaiser may also struggle to drive
up quality in its nursing partnerships.
If providers conclude they must sustain this approach It should be
expected that provider's goals will be in conflict with those of the
food, tobacco, farming and agro value delivery system.
The ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. - CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
potentially
allows a 'virtual' structure to create a Kaiser like superorganism.
Partners
healthcare are a vanguard for much of the ACO logic. Essence group gain
quality credibility from their ACO framework. However, it is
hard to see how the effects of the organizational partitions can be
removed contractually or operationally. M. Blum questions
the ACO structure. Another illustrative example of an
ACO business dilemma is expressed
by a SNF is skilled nursing facility. and reinforced
by a HHA is home health agency. . The
Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
-certified
ACO experiments have not demonstrated a likelihood of long term
return on investment or sustainability. The cost of necessary
infrastructure was higher than the shared savings is the Medicare Shared Savings Program. The program began in 2012 with 3 year term contracts. ACO Physician groups and hospitals are eligible to participate but there must be primary care physicians in the ACO. Participating ACOs must serve > 5000 Medicare beneficiaries. The potential for a bonus payment is based on Medicare cost savings and quality metrics. Two payment models are available. Only one has downside risk involved. CMS included 'robust' quality measures to monitor the quality of care provided and beneficiary satisfaction (see fact sheet 'Improving Quality of Care for Medicare Patients: Accountable Care Organizations').
payments obtained!
Like Kaiser, ACO strategists will see home care and Tele-health is the use of remote health care. It includes telepharmacy and clinical telehealth for stroke and psychiatry. It also includes sessions between primary care providers and patients and assisted caregiving such as medication reminders and DME usage monitors. , which
is increasingly being deployed, as key ways to limit costs,
support margins and control readmission have become a source of increased revenue for hospitals. But with government interested in reducing the US health care cost curve ACA's HRRP (pay-for-performance), BPCI and CTI and Interact discharge initiative have all increased the focus on unnecessary readmissions. Now the end-to-end process is under scrutiny with hospitals reengineering discharge (RED) and PAC providers using RAI and TCN.
penalties.
If an ACO becomes the dominant health care organization in an area
it should obtain better payer include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
contracts and payment rates. Geisinger
has found
structuring as an ACO to be valuable. As an ACO gains PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. s and patients it will
then be beneficial for other specialists to become part of the
organization to benefit from the rates and access to patients
obtained. To enter the ACO on good contractual terms the
specialists may have to organize as a super group is an integrated single practice combining independent specialists and specialist organizations with one tax identification number. They aim to improve market power for the specialists by capturing essential agents and so making the SuperGroups participation in a value delivery system necessary for the delivery of efficient, effective health care. The focus on a single specialty can improve efficiency and effectiveness. They can avoid Stark laws and Kickback statutes but are often limited in the total percentage of specialists they can encompass and may need an antitrust assessment. They can organize as centrally managed medical groups with pooled revenues or as a set of autonomous operating divisions (practices) within a group practice 'without walls' where only centralized expenses are allocated. But such organizations are often unstable due to the independent nature of the experts they leverage and constrain. And it can be difficult to build the original super group since it must combine different cultures, billing arrangements, debt profiles, payment contracts, IT systems, values and approaches to quality. or clinically
integrated network is a legally acceptable clinical integration of hospital, physicians and/or other dedicated health care providers who deliver services focused on quality, performance, efficiency and value to the patient. In comparison with a SuperGroup it also increases market power while sustaining expert agent independence. But it is hard to manage and requires significant infrastructure expense to support clinical integration and management of utilization and financial uncertainty. Initial setup will have to manage the problem of prior contracts the new members have with IPA, PHO or ACOs. An alternative to a clinically integrated network is a messenger model network. The Joint Commission specified an OPPE requirement for general performance improvement. Network providers must develop and sustain clinical initiatives that enhance access to care, clinical quality, cost control and the patient experience by: - Coordination across the network,
- Implementing evidence-based clinical protocols,
- Improving efficiency in the delivery of care,
- Partnering with payers to develop contracts that drive definable clinical improvement and add value to patients.
. This will also help with developing
focus and thus specialty value-add that is likely to be necessary to
obtain significant future rewards from the ACO and payers.
There is consequent need for information and control systems that
can identify and highlight best practices to support networked
clinical integration.
When it is less certain that an ACO will be successful it is likely
that specialists will aim to undermine Medicare ACOs to stop power
shifting to the PCPs. Spurred to organize they can
contractually constrain: service level, payment guarantees, levels
and risk, easy termination, beneficial dispute resolution, require
access to audit trails, limit covenants and offset patient decisions
to go to out of network specialists.
Hospital network power
Sutter Health is
an example of a hospital strategy based on network
effects.
Notable events involving these hospital networks include:
- Major hospital
systems is the owner of a set of hospitals and other owned infrastructure and employer of direct staff. : Dignity + Catholic
Health Initiatives, Ascension,
Advocate
+ Aurora;
plan mergers; Tenet
& Community
Health sell off poor performing hospitals & shift
further to outpatient services. All are hoping to capture
patient base before new entrents: UnitedHealth,
CVS Health, Amazon; can.
And scale may help with margin & HCIT is health care information technology. The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets. Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.;
costs.
UnitedHealth's Optum
purchases the Advisory
Board. Republican tax law suggests reduced funding
of: ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
, Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
& Medicaid is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; will all
be further impacting revenue to hospitals (Dec
2017)
- NYT/UC
Berkeley study finds prices rise after hospital mergers,
since these: reduce competition, raise price of admission,
undermine quality; with major groups: Baylor
Scott, CHI
Franciscan Health, Dignity, Hartford,
Memorial
Hermann, Phoebe
Putney Health System, Sutter Health,
West
Virginia University Medicine, Yale
New Haven Health; integrating other hospitals and
especially physician groups (Nov
2018)
- Frail elderly hot
spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community. patient numbers have grown significantly. They
get better primary care at home: VA - Department of Veterans Affairs. Includes the Veterans Health Administration.
home-based primary
care, Sutter's
AIM is Sutter Health's Advanced Illness Management, a home-based primary care program for treating its frail elderly hot spot patients. By keeping patients out of the hospital whenever possible, it saves Medicare > $2000 per patient per month. (Brad Stuart's ACIStrategies
Advanced Care Innovation consultancy) Hospice of
the Valley's David Butler, Georgetown
university/MedStar
Washington
hospital center's George Taler; see cross functional teams
treating aging hot
spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community. patients at home as better value and removing the
frail from hospital/ICU is intensive care unit. It is now being realized that the procedures and environment of the ICU is highly stressful for the patients. In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD. Intubation and catheterization are also traumatic. Sometimes seperated into MICU and SICU. eICU skill centralization may bring down costs.
dangers. But there were problems: American's think of
hospitals and health care as improving health,
Multi-disciplinary team based treatment focused on the patient's
goals is radical, Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
funding focus historically on hospital based care; all
constrained the strategy. It may be enabled by ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
: readmission
penalties have become a source of increased revenue for hospitals. But with government interested in reducing the US health care cost curve ACA's HRRP (pay-for-performance), BPCI and CTI and Interact discharge initiative have all increased the focus on unnecessary readmissions. Now the end-to-end process is under scrutiny with hospitals reengineering discharge (RED) and PAC providers using RAI and TCN. bundled
payment is where the purchaser disburses a single predefined payment to cover certain combinations of hospital, physician, post-acute, or other services performed during an episode of care relating to a particular condition (unlike capitation). This bundling is assumed (Sep 2018) to allow the value delivery system to optimize around low cost high quality long term health care. With one bundled payment physicians & hospitals must coordinate care and reduce the unit costs to remain profitable. And to avoid taking on risk of expensive complications physicians & hospitals are incented to standardize and focus on quality. This optimization is dependent on quantifying the value of the outcome of the episode of care. Previously FFS payments induced excessive treatment activity. Bundled payment is included in CMS ACE demonstrations and BPCI initiatives. There are significant impacts on IT. - It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.
- Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments.
- Care delivery must be re-architected to reduce costs and improve quality.
- Monitoring sensors can be used to feed reports to ensure re-architected operations conform.
ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. - CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
s, CMMI is the center for Medicare and Medicaid Innovation. It is a test bed for new ways of financing and delivering care. It allowed Congress to institutionalize innovation sending a signal to providers that they would be participating in CMS driven programs that could become mainstream. It funds evaluations of innovative health care models. Under the ACA if the HHS secretary finds any of its projects would reduce Medicare spending without harming the quality of care the projects may be expanded nationwide. The CBO estimates the CMMI will save $34 billion between 2016 and 2026. CMMI projects include: - Medicare will make a bundled payment for hip and knee replacement surgery (CJR) and 90 days of follow-up care forcing hospitals to work closely with doctors, nursing homes and home health agencies.
- New ways to pay for prescription drugs, medical devices, cancer care (OCM).
- HHS secretary has invoked his 3021 authority to institute DPP.
encouraging
insurance companies to seek home based hospice has the key goal of helping people with a fatal illness to have the fullest possible life right now. There are major hospice chains focused on providing palliative care. care; with
Medicare funding linked to cost savings (Dec
2013)
- Digital silos generated by EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses:
- The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
IOP is: - Interoperability. ONC offers a vision. Interoperability providers aim to integrate all the HCIT.
- Intraocular pressure
issues.
National coordinator for HIT the health information technology infrastructure. - The HIT strategic plan includes 5 goals:
- Achieve adoption and Information Exchange through Meaningful Use of health IT. ONC and AHRQ identified best practices will be distributed by HITRC and REC to providers in the community. HITECH Beacon community grants have created 17 demonstration communities using HIT. CMMI will test innovative payment and service delivery models. There are 3 objectives:
- Accelerate adoption of EHRs. Incentives for Meaningful use. Provide implementation help. Train an implementation workforce. Add meaningful use to professional certification. Certify EHR technology that supports meaningful use. Promote the benefits. Align federal programs. Encourage private payers to align.
- Facilitate information exchange to support meaningful use of electronic health records. Support exchange based business models. Fill gaps in provider options. Develop standards.
- Support heath IT adoption and information exchange for public health and populations with unique needs. Ensure public health agencies can exchange EHRs. Track health disparities and promote HIT that reduces them. Support HIT adoption in post-acute, behavioral health and ER.
- Improve Care, Improve Population Health, and Reduce Health Care Costs through the Use of Health IT. There are 4 objectives:
- Support more sophisticated uses of EHRs (viewed as a necessary step to the three aims) and other health IT to improve health system performance. ICD-10 migration is viewed as necessary to obtain fine granularity of health care treatments, outcomes and costs. Enrollment in federal health programs will be improved by development of interoperable and secure standards and protocols for enrollment.
- Better manage care, efficiency, and population health through EHR-generated reporting measures. HHS National Quality Strategy has 6 priorities which will be the focus of measures. These will then be incorporated in EHR.
- Demonstrate health IT-enabled reform of payment structures, clinical practices, and population health management. Beacon demonstrator best practices will be replicated into the community. Payment reforms were also piloted (bundled payments, medical home). CMS will translate the best practices into policy.
- Support new approaches to the use of health IT in research, public and population health, and national health security. CDC is encouraging deployment of Health IT and communications infrastructure at public health departments.
- Inspire Confidence and Trust in Health IT. There are 3 objectives:
- Protect confidentiality, integrity, and availability of health information. HIPAA is being strengthened by the OCR to match HITECH. EHRs must be encrypted, with access controls, audit logs, and login timeouts. EHRs will be made granular so certain aspects can be withheld from sharing (substance abuse notes for example). Assess security vulnerabilities of EHR systems. Identify privacy/security requirements and best practices and communicate them.
- Inform individuals of their rights and increase transparency regarding the uses of protected health information. Transparent policy making and explanations of rights.
- Improve safety and effectiveness of health IT. Safety concerns of patients researched and monitored.
- Empower Individuals with Health IT to Improve their Health and the Health Care System. There are 3 objectives:
- Engage individuals with health IT. Most individuals don't use EHR. HIT argues if they did their health data could become centered on them and enable Tele-health including local sensors reporting back to the HIT infrastructure and applications providing [social] support and advice. It is also presumed it would enable new classes of health care market. HIT hopes that involving individuals in the policy making through participation via HITPC and HITSC will increase confidence in EHR. Ensuring individuals are aware of the benefits of HIPAA privacy and that EHR supports HIPAA may build confidence and use of EHR. HIT also promotes generating AIDA via social networks and social media.
- Accelerate individual and caregiver access to their electronic health information in a format they can use and reuse. HIT is using Medicare and Medicaid EHR incentives to encourage providers to give individuals and caregivers access to EHRs as PHRs and secure m-Health applications. Blue Button presents a use case.
- Integrate patient-generated health information and consumer health IT with clinical applications to support patient-centered care. ONC will use device certification to enable the integration of consumer health device data with the individuals EHRs. HHS is studying how to enable the integration of patient generated insights from blog entries, health journals etc. Diabetes management is being used to identify tools for benefiting from EHR data.
- Achieve Rapid Learning and Technological Advancement. There are 2 objectives:
- Lead the creation of a learning health system to support quality, research, and public and population health. HIT conjectures that electronic records will provide a foundation for learning about the population's health. Examples include tracking and managing epidemics (CDC) and improving quality and efficiency of prevention and care (FDA sentinel). New standards (spearheaded by IOM) will be developed for technologies supporting de-identification, aggregation, querying and analysis of population health data. Individuals and providers will be encouraged to share information with the learning health infrastructure users.
- Broaden the capacity of health IT through innovation and research. CHDI is making many large data sets and tools to analyze them available. The best practices from SHARP funded (NIH and AHRQ) research programs will be promoted into the practice of medicine. The focus topics are: usability of EHRs, clinical decision support, consumer health IT, HIEs and Tele-health. NITRD is developing the programs and strategic plans that HITECH requires to coordinate research and development relating to Heath IT. VA, DOD and CMS are acting as test beds for Health IT.
sees information blocking. PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. s and specialist
groups can't integrate with local hospitals. Lady
of Lourdes Medical Center has IOP issues within its
network (May
2015)
- Epic EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses:
- The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
at Vidant
Roanoak not interconnecting with Independent specialist's
Practice fusion
EHR (Oct
2014)
Medical system
Innovation focus strategies
UCSF, Johns Hopkins, Harvard
affiliated Partners
Healthcare, UCLA
Health, and NYULMC
are examples of a niche business AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017); strategy focused on
innovative medical science and technology.
The business alignment with innovation is the economic realization of invention and combinatorial exaptation. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy. provides
a 'do the right product' quality focus and a channel for leading
edge drugs and devices to deploy through. The research focus
reduces the constraining fear of mistakenly
killing a patient which otherwise forces doctors to carefully
follow historic precedent.
Notable events involving these hospital networks include:
- The difficulty in finding patients with specific cancer
mutations leaves biotechnology & AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017);
s struggling to
increase the patient base. Early F.D.A. Food and Drug Administration. approvals become
significant competitive advantages:
- Brown
University accepts CV Properties
vision & partners
with public schools: University
of Rhode Island, Rhode
Island College; deploying a nursing school, to complement
its medical school & Lifespan's AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017);
: Rhode
Island Hospital, and create innovation is the economic realization of invention and combinatorial exaptation. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy. hub (Nov
2017)
- Alzheimer's is a dementia which correlates with deposition of amyloid plaques in the neurons. As of 2015 there are 5 million Alzheimer's patients in the USA. It was originally defined as starting in middle age which is rare, so it was a rare dementia. But in 1980s it was redefined as any dementia without another known cause. Early indications include mood and behavioral changes (MBI) and declarative memory and thinking problems (MCI). Specific cells within the hippocampal circuitry and its gateway, the entorhinal cortex, are damaged. The amygdala, cerebelum and other areas supporting implicit memory are not impacted during the early stages of the disease. Grid cell destruction results in a sense of being lost. The default mode network is disrupted. Variants include: late-onset sporadic; with risk factors - ApoE4 for late onset Alzheimer's, presenilin, androgen deprivation therapy (Dec 2015), type 2 diabetes. There are multiple theories of the mechanism of Alzheimer's during aging: Allen Roses argues that it is due to gene alleles that limit the capacity of mitochondria to support neuron operation, Neurons of sporadic Alzheimer's sufferers show greater APP gene diversity due to somatic recombination; It may be initiated by: stress induced HHV-6a, HHV7 herpes activation (Jun 2018) and or an increasingly leaky blood-brain barrier; and a subsequent innate immune response to the infections (May 2016). The Alzheimer's pathway follows:
- Plaques form. These are seen in fMRIs 10 to 15 years prior to detecting memory and thinking changes. APP deployed in the cell membrane is cut into three parts. The external part becomes amyloid-beta peptide which aggregates into Amyloid plaques, external to the neurons, if too much is generated or it is not removed fast enough.
- Solanezumab aimed to inhibit plaque formation but clinical trials failed (Nov 2016).
- Encouraging the garbage collection of amyloid and tau with gamma rhythms stimulation retards Alzheimer's in mice studies (Mar 2019)
- BACE inhibitors block an enzyme needed to form amyloid.
- Mutation driven misfolded Tau proteins can form tangles within the cytoplasm of neurons. The Tau tangles kill nerve cells. LMTX is a drug treatment targeted at these tangles.
- The brain becomes inflamed resulting in the killing of many more nerve cells. The hippocampus disintegrates and the brain loses critical functions and memory loss becomes noticeable.
plaque inhibition trial by Eli Lilly with Solanezumab
fails (Nov
2016)
- NYT Aug 11 2013 Sendhil
Mullainathan's economic view on Behavioral
hazard is Sendhil Mullainathan, Katherine Baicker and Josh Schwartzstein's name for patients underuse of highly effective drugs so they can avoid constraining copayments. and copayments is a fixed payment for a covered service after any deductible has been met. It is a key strategy of the ACA to make subscribers aware of the costs of treatment and to put pressure on high cost health services. As such suppliers and providers are keen to undermine the copayment: value based health insurance, Paying the copayment (Oct 2015), Place on the USPSTF list of preventative services (Sep 2016);
:
- BMS checkpoint
inhibitors release the immune system's checkpoints: PD-1, CTLA-4; on attacking host cells: by 1) stopping T-cell division and 2) reducing their life spans. They are used in immuno-oncology where, in 2016: They are approved for treatment of: Advanced melanoma, HL, lung, kidney, liver cancer; They have a general success rate of 20 - 40% and higher for melanoma. Checkpoint inhibitors work best for tumors that have many mutations: melanomas, lung and bladder cancers. They are enhanced by adjunct treatments that kill tumor cells generating debris to stimulate the immune system. The drugs include: ipilimumab (CTLA-4 inhbition), nivolumab, pembrolizumab, atezolizumab (PD-1 inhibitors); They are costly and often have high copayments. They cause auto-immune side effects including inflammation, rheumatoid arthritis and damage to glands: Adrenal, Thyroid, Pituitary. Powerful steroids such as prednisone can help reduce the inflammation. Damaged glands require sustained hormone treatment. Checkpoint inhibitor research is funded by the CRI. cause
heart damage in rare cases Vanderbilt
cardio-oncology/Brigham
& Women's find (Nov
2016)
- Major DCIS is ductal carcinoma in situ where abnormal cells have been found piled up confined to the lining of the milk ducts of the breast. They are detectable in a mammogram and can look like cancer cells to a pathologist. The cells could be spread along the whole of the milk duct suggesting a need for mastectomy rather than lumpectomy analogous to cervical cancer treatments after a Pap test. It is now known that the DCIS may disappear over time, or stop growing and remain stable. Most women diagnosed with early stage DCIS have surgical or chemotherapy treatment, which does not alter their life expectancy (Aug 2015). No data is available detailing a correlation with breast cancer. But it is now understood that metastatic cancers are different from localized cancers.
study
questions use of aggressive treatment (Aug
2015, Cardiologist comment Aug
2015)
- New specialty bulbs help sleep and alertness (Sep
2015)
- Brigham
& Women's finds
mothers' sounds needed for babies' brains to grow (Feb
2015)
- Nonadherence is focused on improving how effectively patients take their medicines. In the US in 2017 the problem is huge and costly (Apr 2017). Chronic diseases such as Malaria illustrate the complexity of the task. A coherent medical network with shared access to EHR should help. So do blister packs with the days of the week marked. M-health glow caps with a wireless transmitter that lights up if medication has not been taken as expected. An improved prescription label is less open to confusion. Codes on drugs can be scanned by smartphones to initiate download of an informational video. Smart pillboxes control when pills are dispensed. Measuring the contents of a medication bottle can alert for intervention if too much or too little is in the bottle. Drug manufacturers see ways to get closer to the patient: Sanofi Toujeo deployment; Pharmacies are implementing VDS to support medication adherence: Connected Care;
is a huge problem in US agree National Jewish's
Bender,
Brigham
& Women's hospital's Rosenbaum, Pittsburgh
Health Plan's Shrank
& Aetna (Apr
2017)
- Study by Brigham
& Women's Dr. Ridker of Novartis's rheumatoid
arthritis is an autoimmune disorder where the immune system attacks the joints and can generate inflammation around the lungs and heart. It can be treated with: Enbrel, Humira, Ilaris, Xeljanz;
drug Ilaris
shows by reducing inflammation it also lowers cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016). and cardiac is coronary artery disease, also called heart disease or CHD. It reflects atherosclerosis of the coronary arteries. risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. but high cost
will limit its deployment (Aug
2017)
- Rare gene mutation of ANGPTL3 is angiopoietin-like 3, a protein encoded by the ANGPTL3 gene, that participates in angiogenesis in the liver. The preprotein is proteolytically processed into active proteins which inhibit triglyceride metabolism. Gene knockouts result in reduced plasma lipid concentrations.
that stops
inhibition of triglyceride metabolism in angiogenesis is the formation of new blood vessels from existing vessels. It is important in growth, development and wound healing. To become malignant many tumors stimulate angiogenesis.
found associated with reduced CVD is cardiovascular disease which refers to:
- Conditions where narrowed and blocked blood vessels
result in angina, hypertension,
CHD and heart
attacks and hemorrhagic/ischemic strokes.
Mutations of the gene PCSK9 have
been implicated in cardiovascular disease. Rare
families with dominant inheritence of the mutations have
an overactive protein, very high levels of blood
cholesterol and cardiac disease. Other rare PCSK9
mutations result in an 88% reduced risk from heart disease.
Inflammation is associated with cardiovascular disease (Aug
2017).
. Prompts
medical studies: Massachusetts
General Hospital, University
of Pennsylvania, Washington
University; & commercial research & development: Regeneron ANGPTL3 drug,
Ionis;
for blockbuster drug (May
2017)
- 2006 Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
demonstration program promoting cost reductions related to the
most chronically expensive patients. Example participant
is Massachusetts
General.
- CHIP is:
- The Children's Health Insurance Program started in 1997 as part of the BBA as SCHIP. It provides health insurance coverage for children in families with income below 200 percent of the poverty line. The coverage is focused on care specialized for children including: developmental delays, chronic conditions including asthma and obesity. CHIP's funding must be iteratively re-authorized by Congress. CHIP is financed federally, but states must enroll eligible children. In many states one agency administers CHIP and Medicaid. CHIP is leveraged by families that have employer based insurance with costly premiums, so the families only cover the adults.
- Clonal Hematopoiesis of Indeterminate Potential, where stem cells develop a somatic mutation cluster pair often found in leukemia, which is expressed in white blood cells they produce. The mutation clusters give these stem cells a competitive advantage and they accumulate over time. The white blood cells form inflammatory plaques. CHIP increases with age, increasing the risk of dying, of clot fragment induced heart attacks and stroke, over the subsequent 10 years by 54%
mechanism
identified: somatic, Schematic structures which are used to support the operation of the agent. They are modified as the agent's state changes unlike the germ-line schemata.
mutated stem cells is a biological cell which is partly or wholly undifferentiated. A totipotent cell can generate a complete embryo and placenta. Embryos include pluripotent cells which can generate any tissue in the body. Adult humans' cells have turned off this ability but still include multipotent stem cells that differentiate into multiple cell types. Typically a cell's local environment will have the signals required for it to obtain context and differentiate appropriately. This will include both the external environment and the internal state of the cell which has replicated from a parent and obtained its epi-genetic state. So introduction of undifferentiated stem cells into an injured area is not likely to have either aspect of the environment suitable. Consequently development is aiming to encourage differentiation to progenitor cells for the damaged region. This requires delivering the cells to the appropriate part of the body. To avoid rejection by the immune system techniques aim to use cell lines developed from the patient's cells. The techniques to generate these cell lines include: SCNT, iPS. Possible mechanisms of stem cell therapy are: Generation of new differentiated cells, Stimulation of growth of new blood vessels to repopulate damaged regions, Secretion of growth factors, Treatment of diabetes (1 and 2) with addition of pancreatic cells, Assistance of other mechanisms;,
with certain leukemia is a group of cancers of blood forming tissues: bone marrow, lymphatic network; where abnormal white blood cells are generated. One type of leukemia is induced when TAD boundaries near the TAL1 gene fail allowing promotors from across the TAD border to distort the operation of the TAL transcription factor. Mutation clusters common in leukemia have been identified in CHIP.
mutations, accumulate in bone marrow and generate white blood
cells that are highly inflammatory; encouraging: arthritis, clot formation or coagulation is formation of a clot: - Platlets become activated, adhere and aggregate supported by
- Fibrin polymerization, deposition and maturation.
and
collapse resulting in high incidence of heart attack is an AMI. It can induce cardiac arrest. Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI. Risk factors include: taking NSAID pain killers (May 2017). There is uncertainty about why AMI occur. Alternative hypotheses include: - Plaques started to gather in the coronary arteries and grew until no blood flow was possible. If this is true it makes sense to preventatively treat the buildup with angioplasty.
- Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot. If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors.
and stroke is when brain cells are deprived of oxygen and begin to die. 750,000 patients a year suffer strokes in the US. 85% of those strokes are caused by clots. There are two structural types: Ischemic and hemorrhagic. Thrombectomy has been found to be a highly effective treatment for some stroke situations (Jan 2018). ; Dana-Farber's
Ebert, Broad
Institute/Massachusetts
General's Kathiresan conclude from Big Data encompasses the IT systems and processes necessary to do population based data collection, management and analysis. The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass. Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms: Precision medicine, Protein folding modeling (Feb 2019) assumes coevolutionary methods can be applied to identify contact points in a protein's tertiary structure. Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure: - Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Complex data models must include clinical aspects of the patient specific data, including disease state population wide.
- A key aspect is providing clear signals about the nature of the data using data visualization.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
genomics combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes. (Jan
2018)
- Constrained demand for Proton
Therapy irradiates diseased tissues, including cancers, with protons. The particles destroy the DNA of cells they interact with stopping their reproduction. The powerful control of the large charged particles allows acute focus and limited exit dosage. Cyclotrons, synchrotrons and linear accelerators are used to accelerate and control the protons. A significant drawback is the cost and size of the particle accelerator. The therapy is viewed as useful in treating children and for tumors that are proximate to sensitive organs such as eyes. Infrastructure competition driven over-deployment has resulted in business failures for the treatment centers (Apr 2018)
leaves Cancer Centers: Georgetown
University Hospital,
Indiana
University Health System, University
of Maryland MS Greenebaum
CCC, New York (Memorial
Sloan-Kettering, Mount
Sinai Health System, Montefiore Health),
Northwestern
Medical, Scripps,
Seattle cancer care alliance (Fred
Hutchinson, Seattle
Children's, University
of Washington); with costly underperforming or bankrupt is a legal status for an entity that cannot repay its creditor's loans. It holds creditor lawsuits in abeyance while the restructuring process proceeds to allow the entity to continue operations. It also has legal tools for forcing holdout creditors to accept repayments that are lower than the bond sale initially promised.
investments (Apr
2018)
- Massachusetts
General Hospital Center for Genomic Medicine director, Dr.
Kathiresan, and MGH & Broad Institute
cardiologist is the diagnosis and treatment of: Congenital heart defects, CAD, Heart failure, Valvular heart disease; by cardiologists.
Dr. Amit Khera, report, in Nature Genetics, developing a big data encompasses the IT systems and processes necessary to do population based data collection, management and analysis. The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass. Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms: Precision medicine, Protein folding modeling (Feb 2019) assumes coevolutionary methods can be applied to identify contact points in a protein's tertiary structure. Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure:
- Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Complex data models must include clinical aspects of the patient specific data, including disease state population wide.
- A key aspect is providing clear signals about the nature of the data using data visualization.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
tool,
based on the UK
Biobank and then cross checking for validity with: East
Asian, South Asian, African American and Hispanics; and 20,000
people from Brigham
& Women's, that uses 6.6 million base pair positions
to identify increased risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty.
of: heart
disease is cardiovascular disease which refers to:
- Conditions where narrowed and blocked blood vessels
result in angina, hypertension,
CHD and heart
attacks and hemorrhagic/ischemic strokes.
Mutations of the gene PCSK9 have
been implicated in cardiovascular disease. Rare
families with dominant inheritence of the mutations have
an overactive protein, very high levels of blood
cholesterol and cardiac disease. Other rare PCSK9
mutations result in an 88% reduced risk from heart disease.
Inflammation is associated with cardiovascular disease (Aug
2017).
, breast
cancer is a variety of different cancerous conditions of the breast tissue. World wide it is the leading type of cancer in women and is 100 times more common in women than men. 260,000 new cases of breast cancer will occur in the US in 2018 causing 41,000 deaths. The varieties include: Hormone sensitive tumors that test negative for her2 (the most common type affecting three quarters of breast cancers in the US, BRCA1/2 positive, ductal carcinomas including DCIS, lobular carcinomas including LCIS. Receptor presence on the cancer cells is used as a classification: Her2+/-, estrogen (ER)+/-, progesterone (PR)+/-. Metastasis classes the cancer as stage 4. Genetic risk factors include: BRCA, p53, PTEN, STK11, CHEK2, ATM, GATA3, BRIP1 and PALB2. Treatments include: Tamoxifen, Raloxifene; where worrying racial disparities have been found (Dec 2013). International studies indicate early stage breast cancer typed by a genomic test: Oncotype DX, MammaPrint; can be treated without chemotherapy (Aug 2016, Jun 2018), Type
2 diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
, Chronic IBD is inflammatory bowel disease, which is a chronic inflammation of part of the digestive tract. It includes Crohn's disease and Ulcerative colitis. Johns Hopkins's Bayless noted it differs from irritable bowel syndrome - they require different treatments. Symptoms include: Severe diarrhea, Pain, Fatigue & weight loss. It typically begins in the teens or twenties. Incidence has increased exponentially since 1945 in developed countries. 160 genes have been associated with IBD. These genes all relate to: Producing mucus, solidifying the lining of the gut, or regulating the immune system. The rapid increase in the incidence of IBD can be explained by societal impacts on the gut microbiome which interacts with these genes and their products. No particular culprit has been found. It is probably an ecological shift away from symbiosis. There is a shift from fibre-fermenters: Faecalibaterium prausnitzii, Bacteroides fragilis; to: Fusobacterium nucleatum, Escherichia coli; which are more inflammatory. The trigger for disease appears complex: Less early infections with tapeworms, bacteria & viruses, Smaller families - which are typically cleaner, More urban environments - resulting in less contact with higher animals, Less pets, Antibiotics, Endocrine disrupters, Caeserean births, Formula fed babies - rather than breast milk; all potentially contributing to the altered setup and operation of the immune system and microbiome. ,
AF is atrial fibrillation, an abnormal heart rhythm: rapid, irregular. It:
- Can lead to blood clots, stroke, CHF,
dementia and other
complications.
- Fibrillations allow blood to pool in the heart
chambers and form small clots which can then lodge in
small arteries and block blood flow.
- Has become much more common being induced by endemic
diseases: hypertension, obesity and type-2-diabetes.
- Cocoa reduces risk of AF (May
2017)
- Treatments include: digoxin;
; accessible via a
web site (Aug
2018)
- Scientific reprogramming of the immune response, helps with organ transplants.
A patient with NASH is non-alcoholic steatohepatitis.
induced liver is an emergent cellular system providing metabolic: Dietary compound metabolism and signalling: After gorging on sugar-rich foods the liver releases FGF21 hormone to dampen further eating activity; Detoxification, Regulation of glucose through glycogen storage (asprosin signalling from white adipose tissue); clotting, immune, exocrine and endocrine functions. It is supplied with oxygen-rich blood via the hepatic artery and blood rich in semi-processed foodstuffs from the intestines & spleen via the hepatic portal vein. It is constructed from: Hepatocytes which swim in the blood to process it, BECs, Stromal cells, Hepatic stellate cells, Kupffer cells, and blood vessels. The embryonic endoderm cells invade the mesoderm to form the liver bud. Subsequently the liver bud vascularizes and is colonized by hematopoietic cells. The liver operates on a daily cycle (Aug 2018) allowing it time to recover from the stress of processing toxic substances. In a healthy adult liver cells do not divide significantly. But in a damaged liver, the liver cells shift back to a neonatal state to re-enter the cell cycle and rebuild the liver. There are over 100 disorders of the liver. Obesity and diabetes are associated with increased prevalence of these liver disorders worldwide.
failure becomes an early target for reprogramming. Liver
and kidney provides multiple vital functions. It: Produces renin which supports negative feedback, Removes excess organic molecules from the blood, Regulates electrolytes in the blood, Maintains pH homeostasis, Regulates fluid balance, Regulates blood pressure, monitors blood oxygen concentration and signals erythropoiesis with EPO, Reabsorbs water, glucose (SGLT2) and amino acids. Kidney function is monitored with the GFR. Kidneys can fail acutely or chronically. Kidneys are affected by a variety of cancers including: advanced kidney cancer, von Hippel Landau; some of which are induced by PFAS. Multiple myeloma, type 2 diabetes, TB and drug treatments for MDR TB place a strain on the kidneys and can induce failure.
transplants suffer from immune responses and immune supression
drug impacts. Mass.
Gen's James Markmann & Dana-Farber's
Eva Guinan grow Regulatory
T-cells or T lymphocytes, are produced in the thymus & tonsils, and include a T-cell receptor. Alpha beta T cells participate in the adaptive immune system. Gamma delta T cells present antigens to other T cells. CD4+ Helper T cells are activated by MHC class II molecules. They generate cytokines to regulate the immune response. Cytotoxic T cells (CD8+ receptor) destroy virus-infected cells and tumor cells. They can be inactivated to prevent autoimmunity. Memory T cells are formed when undifferentiated T cells are presented with antigen on MHC molecules located on an APC. They are long lived and replicate widely when they detect antigen. Regulatory T cells (suppressor and helper T cells) shut down T cell controlled immunity at the end of an immune reaction. Natural killer T cells respond to CD1d presented glycolipid antigens. MAIT cells defend against microbial infection with targeting by MR1. with donor tissue
invitro, then infuse the T-cells back into the patient to
reprogram the immune
system has to support and protect an inventory of host cell types, detect and respond to invaders and maintain the symbiont equilibrium within the microbiome. It detects microbes which have breached the secreted mucus barrier, driving them back and fortifying the barrier. It culls species within the microbiome that are expanding beyond requirements. It destroys invaders who make it into the internal transport networks. As part of its initialization it has immune cells which suppress the main system to allow the microbiome to bootstrap. The initial microbiome is tailored by the antibodies supplied from the mother's milk while breastfeeding. The immune system consists of two main parts the older non-adaptive part and the newer adaptive part. The adaptive part achieves this property by being schematically specified by DNA which is highly variable. By rapid reproduction the system recombines the DNA variable regions in vast numbers of offspring cells which once they have been shown not to attack the host cell lines are used as templates for interacting with any foreign body (antigen). When the immune cell's DNA hyper-variable regions are expressed as y-shaped antibody proteins they typically include some receptor like structures which match the surfaces of the typical antigen. Once the antibody becomes bound to the antigen the immune system cells can destroy the invader. to accept the donor's liver cells. Pittsburg's
Angus Thomson is using regulatory dendritic cells is an APC that is critical to inflammatory state activation and control of the innate and adaptive immune systems and induction of tolerance during the system's steady-state. Regulatory dendritic cells present environmental antigens to regulatory T-cells to induce immune tolerance. It is possible to push abundant immature white blood cells to transform into dendritic cells in-vitro.
to support kidney transplants (Jan
2019)
- Cervical
cancer is mostly caused by HPV infection. Cervical cancer surgery performs a radical hysterectomy, where the uterus, part of the vagina and other surrounding tissues are removed. In 2017 it was concluded that the rates of cervical cancer had been previously under estimated and far more black women were impacted (Jan 2017). Prophylactic vaccination of young girls is dramatically reducing occurence of this cancer. rates adjusted by Johns
Hopkins epidemiologist studies patterns, causes and effects of health and disease in populations. It identifies risk factors for disease and focuses on preventative health care. Being observational it suffers from a core limitation. It can only show association, not causation. It can suggest hypothesis but it can not disprove them.
Anne
Rositch's improved methodology, now indicate there is a
larger disparity between black and white women (Jan
2017)
- Purpose of sleep facilitates salient memory formation and removal of non-salient memories. The five different stages of the nightly sleep cycles support different aspects of memory formation. The sleep stages follow Pre-sleep and include: Stage one characterized by light sleep and lasting 10 minutes, Stage two where theta waves and sleep spindles occur, Stage three and Stage four together represent deep slow-wave sleep (SWS) with delta waves, Stage five is REM sleep; sleep cycles last between 90-110 minutes each and as the night progresses SWS times reduce and REM times increase. Sleep includes the operation of synapse synthesis and maintenance through DNA based activity including membrane trafficking, synaptic vesicle recycling, myelin structural protein formation and cholesterol and protein synthesis. Sleep also controls inflammation (Jan 2019) Sleep deprivation undermines the thalamus & nucleus accumbens management of pain.
is to forget. The mechanism includes removing synapses, a neuron structure which provides a junction with other neurons. It generates signal molecules, either excitatory or inhibitory, which are kept in vesicles until the synapse is stimulated when the signal molecules are released across the synaptic cleft from the neuron. The provisioning of synapses is under genetic control and is part of long term memory formation as identified by Eric Kandel. Modulation signals (from slow receptors) initiate the synaptic strengthening which occurs in memory. . Wisconsin-Madison's
de Vivo
supports synaptic
homeostasis is Tonini & Cirelli's hypothesis that proposes sleep-wake cycles cause generalized synaptic weakening which leads to down-selection of weak synapses. Pruning does not strike every synapse. They argue that well established memories are left intact. . Johns
Hopkins's Diering
shows Homer1A is the product of the Homer1 gene short form splice. The HomeriA has an EVH1 domain which competes with the long splice forms such as Homer1B and Homer1C, uncoupling mGluR signalling and shrinking dendritic spline structures. Homer1a is expressed by neuronal activity. is
shipped to synapses where in sleep it pairs back synapses (Feb
2017).
- Problematic cancers is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
:
Pancreatic is most often an exocrine tumor. Islet cell tumors are less common. These are rare cancers: less than 200,000 US cases per year, but the five year survival rates are extremely low 3%. They all have KRAS mutations. They are associated with obesity. Diagnostics are starting to leverage genomics and big databases (23 and me). Treatments include: ,
Prostate is cancer of the prostate gland. Genomics detected several common DNA variants associated with increased risk of prostate cancer. Dr. Francis Collins explains that a cluster of these risk variants lies in a stretch of 1 million DNA base pairs on chromosome 8. The cluster contains seven or more risk variants, each of which can raise the risk of prostate cancer by 10 to 30%. The high risk variants occur more frequently in African-American men than European or Asians. African-Americans die from prostate cancer at more than twice the rate of Europeans. Research in mice may explain a link between obesity and prostate cancer (Jan 2018). The average diagnosis is at age 66. Worldwide in 2012 there were 1.1 million cases from which 307,000 died. A common life-saving (Feb 2017) treatment is androgen deprivation therapy, but it has worrying side effects. Various classically defined types of cancer can occur. The most common is adenocarcinoma associated with the epithelial gland cells that generate seminal fluid. Epithelial cell differentiation potency makes these significant cancer agents. Other very rare types of cancer that can start in the prostate are: - Sarcomas
- Small cell carcinomas
- Neuroendocrine tumors
- Transitional cell carcinomas
,
Uterus, Bone; with DNA (DNA), a polymer composed of a chain of deoxy ribose sugars with purine or pyrimidine side chains. DNA naturally forms into helical pairs with the side chains stacked in the center of the helix. It is a natural form of schematic string. The purines and pyrimidines couple so that AT and GC pairs make up the stackable items. A code of triplets of base pairs (enabling 64 separate items to be named) has evolved which now redundantly represents each of the 20 amino-acids that are deployed into proteins, along with triplets representing the termination sequence. Chemical modifications and histone binding (chromatin) allow cells to represent state directly on the DNA schema. To cope with inconsistencies in the cell wide state second messenger and evolved amplification strategies are used.
repair: Caretaker proteins, detect and repair mutations of the DNA. Genes coding for mismatch proteins include: MLH1, MSH2, MLH3. Mutations in these genes are associated with high risk of colon and uterine cancer. The gene BRCA1 is also involved in DNA repair. ;
inhibition, respond in trial by Johns
Hopkins/MS-KCC's
Diaz, to PD-1 is programmed cell death protein 1 (CD279) is encoded by the PDCD1 gene. It is a cell surface receptor that belongs to the immunoglobulin superfamily. It is expressed on T-cells and pro-B cells. It acts as an immune checkpoint preventing the activation of T-cells to help self-tolerance and reduce autoimmunity. When it fails people can suffer from: Lupus, Crohn's disease, Rheumatoid arthritis. PD-1 inhibitor drugs activate the immune system to attack tumors. PD-1 inhibitors are being approved for Melanoma and squamous-cell form of lung cancer.
blocker - Keytruda,
encouraging F.D.A. Food and Drug Administration. to
issue approval for treating this mutational mechanism, for which
there is a specific test (Jun
2017)
- Appleby
leak shows how investment advisers such as: Quintana
Capital Group; helped university endowments:
Indiana
University, Texas Christian University, Colgate, Columbia,
Dartmouth,
Duke, Johns
Hopkins, Stanford,
University
of Texas, University
of Southern California, University of Alabama, DePauw,
Northeastern, Pittsburgh,
Purdue, Reed College, Rutgers, Syracuse, Texas Tech and
Washington State; use offshore blocker
corporations are used to place a legal entity between the highly leveraged activities of hedge funds and private equity companies and their clients. The structure avoids a federal tax on returns derived from borrowed money, which was designed to prevent nonprofits from competing unfairly with for-profit businesses. It effectively blocks any taxable income from flowing to the clients who include US university endowments (Nov 2017). The blocker corporations are setup in a low tax domicile such as the Cayman Islands or British Virgin Islands. : H&F investors, TX Liquidity Capital;
limiting taxable profit flows to the endowments from
their private
equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors. Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges. Private equity companies were initially corporate raiders.
funds: EnCap
Investments, Genstar Capital,
Hellman &
Friedman; that: limit taxes, obscure unpalatable
investments: Oil, Gas & Ferrous Resources; successfully (Nov
2017)
- Apple adds
Beta of EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses:
- The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
access to
its iPhone health app. It will download from EHR systems
of 12 medical institutions: Johns
Hopkins, Cedars-Sinai
(Jan
2018)
- Johns
Hopkins Cynthia Sears & Drew Pardoll report gut microbiome, the trillions of bacteria and viruses that live inside higher animals' guts, on their skin etc. These bacteria and viruses seem to play a role in: immune responses, digesting food, making nutrients, controlling mental health and maintaining a healthy weight. The signals from the gut microbiota are relayed by major nerve fibers: vagus; to the central nervous system. The symbiotic relationship must be actively managed. Human armpits include glands which provide food favoring certain symbionts who build a defensive shield above the skin. In the human gut: Barriers are setup: Mucus secretions form a physical constraint and provide sites for bacteriophages to anchor and attack pathogenic bacteria; Symbiont tailored nourishment: Plant-heavy food creates opportunities for fibre specialists like Bacteroides thetaiotaomicron; is provided, Selective binding sites are provided, Poisons are deployed against the unwelcome, and Temperature, acidity and oxygenation are managed. High throughput sequencing allows the characterization of bacterial populations inside guts. Beginning at birth, as they pass down the birth canal infants are supplied with a microbiome from their mothers. If they are borne via cesarean they never receive some of the key bacteria: Bifidobaterium infantis which is also dependent on oligosaccharides in breast milk; from their mothers. A variety of diseases may be caused by changes in the microbiome:
- Eczema can be related to changes in the skin microbiome.
- Obesity can be induced by changes to the gut microbiome.
- Chronic inflammation
- Allergies
- Type 1 diabetes
:
Bacteriodes fragilis & Escherichia coli; stimulate colon cancer is a major hereditary cancer also called colorectal cancer. It: - Follows a slow, many yearlong, progression from a benign polyp to a localized cancer to an invasive one. Two bacteria: Bacteroides fragilis, Escherichia coli variant; from the gut microbiome have been implicated in the early stages of tumor induction (Feb 2018). It
- Is often associated with Ras mutations and the high risk allele TCF7L2. 30 to 50% of colon cancers have KRAS mutations. Intensive medical surveillance and removal of polyps can be lifesaving for those at high risk. Types of colon cancer include the single gene mutation hereditary: FAP, HNPCC;
- Is linked to obesity.
by invading the mucus is used to cover tissues that are exposed. It is made from mucins. Mucous membranes may secrete mucus to generate a robust barrier.
epithelium is a core cell type that lines cavities and surfaces of blood vessels and organs. All glands are constructed from epithelial cells. Epithelial cells: secrete, absorb, protect, transport and sense. They have no blood supply so they are nourished via diffusion through the basement membrane from underlying connective tissue. Epithelial cell differentiation potency makes these significant cancer agents. of
the colon, developing biofilms is a sheet of bacteria that have invaded the mucus epithelium covering an organ. ,
and damaging the DNA (DNA), a polymer composed of a chain of deoxy ribose sugars with purine or pyrimidine side chains. DNA naturally forms into helical pairs with the side chains stacked in the center of the helix. It is a natural form of schematic string. The purines and pyrimidines couple so that AT and GC pairs make up the stackable items. A code of triplets of base pairs (enabling 64 separate items to be named) has evolved which now redundantly represents each of the 20 amino-acids that are deployed into proteins, along with triplets representing the termination sequence. Chemical modifications and histone binding (chromatin) allow cells to represent state directly on the DNA schema. To cope with inconsistencies in the cell wide state second messenger and evolved amplification strategies are used.
(Feb
2018)
- Johns
Hopkins study finds the number of chronic inflammatory
events in middle age correlates with increased memory loss later
in life (Feb
2019)
- Free standing ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016).
, North
shore Long-Island Jewish's Lenox Hill
HealthPlex, & equivalent from: Mount
Sinai Beth Isreal, NYU
Langone; funnel in patients from improving neighborhoods (Jul
2014)
- Major immuno-oncology uses the immune system to treat cancer. Cancer cells often have different molecules on their cell surface. Studies have shown that genetic signatures of tumors can help predict which patients will benefit from treatment with PD-1 checkpoint inhibitors. Checkpoint inhibitor based treatments aim to make the immune system target these antigens. Clinical trial results indicate they are prolonging lives - even if only by a few months. They have reduced side effects relative to generic chemo therapy. There are three main strategies: cellular, antibody and cytokine.
- Antibody therapies target receptors including CD20, CD274, CD279 and CTLA-4. These therapies include MABs: Alemtuzumab, Ofatumumab, Rituximab; and may induce checkpoint inhibition.
- Cellular therapies have typically involved removing the immune cells from the blood or a tumor, activating, culturing and then returning them to the patient. Trials of these CAR and TCR therapies are proceeding, with some significant problems (Jul 2016).
- Cytokine therapies enhance anti-tumor activity through the cytokine's regulation and coordination of the immune system.
- Vaccines, including Sipuleucel-T for prostate cancer and BCG, classically a vaccine for tuberculosis, which is used for treating bladder cancer.
trial of Keytruda,
by NYU
Langone Perlmutter
Cancer Center's Dr.
Leena Gandhi, funded by Merck, suggests
non-squamous non-small-cell lung cancer affects 200,000 Americans each year. Inflammation is a driver of lung cancer spread (Aug 2017). All these cancers are carcinomas. There are two main hystological types: - Non-small-cell carcinomas are of three sub-types:
- Adenocarcinomas (40% of lung cancers) are typically peripherally situated and mostly induced by smoking.
- Squamous-cell carcinomas (30% of lung cancers) arise in the large bronchi an are highly correlated with smoking.
- Large-cell carcinomas (5 to 10% of lung cancers).
- Small-cell carcinomas.
patients with a biomarker have improved outcomes with early
application of Keytruda and chemotherapy. Result may
change clinical practice (Apr
2018)
- Columbia/New
York-Presbyterian principal investigator Dr. Gregg Stone
reported heart failure is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands. There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). Treatments include: digoxin;
now has a powerful treatment, Abbott labs's MitraClip,
a small device that improves the efficiency of the mitral valve allows blood to flow from the heart's left atrium to the left ventricle. If it fails the heart will have trouble pumping blood around the body resulting in CHF.
that has been damaged by a heart attack is an AMI. It can induce cardiac arrest. Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI. Risk factors include: taking NSAID pain killers (May 2017). There is uncertainty about why AMI occur. Alternative hypotheses include:
- Plaques started to gather in the coronary arteries and grew until no blood flow was possible. If this is true it makes sense to preventatively treat the buildup with angioplasty.
- Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot. If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors.
,
a 614 patient trial including patients at: University
of Pennsylvania, Mount
Sinai, NYU
Langone; showed. The device still needs F.D.A. Food and Drug Administration. approval for the
trialed surgery (Sep
2018)
- UCSF's Computational
Health Sciences leader Atul
Butte reviews: DNA (DNA), a polymer composed of a chain of deoxy ribose sugars with purine or pyrimidine side chains. DNA naturally forms into helical pairs with the side chains stacked in the center of the helix. It is a natural form of schematic string. The purines and pyrimidines couple so that AT and GC pairs make up the stackable items. A code of triplets of base pairs (enabling 64 separate items to be named) has evolved which now redundantly represents each of the 20 amino-acids that are deployed into proteins, along with triplets representing the termination sequence. Chemical modifications and histone binding (chromatin) allow cells to represent state directly on the DNA schema. To cope with inconsistencies in the cell wide state second messenger and evolved amplification strategies are used.
and limits to its impact, genome web sites: 23andMe etc., Precision
medicine is the integration of molecular research: genomics, proteomics, transcriptomics, metabolomics, cell signalling; and clinical data through a taxonomy based on CAS modeling overlaid on an information commons. It aims to support treatment of disease and remove the organ and symptom based methodological flaws in the ICD. Supporters of the D.S.M. note the aggressive shift to precision medicine at the NIMH under Dr. Insel, constrained useful clinical research (Nov 2015).
(ICD is the International Classification of Diseases diagnosis codes which doctors must specify and associate with a correct CPT procedure code to have treatment accepted and reimbursed. ICD is mainly focused on billing. Methodological issues (Jun 2018) are driving a shift to precision medicine.
history and classification issues, Challenge of studying and
understanding long term illness), Privacy, Whole genome vs.
Specific strategies, Sequencing directions describes methods of DNA sequencing, that replace traditional Sanger sequencing, which have been implemented in commercial DNA sequencers after 2000. The methods include: - Base-by-base is stepwise sequencing where there are 3' removable blockers on the DNA arrays.
- Pyrosequencing,
- Sequencing by synthesis,
- Sequencing by ligation,
- SMRT,
- DNA colony sequencing,
- DNA nanoball,
- Nanopore sequencing,
- MPSS was the first of the next generation sequencing methods,
- Polony sequencing.
:
Helix; CRISPR is clustered replicating interspersed silent palindromic repeats; a technique for exact targeting, cutting and editing of DNA based on leveraging bacterial enzymatic defenses against viruses generalized to any DNA sequence in a prokaryotic or eukaryotic cell. It was identified during studies of a bacterial adaptive immune system. In that system bacterial proteins grab parts of a virus that has infected them and record it within the palindromic structures that mark an array of inserted viral DNA used as a log persisted over generations. If a new infection occurs the viral DNA is compared with the sequences and if a match exists the CAS proteins break up the viral DNA initiating its destruction. This bacterial system was then updated and repurposed by the researchers to support targeted genetic engineering. As explained by Dr. Doudna, the CRISPR proteins and the 20 nucleotide RNA template migrate into the nucleus where they rapidly target DNA which complements the RNA template and the Cas9 enzyme performs the edits. Being a bacterial system CRISPR Cas9 does not target eukaryotic heterochromatic DNA well. It is not fully understood how they find the target sequence so quickly. It has been shown that Cas9 will bind to sites with a 5-8 base match but then it releases rapidly without cutting. To cut, Cas9 has to reconfigure, which does not occur in the mismatch situations. and challenge
of treatment delivery, Surprises: Interest in ancestry, Failure
to comprehend risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. ;
Leverage of personal
fitness probes, Problems of rapid change overloading
doctors (Jun
2018)
- BMS/NCI is the national cancer institute.
funded PD-1 is programmed cell death protein 1 (CD279) is encoded by the PDCD1 gene. It is a cell surface receptor that belongs to the immunoglobulin superfamily. It is expressed on T-cells and pro-B cells. It acts as an immune checkpoint preventing the activation of T-cells to help self-tolerance and reduce autoimmunity. When it fails people can suffer from: Lupus, Crohn's disease, Rheumatoid arthritis. PD-1 inhibitor drugs activate the immune system to attack tumors. PD-1 inhibitors are being approved for Melanoma and squamous-cell form of lung cancer. checkpoint
inhibitor release the immune system's checkpoints: PD-1, CTLA-4; on attacking host cells: by 1) stopping T-cell division and 2) reducing their life spans. They are used in immuno-oncology where, in 2016: They are approved for treatment of: Advanced melanoma, HL, lung, kidney, liver cancer; They have a general success rate of 20 - 40% and higher for melanoma. Checkpoint inhibitors work best for tumors that have many mutations: melanomas, lung and bladder cancers. They are enhanced by adjunct treatments that kill tumor cells generating debris to stimulate the immune system. The drugs include: ipilimumab (CTLA-4 inhbition), nivolumab, pembrolizumab, atezolizumab (PD-1 inhibitors); They are costly and often have high copayments. They cause auto-immune side effects including inflammation, rheumatoid arthritis and damage to glands: Adrenal, Thyroid, Pituitary. Powerful steroids such as prednisone can help reduce the inflammation. Damaged glands require sustained hormone treatment. Checkpoint inhibitor research is funded by the CRI. immuno-oncology uses the immune system to treat cancer. Cancer cells often have different molecules on their cell surface. Studies have shown that genetic signatures of tumors can help predict which patients will benefit from treatment with PD-1 checkpoint inhibitors. Checkpoint inhibitor based treatments aim to make the immune system target these antigens. Clinical trial results indicate they are prolonging lives - even if only by a few months. They have reduced side effects relative to generic chemo therapy. There are three main strategies: cellular, antibody and cytokine. - Antibody therapies target receptors including CD20, CD274, CD279 and CTLA-4. These therapies include MABs: Alemtuzumab, Ofatumumab, Rituximab; and may induce checkpoint inhibition.
- Cellular therapies have typically involved removing the immune cells from the blood or a tumor, activating, culturing and then returning them to the patient. Trials of these CAR and TCR therapies are proceeding, with some significant problems (Jul 2016).
- Cytokine therapies enhance anti-tumor activity through the cytokine's regulation and coordination of the immune system.
- Vaccines, including Sipuleucel-T for prostate cancer and BCG, classically a vaccine for tuberculosis, which is used for treating bladder cancer.
study by MD
Anderson's Dr. Hussain Tawbi reports Opdivo & Yervoy combination
used to treat melanoma is a cancer of the melanocytes. It is a less common form of skin cancer but is the most deadly once it has invaded deeply into layers of skin. It is primarily caused by UV light. It is tied to mutations in the signalling pathway (BRAF) and regulatory genes (P53) with a key dependency on crestin reactivation (Jan 2016).
(and likely other cancers of 200,000 people a year) patients
with consequent metastatic brain cancers, at 28 AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017); s: MS-KCC;
find survival rate expands beyond a year, like Jimmy Carter
after he was treated with Keytruda.
But 50% of patients had significant side effects of which 20%
quit the treatment (Aug
2018)
- Corruption of academic medical research was catalyzed by
1980's laws: Stevenson
Wydler of 1980 required federal laboratories to actively participate in and budget for technology transfer activities.
, Bayh-Dole is the Patent and Trademark Law Amendments Act which allowed universities, small businesses and non-profits working with federal researchers to elect to pursue ownership of an invention in preference to the government taking ownership. ,
FTTA is the Federal Technology Transfer Act of 1986. It amended the Stevenson-Wydler Technology Innovation Act to allow Government-operated laboratories to enter into cooperative research agreements and by establishing the NSF's Federal Laboratory Consortium for Technology Transfer. ; that allowed AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017); s to partner with
drug companies that provided funding and inputs on research, and
paid a royalty from product sales to the AMC. This
resulted in distorted: designs, reports; and academic key opinion
leaders are highly influential physicians who, according to Dr. Marcia Angell, write textbooks and medical journal articles, issue practice guidelines, sit on the F.D.A. advisory panels, head physician specialty societies and speak at events where clinicians are taught about prescription drugs. acting as an informal sales force for the
pharmaceutical companies (Sep
2018)
- Time of day, month during the year, and type of hospital,
affect the uncertainty is when a factor is hard to measure because it is dependent on many interconnected agents and may be affected by infrastructure and evolved amplifiers. This is different from risk, although the two are deliberately conflated by ERISA. Keynes argued that most aspects of the future are uncertain, at best represented by ordinal probabilities, and often only by capricious hope for future innovation, fear inducing expectations of limited confidence, which evolutionary psychology implies is based on the demands of our hunter gatherer past. Deacon notes reduced uncertainty equates to information.
of complications from giving birth. 12,000 of two million
births included: severe perineal laceration, ruptured uterus,
unplanned hysterectomy, admission to ICU is intensive care unit. It is now being realized that the procedures and environment of the ICU is highly stressful for the patients. In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD. Intubation and catheterization are also traumatic. Sometimes seperated into MICU and SICU. eICU skill centralization may bring down costs. , unplanned
follow-on operation; with night shift risk 21% higher, weekends
9% higher, holidays 29% higher. Teaching hospitals is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017); , at
the start of new residencies, are 28% higher - with risk droping
to normal by June. All these factors increase the costs of
a hospital birth (Mar
2019)
- Are good doctors bad for your health? (Nov
2015)
- Chicago Northwestern
Memorial AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017);
lupus is a chronic autoimmune disease, in which many parts of the body can be attacked: joints, skin, kidneys, blood cells, brain, heart, lungs. Its cause is unknown, there is little linkage within families, but women are affected 4 to 12 times as often as men - especially those of childbearing age. There are various types: SLE, cutaneous lupus, drug-induced lupus, Neonatal lupus. It is treated with Belimumab, prednisone corticosteroid; patient, Ms.
Spoor, collapsed after a lung biopsy resulting in cardiac arrest is a sudden halt in the effective blood circulation due to the heart not contracting effectively. This prevents delivery of oxygen and glucose to the body. It can be caused by a heart attack. CHF in contrast, typically has substandard circulation but the heart is still pumping sufficient blood to sustain life. Cardiac arrest may be reversed with effective treatment. The treatment regime and effectiveness vary significantly. They can include: - CPR which needs endurance training to sustain for at least 45 minutes of deployment needed for success. If no pulse is detected after 20 minutes more powerful treatments should be deployed.
- ECMO which is more widely used in Japan and South Korea than in the US.
- Once circulation is restored additional interventions are required for success, but their application is not benchmarked, standardized or regulated:
- Therapeutic hypothermia - people who remain comatose after being in cardiac arrest should be cooled for at least 24 hours to a temperature between 89.6 and 96.8 F.
- Avoiding toxic amounts of oxygen
- Maintaining normal co2 levels
- Maintaining high blood pressure
- If needed cardiac catheterization.
,
provided ECMO is extracorporeal membrane oxygenation where blood is drawn from the patient and passed through an oxygenator and then back into the body.
breathing assists, subsequently found by blood test to be
infected with Candida
auris is a fungus resident in soils, which has developed resistance to medical antifungals: itraconazole; as well as azole agricultural fungicides. 90% of C. auris infections are resistant to an antifungal. 30% are resistant to two of the drugs. Genome analysis indicates four ancient strains persist. It has been assisted by the widespread use of fungicides enabling it to opportunistically migrate to niches cleared of its normal competitors. C. auris was first identified in an ear infection of a Japanese patient in 2009. But it had subsequently colonized all proximate surfaces and was detected in the air. It infects the very ill and those with weakened immune systems. 50% of those infected die within 90 days. , possibly HAC is Hospital-Acquired Condition.
from one of the tubes, which proved to be multiple drug
resistant results from evolutionary pressure of antibiotics, supported by plasmids and R factors: NDN1; which encode resistance properties for otherwise lethal antibiotics. World leaders hope cooperation can preserve the power of last resort antibiotics: Carbapenems, Colistin (Oct 2016). Worrying trends include: C. auris resistance to medical antifungals: itraconazole; as well as azole agricultural fungicides (Apr 2019), CRE (May 2016), C. diff (May 2015), MDR & XDR TB; resulting in increased risk of sepsis and death. The World Bank estimates full resistance would reduce the global economy in 2050 by between 1.1 and 3.8%. and she died. She is one of 158 C. auris
cases in Illinois since 2016 (Apr
2019)
Porter
describes the risks of focus:
- The cost differential between broad-range competitors and the
focused firm widens to eliminate the cost advantages of serving
a narrow target or to offset the differentiation achieved by
focus;
- The differences in desired products or services between the
strategic target and the market as a whole narrows;
- Competitors find submarkets within the strategic target and
out focus the focuser.
Strengths:
- 1: Extensive education &
research skills
- 2: Advanced clinical labs
support medical researchers
- 3: Perfect partners for drug
& technology companies and their researchers (Jun
2017, Jan
2018)
- 4: Colocation with health
economists etc.
- 5: Organization setup to
reflect latest theory & practice (Sep
2015, Feb
2017, Feb
2018, Jan
2018)
- 6: Benefit from presence of
advanced devices
- 7: Experts in genomics combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes.
can leverage big data encompasses the IT systems and processes necessary to do population based data collection, management and analysis. The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass. Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms: Precision medicine, Protein folding modeling (Feb 2019) assumes coevolutionary methods can be applied to identify contact points in a protein's tertiary structure. Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure:
- Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Complex data models must include clinical aspects of the patient specific data, including disease state population wide.
- A key aspect is providing clear signals about the nature of the data using data visualization.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
to highlight risks, and find good mutations and search
internationally for target patients for trials (May
2017, Aug
2018)
- 8: Powerful brands (Jul
2014)
- 9: Clinical labs history data
supports deep
learning is an artificial intelligence approach where engineers deploy data into deep neural networks.
& genomics
- 10: Imaging history supports deep
learning is an artificial intelligence approach where engineers deploy data into deep neural networks.
- 11: Citizen's United (SCOTUS)
|
Weaknesses
- 1: Lack of patients for biologic are drugs made in living cells. Typically they are proteins developed using genetic engineering to develop the cellular host, and to customize animal source, DNA to produce human target proteins. Such biologics partially solve the problem of previous protein sources, extracted from animals or human sources, of contamination and immune responses. The strategy is very effective for blood transported proteins such as antibodies (MABs), hormones and blood factors. But intra-cellular proteins still demand delivery and accurate cell targeting. This creates analogous problems to those of gene therapy.
treatment trials (Aug
2017)
- 2: AMC investment strategies
are relatively costly & risky (Dec
2015, Nov
2017, Apr
2018)
- 3: Margins demanded by
independent specialists
- 4: Lack of leverage of EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses:
- The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
based
process integration to 3rd party specialists but AMCs
have all the costs
- 5: Disconnected from health
plan
- 6: Current procedure lags best
practice at NCCN
(Aug
2015)
- 7: Limited power, relative to
large insurers, facilitates integration with larger
hospital networks
- 8: Influx of new trainee
residents impacts quality of patients' outcomes (Mar
2019)
- 9:
- 10:
- 11:
- 12:
- 13:
- 14:
- 15:
- 16:
- 17:
- 18:
- 19:
- 20:
- 21:
- 22:
- 23:
- 24:
|
Opportunities:
- 1: Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
demonstrator funding for hot spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community.
patient care
coordination aims to transfer information between the patient and each care participant as required and establish accountability by defining who is responsible for each care delivery activity, the extent of that responsibility and when that responsibility will be transferred to other care participants or the patient and family. Successful care coordination requires face-to-face interactions. It also requires aligned incentives (ACO, Bundled payments). AHRQ defines quality measures for care coordination. The situation is usually complex and adaptive due to the interactions of all the providers, settings, the patients' preferences, and the number of physical health problems, treatments, and the patients' social situation. The potentially exponential increase in complexity as the number of these factors present increases leads to patient hot spots requiring explicit proactive coordination of care. It is argued that care coordination must include six specific activities: - Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history. It needs to be updated periodically and after new diagnosis and other changes in health or functional status.
- Creation and updating of proactive plan of care
- Communication
- Facilitation of transitions: typical transition problems are detailed by Project Boost. A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff.
- Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness.
- Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.
nurses, which induce a 5% cost
reduction.
- 2: Research focus allows
reduction in fear of killing patients. This
enables risky, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty.
innovative is the economic realization of invention and combinatorial exaptation. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy.
treatment
- 3: Integration with larger hospital
systems is the owner of a set of hospitals and other owned infrastructure and employer of direct staff. to increase competitive power and gain
access to more patients.
- 4: Attract clinical researchers
with access to clinical labs and experts (Jun
2017).
- 5: Early F.D.A. Food and Drug Administration.
approval locks down trial opportunities (Jun
2017, Apr
2018)
- 6: Participation in random
control trials that clarify strategy for good
treatment (Feb
2015, Jan
2017)
- 7: Experts help in handling
patients rational fears (DCIS is ductal carcinoma in situ where abnormal cells have been found piled up confined to the lining of the milk ducts of the breast. They are detectable in a mammogram and can look like cancer cells to a pathologist. The cells could be spread along the whole of the milk duct suggesting a need for mastectomy rather than lumpectomy analogous to cervical cancer treatments after a Pap test. It is now known that the DCIS may disappear over time, or stop growing and remain stable. Most women diagnosed with early stage DCIS have surgical or chemotherapy treatment, which does not alter their life expectancy (Aug 2015). No data is available detailing a correlation with breast cancer. But it is now understood that metastatic cancers are different from localized cancers.
: Aug
2015)
- 8: Able to leverage all health
plans except HMO is a Health Maintenance organization managed care plan as opposed to a PPO plan. It uses the allocated PCP as a gatekeeper who must refer a patient to any health specialist for the patient to gain access.
.
- 9: Can participate in innovation is the economic realization of invention and combinatorial exaptation. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy.
hubs with other local
public and private universities (Nov
2017)
- 10: Desperate patients want
access to trials
- 11: Improving medication
adherence is focused on improving how effectively patients take their medicines. In the US in 2017 the problem is huge and costly (Apr 2017). Chronic diseases such as Malaria illustrate the complexity of the task. A coherent medical network with shared access to EHR should help. So do blister packs with the days of the week marked. M-health glow caps with a wireless transmitter that lights up if medication has not been taken as expected. An improved prescription label is less open to confusion. Codes on drugs can be scanned by smartphones to initiate download of an informational video. Smart pillboxes control when pills are dispensed. Measuring the contents of a medication bottle can alert for intervention if too much or too little is in the bottle. Drug manufacturers see ways to get closer to the patient: Sanofi Toujeo deployment; Pharmacies are implementing VDS to support medication adherence: Connected Care;
(Apr
2017)
- 12: Use brand to leverage
collapse and capture additional valuable patients with
free standing ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016).
s
(Jul
2014)
- 13: EBM is evidence based medicine where explicit and judicious use of current best practice evidence is used in making decisions about the care of patients. There are differences in the application to individuals and populations. Still the goal was to replace subjective use of basic and clinical research with:
- Prioritization of clinical trial results to build conclusions.
- Adoption of processes that translated epidemiological methods to physician decision making.
- Widely used but innapropriate procedures were abandoned.
- There is now explicit evaluation of evidence of effectiveness before issuing practice guidelines. A rational for adoption is required.
- HHS appointed USPSTF to develop evidence based recommendations.
&
research investments make humanity focused treatments
robust to budget cuts
- 14: Leverage xG
Health Solutions to integrate processes to
doctors
- 15: Deep
learning is an artificial intelligence approach where engineers deploy data into deep neural networks.
& nanotechnology reduces number of
damaging imaging scans (Feb
2019)
- 16: Increasing network returns
from a helicopter pad (Cleveland,
UCLA,
Jul
2018)
- 17:
- 18:
- 19:
- 20:
- 21:
- 22:
|
Threats
- 1: Cost of advanced medicines
reduces the value of trials and constrains treatment (Aug 2013,
Aug
2017)
- 2: No opportunity to share
infrastructure.
- 3: High cost chronic complex hot spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community.
patients.
- 4: Stark laws block EMR refers to electronic medical records which are a synonym of EHR. EMRs have strengths and weaknesses:
- The EHR provides an integrated record of the health
systems notes on a patient including: Diagnosis and
Treatment plans and protocols followed, Prescribed drugs
with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's
situation accurately.
- The EHR often acts as a catch-all. There is often
little time for a doctor, newly attending the patient, to
review and validate the historic details.
- The meaningful use
requirements of HITECH and Medicare/Medicaid
specify compliance of an EHR system or EHR module for specific
environments such as an ambulatory
or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and
undermines face-to-face time between doctor and
patient. Doctors are allocated 12 minutes to
interact with a patient of which less than five minutes
was used for recording hand written notes. With the
EHR 12 minutes may be required to update the record!
linkups
with partner physicians.
- 5: Cost of Epic & Cerner EMR refers to electronic medical records which are a synonym of EHR. EMRs have strengths and weaknesses:
- The EHR provides an integrated record of the health
systems notes on a patient including: Diagnosis and
Treatment plans and protocols followed, Prescribed drugs
with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's
situation accurately.
- The EHR often acts as a catch-all. There is often
little time for a doctor, newly attending the patient, to
review and validate the historic details.
- The meaningful use
requirements of HITECH and Medicare/Medicaid
specify compliance of an EHR system or EHR module for specific
environments such as an ambulatory
or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and
undermines face-to-face time between doctor and
patient. Doctors are allocated 12 minutes to
interact with a patient of which less than five minutes
was used for recording hand written notes. With the
EHR 12 minutes may be required to update the record!
systems
and power of the companies
- 6: Trial failures include risk
of patient damage (Nov
2016, 2)
- 7: Follow early treatment
strategies, which can be high risk for patients
- 8: Corrupting
incentives for academics undermines the
reputation of the AMC.
- 9: Powerful insurers entering
treatment space with access to health plan data (UHC)
- 10: Endowment management
important but politically risky (Nov
2017)
- 11: Complexity of genomic
medicine (Aug
2016, Jun
2018)
- 12: ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016).
immediate
access to infrastructure (CT is computerized tomography in which a series of X-ray views taken from many angles are combined by computer processing to create 3-D images. It is very useful for examining people who have been subject to trauma such as car accidents. The high dose of radiation is a cause for concern with over use of CT scanning (Jan 2014). The Banyan Brain Trauma Indicator blood test should help here. scans etc.)
limits shared infrastructure possibilities
- 13: Amazon (Chase)
disruption
- 14: Dependence on antibiotics are compounds which kill bacteria, molds, etc. Sulfur dye stuffs were found to be effective antibiotics. The first evolved antibiotic discovered was penicillin. Antibiotics are central to modern health care supporting the processes of: Surgery, Wound management, Infection control; which makes the development of antibiotic resistance worrying. Antibiotics are:
- Economically problematic to develop and sell.
- Congress enacted GAIN to encourage development of new antibiotics. But it has not developed any market-entry award scheme, which seems necessary to encourage new antibiotic R&D.
- Medicare has required hospitals and SNFs to execute plans to ensure correct use of antibiotics & prevent the spread of drug-resistant infections.
- C.D.C. is acting to stop the spread of resistant infections and reduce unnecessary use of antibiotics.
- F.D.A. has simplified approval standards. It is working with industry to limit use of antibiotics in livestock.
- BARDA is promoting public-private partnerships to support promising research.
- Impacting the microbiome of the recipient. Stool banking is a solution (Sloan-Kettering stool banking).
- Associated with obesity, although evidence suggests childhood obesity relates to the infections not the antibiotic treatments (Nov 2016).
- Monitored globally by W.H.O.
- Regulated in the US by the F.D.A. who promote voluntary labeling by industry to discourage livestock fattening (Dec 2013).
- Customer demands have more effect - Perdue shifts to no antibiotics in premier chickens (Aug 2015).
undermined by increasing resistance results from evolutionary pressure of antibiotics, supported by plasmids and R factors: NDN1; which encode resistance properties for otherwise lethal antibiotics. World leaders hope cooperation can preserve the power of last resort antibiotics: Carbapenems, Colistin (Oct 2016). Worrying trends include: C. auris resistance to medical antifungals: itraconazole; as well as azole agricultural fungicides (Apr 2019), CRE (May 2016), C. diff (May 2015), MDR & XDR TB; resulting in increased risk of sepsis and death. The World Bank estimates full resistance would reduce the global economy in 2050 by between 1.1 and 3.8%.
|
The following analysis discusses the gross implications of the
attributes of the SWOT matrix (Imbalances).
Cluster 1 - ?? (W9, W10, W22,
S2, S3, S4, O2, O11, O16, O17, O18, O21, O22, T6, )
Cluster 2 - ?? (W13, W14, W15, W16, )
Cluster 3 - ?? (W1, W17, S5, )
Cluster 4 - ?? (W18, W19, O6, O7, )
Un assigned (S1, W2, W3, W4, W5, W6, W7, W8, W12, W20, W21, O1,
O3, O4, O5, O8, O9, O10, O12, O13, O14, O15, O16, T1, T2, T3, T4,
T5, T7, T8, T9, T10, T11, T12, T13, T14)
Like Geisinger
with its xG
startup many of these hospital groups are looking to spinoff
technologies and startups from their health care IT incubators and
so gain access to HCIT is health care information technology. The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets. Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.;
revenues. A value delivery system is forming with clusters of
providers such as UHC,
and health care technology incubators such as AVIA.
UCLA describes
how investment in research and EBM is evidence based medicine where explicit and judicious use of current best practice evidence is used in making decisions about the care of patients. There are differences in the application to individuals and populations. Still the goal was to replace subjective use of basic and clinical research with: - Prioritization of clinical trial results to build conclusions.
- Adoption of processes that translated epidemiological methods to physician decision making.
- Widely used but innapropriate procedures were abandoned.
- There is now explicit evaluation of evidence of effectiveness before issuing practice guidelines. A rational for adoption is required.
- HHS appointed USPSTF to develop evidence based recommendations.
processes can be used
to make treatments, such as People-Animal Connection, robust in the
face of budget cuts. At Laguna Honda
equivalent therapy strategies (the barnyard, the greenhouse, and the
aviary) were undermined by cost cutting and regulations aimed at
cleanliness. Without evidence of benefits the Laguna Honda
programs were easily constrained.
UCLA Health also
focuses on JIT.
UCLA Health show
how an exceptional leader now aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group. Pinker notes the evolved pressure of social rivalry associating power with leadership. Different evolved personality types reinforced during development provided hunter-gatherer bands with alternate adult capabilities for coping with the various challenges of the African savanna. As the situation changed different personalities would prove most helpful in leading the band. Big men, chiefs and leaders of early states leveraged their power over the flow of resources to capture and redistribute wealth to their supporters. As the environmental state changed and began threatening the polity's fitness, one leader would be abandoned, replaced by another who the group hoped might improve the situation for all. Sapolsky observes the disconnect that occurs between power hierarchies and wisdom in apes. In modern Anglo-American style corporations, which typically follow Malthus, and are disconnected from the superOrganism nest site, the goal of leadership has become detached from the needs of this broader polity, instead: seeking market and revenue growth, hiring and firing workers, and leveraging power to reduce these commitments further. Dorner notes that corporate executives show an appreciation of how to control a CAS. Robert Iger with personality types: Reformer, Achiever, Investigator; describes his time as Disney CEO, where he experienced a highly aligned environment, working to nurture the good and manage the bad. He notes something is always coming up. Leadership requires the ability to adapt to challenges while compartmentalizing. John Boyd: Achiever, Investigator, Challenger; could not align with the military hierarchy but developed an innovative systematic perspective which his supporters championed and politicians leveraged. John Adair developed a modern leadership methodology based on the three-circles model. 's
differentiation strategy can build and leverage a great culture is how we do and think about things, transmitted by non-genetic means as defined by Frans de Waal. CAS theory views cultures as operating via memetic schemata evolved by memetic operators to support a cultural superorganism. Evolutionary psychology asserts that human culture reflects adaptations generated while hunting and gathering. Dehaene views culture as essentially human, shaped by exaptations and reading, transmitted with support of the neuronal workspace and stabilized by neuronal recycling. Damasio notes prokaryotes and social insects have developed cultural social behaviors. Sapolsky argues that parents must show children how to transform their genetically derived capabilities into a culturally effective toolset. He is interested in the broad differences across cultures of: Life expectancy, GDP, Death in childbirth, Violence, Chronic bullying, Gender equality, Happiness, Response to cheating, Individualist or collectivist, Enforcing honor, Approach to hierarchy; illustrating how different a person's life will be depending on the culture where they are raised. Culture: - Is deployed during pregnancy & childhood, with parental mediation. Nutrients, immune messages and hormones all affect the prenatal brain. Hormones: Testosterone with anti-Mullerian hormone masculinizes the brain by entering target cells and after conversion to estrogen binding to intracellular estrogen receptors; have organizational effects producing lifelong changes. Parenting style typically produces adults who adopt the same approach. And mothering style can alter gene regulation in the fetus in ways that transfer epigenetically to future generations! PMS symptoms vary by culture.
- Is also significantly transmitted to children by their peers during play. So parents try to control their children's peer group.
- Is transmitted to children by their neighborhoods, tribes, nations etc.
- Influences the parenting style that is considered appropriate.
- Can transform dominance into honor. There are ecological correlates of adopting honor cultures. Parents in honor cultures are typically authoritarian.
- Is strongly adapted across a meta-ethnic frontier according to Turchin.
- Across Europe was shaped by the Carolingian empire.
- Can provide varying levels of support for innovation. Damasio suggests culture is influenced by feelings:
- As motives for intellectual creation: prompting
detection and diagnosis of homeostatic
deficiencies, identifying
desirable states worthy of creative effort.
- As monitors of the success and failure of cultural
instruments and practices
- As participants in the negotiation of adjustments
required by the cultural process over time
- Produces consciousness according to Dennet.
to achieve
broad excellence. This builds on itself in various ways:
The 26 hospitals in the National
Comprehensive Cancer Network calls itself "the arbiter of high
quality cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
care." It creates widely used practice guidelines for cancer
treatment.
However, even at these elite centers current use lags best practice
(intraperitoneal ovarian
cancer is a relatively uncommon disease but is often fatal. It has been associated with use of talcum powder (May 2016). treatment 2006 - 2015).
And the participants have still found themselves involved in an innovation is the economic realization of invention and combinatorial exaptation. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy. ,
technology and marketing arms race (Dec
2015).
Nanoparticle drug delivery is slowly moving towards a targeted
metastatic cancer killer (Mar
2016). Ligandal
uses logically similar model for CRISPR is clustered replicating interspersed silent palindromic repeats; a technique for exact targeting, cutting and editing of DNA based on leveraging bacterial enzymatic defenses against viruses generalized to any DNA sequence in a prokaryotic or eukaryotic cell. It was identified during studies of a bacterial adaptive immune system. In that system bacterial proteins grab parts of a virus that has infected them and record it within the palindromic structures that mark an array of inserted viral DNA used as a log persisted over generations. If a new infection occurs the viral DNA is compared with the sequences and if a match exists the CAS proteins break up the viral DNA initiating its destruction. This bacterial system was then updated and repurposed by the researchers to support targeted genetic engineering. As explained by Dr. Doudna, the CRISPR proteins and the 20 nucleotide RNA template migrate into the nucleus where they rapidly target DNA which complements the RNA template and the Cas9 enzyme performs the edits. Being a bacterial system CRISPR Cas9 does not target eukaryotic heterochromatic DNA well. It is not fully understood how they find the target sequence so quickly. It has been shown that Cas9 will bind to sites with a 5-8 base match but then it releases rapidly without cutting. To cut, Cas9 has to reconfigure, which does not occur in the mismatch situations. deployment (Nano
conference).
And the testing statistical frameworks (Bayesian is an iterative form of statistics invented by Thomas Bayes. It uses a 'prior' statistic to represent the prior situation and then performs a calculation that integrates the probability of new events occurring into a 'posterior' probability. This posterior becomes the prior for the next iteration with the application of the Bayesian identity xpost = xprior*y/(xprior*y + z(1-xprior)). The magic in Bayesian statistics is in accurately generating the prior xprior and the current event probabilities y and z. R. A. Fischer was so skeptical of the legitimacy of the prior that he advocated an alternative statistical framework and experimental process. ) and
publishing methodology being used in science is undermining (Aug
2015) the leverage hospitals can obtain from a leading edge
diagnosis and treatment based focus. Often lack of validation
allows powerful business models (stents
to treat angina) to continue unchallenged.
Conversely Memorial
Sloan-Kettering cancer center was able to build focused genomic
databases of patients which reduced misdiagnosis of minority
populations (Aug
2016).
North
Shore's Lenox
Hill HealthPlex is a funnel
of profitable patients through its standalone ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). s to the North Shore
Hospitals. Standalone EDs also undermine
the positioning of low cost urgent care
clinics is an efficient and less costly 'alternative' to the ER. There is no accepted standard. Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls. Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones. Unlike an ER they can not admit patients to a hospital. Some also offer services like pre-employment drug screening and summer camp physicals. which are trying to reengineer the
ED. NYULMC is using the same strategy at Long
Island College Hospital.
The pressure to integrate to combat narrow networks - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans. This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans. By limiting the number of providers/doctors offered in the plans the few that are included should get more business. Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers). In large cities narrow networks are even more common. Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills. There are problems induced by narrow network constraints: - Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts. Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running. If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016).
and the shift to population health aims to segment a patient population by treatment acuity and patient derived impact to raise outcomes efficiently without being rejected like the early HMOs. Small numbers of patients follow life styles which impact themselves and the health care network very significantly. Specialized treatment regimens focused on these high impact patients can improve outcomes and lower costs for these patients and the rest of the geographic patient cluster and the health care network. Population health includes techniques for understanding the health characteristics of a patient population by leveraging analytics, business intelligence etc. so as to determine the patient population's health trends.
management (PHM is population health management. It aims to use big data to extend the EHR infrastructure to provide cost effective personal treatment. This implies reengineering the health care payment and delivery process. - IT tools must be developed.
- Administrative structures must be updated.
- Clinical processes must be redesigned and accepted. Successful workflow process reengineering will depend on integration with existing workflows and presence of added value!
- Payment mechanisms must be overhauled ensuring that the physicians get incented to move on from FFS.
- It must be financed. It is not obvious where this will come from! Providers like fixed costs. ROI seems limited atleast initially. Subscriptions may work for both vendors and providers.
) to manage
chronic disease makes data silos a big issue. Any resulting Big Data encompasses the IT systems and processes necessary to do population based data collection, management and analysis. The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass. Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms: Precision medicine, Protein folding modeling (Feb 2019) assumes coevolutionary methods can be applied to identify contact points in a protein's tertiary structure. Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure: - Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Complex data models must include clinical aspects of the patient specific data, including disease state population wide.
- A key aspect is providing clear signals about the nature of the data using data visualization.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
strategy (UPMC) will encourage IT
solutions to the silo issue. SMART is substitutable medical applications and reusable technology from SMART Health IT. on FHIR is fast healthcare interoperability resources (fire) an HL7 standard defining a set of 'resources' that represent granular clinical concepts. The items include: - Clinical
- General: AdverseReaction, AlergyIntolerance, CarePlan, Condition, Family/History, Procedure, Questionnaire,
- Medications: Medication, MedicationPrescription, Medication/Administration, MedicationDispense, MedicationStatement, Immunization, ImmunizationRecommendation
- Diagnostics: Observation, DiagnosticReport, DiagnosticOrder, ImagingStudy, Specimen
- Device Interactions: DeviceObservationreport
- Administrative
- Attribution: Patient, RelatedPerson, Practitioner, Organization
- Entities: Device, Location, Substance, Group
- Workflow Management: Encounter, Alert, Supply, Order, Order/Response
- Financial:
- Infrastructure
- Support: List, Media, Other, Provenance, SecurityEvent, (Binary)
- Document Handling: Composition, DocumentReference, DocumentManifest
- Exchange: MessageHeader, OperationOutcome, Query
- Conformance: Conformance, Profile, ValueSet, ConceptMap (informative)
is one Government
initiated example.
Johns Hopkins hospital
at home is a Johns Hopkins initiated program which deploys hospital services at home such as intravenous antibiotics, oxygen, breathing treatments, and diagnostic tests to treat patients with urinary and skin infections, pneumonia and heart failure. Doctors visit daily and nurse practitioners visit once or twice a day and remotely monitor the patients. Cost savings vary between 19 and 44 percent. program is reducing costs for chronic care.
Partners
Healthcare has used geographic
concentration to build regional power based on customers
wanting access to its lead hospitals. The strategy limited
insurance companies ability to demand lower prices since Partners
required all or nothing integration with its network.
Hospital
business model focus strategies
Both specialists and service
line is a strategic focus and structuring by a general hospital to optimize for the most locally profitable areas of diagnosis and treatment such as: Cardiovascular, Neurology or Cancer; to respond to competition from specialist focused health care facilities such as the Texas heart institute and local low cost outpatient facilities. It does not abandon other services which the community as a whole needs but limits the losses they generate. A successful service line can: Diagnose and treat a high volume of service specific problems ensuring quality and efficiency, be profitable enough to gain additional investment and attract top physicians. To be effective service line strategies require: - A clear view of the hospital's competitive environment.
- Visibility of the revenue, costs (activity based rather than top down) and benefits of particular procedures and bundles of care. Cost estimates are often averaged by hospital accounting models.
- Effective management of PCP referrals to the hospital and its competitors.
- Changes to the: Organization structure, Incentive plans for doctors, Relationship with physicians (potentially including co-management) - who must own the problems of their service line, Business development, HCIT - which will need to capture all details of a service, HR who will need to support the employees during and after the transition.
focused generalists can leverage this focus generic
strategy.
PCMH is patient centered medical homes:
- Describes a reorganization of the health care delivery
system to focus on the patient and care giver supported by
EHR infrastructure and some form of
process management
which will be necessary to coordinate interventions by
each of the functional entities resources to treat
the patients specific problems. The
disadvantage of a PCMH is the administrative and
technology cost needed to support its complex
processes. The PCMH
- Was promoted as a way to incent more PCP
which had been seen as a low reward role by medical
students. HCI3 argues
this use of PCMH is flawed. PCMH is driven by
the medical home models
of the ACA. In this model the
PCMH is accountable for meeting the vast majority of each
patients physical and mental health care needs including
prevention and wellness, acute
care, and chronic care. It is focused on treating
the whole person. It is tasked with coordinating the
care across all elements of the health care system,
including transitions and building clear and open
communications. It must ensure extended access and
availability of its services and patients preferences
about access. It must continuously improve quality
by monitoring evidence-based medicine
and clinical decision support tools (NCQA).
Many argue that to be effective it must be connected to a
'medical neighborhood'.
The PCMH brings together the specialized resources and
infrastructure required to develop and iteratively
maintain the care plans and
population oriented system descriptions that are central
to ACA care coordination.
structured value
delivery systems such as Lehigh
valley's community
care teams and AtlantiCare's
special
care center aim to use coordination to support efficient
handoffs between specialists.
Businesses can target the employer funded patient niche with added
focus.
A variety of hospitals aim to specialize on particular areas of
complex care: Cardiovascular care specialists such as Texas Heart,
Cancer centers such as MS-KCC;
Notable events involving these hospital networks include:
- Leukemia is a group of cancers of blood forming tissues: bone marrow, lymphatic network; where abnormal white blood cells are generated. One type of leukemia is induced when TAD boundaries near the TAL1 gene fail allowing promotors from across the TAD border to distort the operation of the TAL transcription factor. Mutation clusters common in leukemia have been identified in CHIP.
- Proactive stool banking study
- CHIP is:
- The Children's Health Insurance Program started in 1997 as part of the BBA as SCHIP. It provides health insurance coverage for children in families with income below 200 percent of the poverty line. The coverage is focused on care specialized for children including: developmental delays, chronic conditions including asthma and obesity. CHIP's funding must be iteratively re-authorized by Congress. CHIP is financed federally, but states must enroll eligible children. In many states one agency administers CHIP and Medicaid. CHIP is leveraged by families that have employer based insurance with costly premiums, so the families only cover the adults.
- Clonal Hematopoiesis of Indeterminate Potential, where stem cells develop a somatic mutation cluster pair often found in leukemia, which is expressed in white blood cells they produce. The mutation clusters give these stem cells a competitive advantage and they accumulate over time. The white blood cells form inflammatory plaques. CHIP increases with age, increasing the risk of dying, of clot fragment induced heart attacks and stroke, over the subsequent 10 years by 54%
mechanism
identified: somatic, Schematic structures which are used to support the operation of the agent. They are modified as the agent's state changes unlike the germ-line schemata.
mutated stem cells is a biological cell which is partly or wholly undifferentiated. A totipotent cell can generate a complete embryo and placenta. Embryos include pluripotent cells which can generate any tissue in the body. Adult humans' cells have turned off this ability but still include multipotent stem cells that differentiate into multiple cell types. Typically a cell's local environment will have the signals required for it to obtain context and differentiate appropriately. This will include both the external environment and the internal state of the cell which has replicated from a parent and obtained its epi-genetic state. So introduction of undifferentiated stem cells into an injured area is not likely to have either aspect of the environment suitable. Consequently development is aiming to encourage differentiation to progenitor cells for the damaged region. This requires delivering the cells to the appropriate part of the body. To avoid rejection by the immune system techniques aim to use cell lines developed from the patient's cells. The techniques to generate these cell lines include: SCNT, iPS. Possible mechanisms of stem cell therapy are: Generation of new differentiated cells, Stimulation of growth of new blood vessels to repopulate damaged regions, Secretion of growth factors, Treatment of diabetes (1 and 2) with addition of pancreatic cells, Assistance of other mechanisms;,
with certain leukemia is a group of cancers of blood forming tissues: bone marrow, lymphatic network; where abnormal white blood cells are generated. One type of leukemia is induced when TAD boundaries near the TAL1 gene fail allowing promotors from across the TAD border to distort the operation of the TAL transcription factor. Mutation clusters common in leukemia have been identified in CHIP.
mutations, accumulate in bone marrow and generate white blood
cells that are highly inflammatory; encouraging: arthritis, clot formation or coagulation is formation of a clot: - Platlets become activated, adhere and aggregate supported by
- Fibrin polymerization, deposition and maturation.
and
collapse resulting in high incidence of heart attack is an AMI. It can induce cardiac arrest. Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI. Risk factors include: taking NSAID pain killers (May 2017). There is uncertainty about why AMI occur. Alternative hypotheses include: - Plaques started to gather in the coronary arteries and grew until no blood flow was possible. If this is true it makes sense to preventatively treat the buildup with angioplasty.
- Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot. If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors.
and stroke is when brain cells are deprived of oxygen and begin to die. 750,000 patients a year suffer strokes in the US. 85% of those strokes are caused by clots. There are two structural types: Ischemic and hemorrhagic. Thrombectomy has been found to be a highly effective treatment for some stroke situations (Jan 2018). ; Dana-Farber's
Ebert, Broad
Institute/Massachusetts
General's Kathiresan conclude from Big Data encompasses the IT systems and processes necessary to do population based data collection, management and analysis. The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass. Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms: Precision medicine, Protein folding modeling (Feb 2019) assumes coevolutionary methods can be applied to identify contact points in a protein's tertiary structure. Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure: - Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Complex data models must include clinical aspects of the patient specific data, including disease state population wide.
- A key aspect is providing clear signals about the nature of the data using data visualization.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
genomics combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes. (Jan
2018)
- Melanoma is a cancer of the melanocytes. It is a less common form of skin cancer but is the most deadly once it has invaded deeply into layers of skin. It is primarily caused by UV light. It is tied to mutations in the signalling pathway (BRAF) and regulatory genes (P53) with a key dependency on crestin reactivation (Jan 2016).
- Immunotherapeutics is indirect treatment of disease by altering the immune system. Targeted diseases include: cancers -- immuno-oncology, organ transplants.
studies
- Problematic cancers is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
:
Pancreatic is most often an exocrine tumor. Islet cell tumors are less common. These are rare cancers: less than 200,000 US cases per year, but the five year survival rates are extremely low 3%. They all have KRAS mutations. They are associated with obesity. Diagnostics are starting to leverage genomics and big databases (23 and me). Treatments include: ,
Prostate is cancer of the prostate gland. Genomics detected several common DNA variants associated with increased risk of prostate cancer. Dr. Francis Collins explains that a cluster of these risk variants lies in a stretch of 1 million DNA base pairs on chromosome 8. The cluster contains seven or more risk variants, each of which can raise the risk of prostate cancer by 10 to 30%. The high risk variants occur more frequently in African-American men than European or Asians. African-Americans die from prostate cancer at more than twice the rate of Europeans. Research in mice may explain a link between obesity and prostate cancer (Jan 2018). The average diagnosis is at age 66. Worldwide in 2012 there were 1.1 million cases from which 307,000 died. A common life-saving (Feb 2017) treatment is androgen deprivation therapy, but it has worrying side effects. Various classically defined types of cancer can occur. The most common is adenocarcinoma associated with the epithelial gland cells that generate seminal fluid. Epithelial cell differentiation potency makes these significant cancer agents. Other very rare types of cancer that can start in the prostate are: - Sarcomas
- Small cell carcinomas
- Neuroendocrine tumors
- Transitional cell carcinomas
,
Uterus, Bone; with DNA (DNA), a polymer composed of a chain of deoxy ribose sugars with purine or pyrimidine side chains. DNA naturally forms into helical pairs with the side chains stacked in the center of the helix. It is a natural form of schematic string. The purines and pyrimidines couple so that AT and GC pairs make up the stackable items. A code of triplets of base pairs (enabling 64 separate items to be named) has evolved which now redundantly represents each of the 20 amino-acids that are deployed into proteins, along with triplets representing the termination sequence. Chemical modifications and histone binding (chromatin) allow cells to represent state directly on the DNA schema. To cope with inconsistencies in the cell wide state second messenger and evolved amplification strategies are used.
repair: Caretaker proteins, detect and repair mutations of the DNA. Genes coding for mismatch proteins include: MLH1, MSH2, MLH3. Mutations in these genes are associated with high risk of colon and uterine cancer. The gene BRCA1 is also involved in DNA repair. ;
inhibition, respond in trial by Johns
Hopkins/MS-KCC's
Diaz, to PD-1 is programmed cell death protein 1 (CD279) is encoded by the PDCD1 gene. It is a cell surface receptor that belongs to the immunoglobulin superfamily. It is expressed on T-cells and pro-B cells. It acts as an immune checkpoint preventing the activation of T-cells to help self-tolerance and reduce autoimmunity. When it fails people can suffer from: Lupus, Crohn's disease, Rheumatoid arthritis. PD-1 inhibitor drugs activate the immune system to attack tumors. PD-1 inhibitors are being approved for Melanoma and squamous-cell form of lung cancer.
blocker - Keytruda,
encouraging F.D.A. Food and Drug Administration. to
issue approval for treating this mutational mechanism, for which
there is a specific test (Jun
2017)
- BMS/NCI is the national cancer institute.
funded PD-1 is programmed cell death protein 1 (CD279) is encoded by the PDCD1 gene. It is a cell surface receptor that belongs to the immunoglobulin superfamily. It is expressed on T-cells and pro-B cells. It acts as an immune checkpoint preventing the activation of T-cells to help self-tolerance and reduce autoimmunity. When it fails people can suffer from: Lupus, Crohn's disease, Rheumatoid arthritis. PD-1 inhibitor drugs activate the immune system to attack tumors. PD-1 inhibitors are being approved for Melanoma and squamous-cell form of lung cancer. checkpoint
inhibitor release the immune system's checkpoints: PD-1, CTLA-4; on attacking host cells: by 1) stopping T-cell division and 2) reducing their life spans. They are used in immuno-oncology where, in 2016: They are approved for treatment of: Advanced melanoma, HL, lung, kidney, liver cancer; They have a general success rate of 20 - 40% and higher for melanoma. Checkpoint inhibitors work best for tumors that have many mutations: melanomas, lung and bladder cancers. They are enhanced by adjunct treatments that kill tumor cells generating debris to stimulate the immune system. The drugs include: ipilimumab (CTLA-4 inhbition), nivolumab, pembrolizumab, atezolizumab (PD-1 inhibitors); They are costly and often have high copayments. They cause auto-immune side effects including inflammation, rheumatoid arthritis and damage to glands: Adrenal, Thyroid, Pituitary. Powerful steroids such as prednisone can help reduce the inflammation. Damaged glands require sustained hormone treatment. Checkpoint inhibitor research is funded by the CRI. immuno-oncology uses the immune system to treat cancer. Cancer cells often have different molecules on their cell surface. Studies have shown that genetic signatures of tumors can help predict which patients will benefit from treatment with PD-1 checkpoint inhibitors. Checkpoint inhibitor based treatments aim to make the immune system target these antigens. Clinical trial results indicate they are prolonging lives - even if only by a few months. They have reduced side effects relative to generic chemo therapy. There are three main strategies: cellular, antibody and cytokine. - Antibody therapies target receptors including CD20, CD274, CD279 and CTLA-4. These therapies include MABs: Alemtuzumab, Ofatumumab, Rituximab; and may induce checkpoint inhibition.
- Cellular therapies have typically involved removing the immune cells from the blood or a tumor, activating, culturing and then returning them to the patient. Trials of these CAR and TCR therapies are proceeding, with some significant problems (Jul 2016).
- Cytokine therapies enhance anti-tumor activity through the cytokine's regulation and coordination of the immune system.
- Vaccines, including Sipuleucel-T for prostate cancer and BCG, classically a vaccine for tuberculosis, which is used for treating bladder cancer.
study by MD
Anderson's Dr. Hussain Tawbi reports Opdivo & Yervoy combination
used to treat melanoma is a cancer of the melanocytes. It is a less common form of skin cancer but is the most deadly once it has invaded deeply into layers of skin. It is primarily caused by UV light. It is tied to mutations in the signalling pathway (BRAF) and regulatory genes (P53) with a key dependency on crestin reactivation (Jan 2016).
(and likely other cancers of 200,000 people a year) patients
with consequent metastatic brain cancers, at 28 AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017); s: MS-KCC;
find survival rate expands beyond a year, like Jimmy Carter
after he was treated with Keytruda.
But 50% of patients had significant side effects of which 20%
quit the treatment (Aug
2018)
- Cell
engineering for gene therapy is the deployment of genes into patient's cells to treat or prevent diseases. It can be performed outside the body (ex vivo) or in place (in vivo). It requires a vector such as a: Virus, Ligandal style nanoparticle, electric field (Jul 2018); to perform the deployment. But viruses are: Difficult to sanitize (bringing in oncogenes etc.) and hard to target as needed, Unable to target where the DNA is deployed into the target cell chromosomes, Key targets of the immune system. The process is disease specific:
- Blood cancers: NHL; can be treated with ex vivo CAR-T (Jul 2017, Oct 2017)
- Cystic fibrosis requires a virus that infects the airways and then deploys a non-cystic fibrosis allele into the nucleus of the patient's cells. The obstacles to this process have been challenging:
- The virus must not have any problematic effects. In the case of cystic fibrosis one virus activated a cancer gene leaving several trial subjects with leukemia.
- Efficiency of delivery has to be very high and this has not proved possible as of 2015.
- The newly delivered DNA must remain intact and be replicated and transcribed. This has not proved to be the case.
- The process has not been able to avoid an immune response. Gene therapy has consequently been of limited value for cystic fibrosis.
- Hemophilia A and B; virus delivered in vivo therapies enter final stage trials (Aug 2018)
- ADA based SCID was the first human treatment with gene therapy. A normal ADA gene was inserted ex vivo into immune system cells. Initially the updated cells did not live as long as needed.
- Sickle-cell anemia requires a non-sickle-cell trait allele of the hemoglobin gene to be vectored into the bone marrow of the affected person.
- T-lymphocyte DNA updates for: mutation induced autoimmune diseases, melanoma treatment; using gene editing delivered with an electric field.
- Director Michel
Sadelain
- CAR is chimeric antigen receptor. Killer T lymphocytes are genetically engineered to produce a novel protein, composed of pieces from different parts of the immune system such as: antibody components to construct a new receptor binding site on the T cell that targeted an antigen exposed on the cell surface of cancer cells, and two receptor associated signals that switch the T-cell into kill mode and sustain it in that mode. Small clinical trials of CAR-T cells have shown substantial remissions among patients with various blood cancers (Aug 2016, Jul 2017, Oct 2017, Nov 2017). But there are severe side effects. -T trials
history detailed, including: Saint
Judes's Dr.
Campana - Juno, University
of Pennsylvania's Dr.
June - Novartis;
Trials progressing (Aug
2016)
but
- Juno Immuno-oncology uses the immune system to treat cancer. Cancer cells often have different molecules on their cell surface. Studies have shown that genetic signatures of tumors can help predict which patients will benefit from treatment with PD-1 checkpoint inhibitors. Checkpoint inhibitor based treatments aim to make the immune system target these antigens. Clinical trial results indicate they are prolonging lives - even if only by a few months. They have reduced side effects relative to generic chemo therapy. There are three main strategies: cellular, antibody and cytokine.
- Antibody therapies target receptors including CD20, CD274, CD279 and CTLA-4. These therapies include MABs: Alemtuzumab, Ofatumumab, Rituximab; and may induce checkpoint inhibition.
- Cellular therapies have typically involved removing the immune cells from the blood or a tumor, activating, culturing and then returning them to the patient. Trials of these CAR and TCR therapies are proceeding, with some significant problems (Jul 2016).
- Cytokine therapies enhance anti-tumor activity through the cytokine's regulation and coordination of the immune system.
- Vaccines, including Sipuleucel-T for prostate cancer and BCG, classically a vaccine for tuberculosis, which is used for treating bladder cancer.
CAR is chimeric antigen receptor. Killer T lymphocytes are genetically engineered to produce a novel protein, composed of pieces from different parts of the immune system such as: antibody components to construct a new receptor binding site on the T cell that targeted an antigen exposed on the cell surface of cancer cells, and two receptor associated signals that switch the T-cell into kill mode and sustain it in that mode. Small clinical trials of CAR-T cells have shown substantial remissions among patients with various blood cancers (Aug 2016, Jul 2017, Oct 2017, Nov 2017). But there are severe side effects. -T trial
for adult ALL is acute lymphocytic/lymphoblastic leukemia. The cancer starts in the lymphocytes of the bone marrow. Too many lymphocytes are produced instead of mature white blood cells. In 2010 combination chemotherapy, including 6-mercaptopurine, cures 85 to 90% of children suffering from ALL.
suspended after deaths (Jul
2016)
- Gilead to
acquire Kite
Pharma for $11.9 billion (Aug
2017)
- Kite Pharma (Gilead)'s CAR is chimeric antigen receptor. Killer T lymphocytes are genetically engineered to produce a novel protein, composed of pieces from different parts of the immune system such as: antibody components to construct a new receptor binding site on the T cell that targeted an antigen exposed on the cell surface of cancer cells, and two receptor associated signals that switch the T-cell into kill mode and sustain it in that mode. Small clinical trials of CAR-T cells have shown substantial remissions among patients with various blood cancers (Aug 2016, Jul 2017, Oct 2017, Nov 2017). But there are severe side effects. -T gene therapy is the deployment of genes into patient's cells to treat or prevent diseases. It can be performed outside the body (ex vivo) or in place (in vivo). It requires a vector such as a: Virus, Ligandal style nanoparticle, electric field (Jul 2018); to perform the deployment. But viruses are: Difficult to sanitize (bringing in oncogenes etc.) and hard to target as needed, Unable to target where the DNA is deployed into the target cell chromosomes, Key targets of the immune system. The process is disease specific:
- Blood cancers: NHL; can be treated with ex vivo CAR-T (Jul 2017, Oct 2017)
- Cystic fibrosis requires a virus that infects the airways and then deploys a non-cystic fibrosis allele into the nucleus of the patient's cells. The obstacles to this process have been challenging:
- The virus must not have any problematic effects. In the case of cystic fibrosis one virus activated a cancer gene leaving several trial subjects with leukemia.
- Efficiency of delivery has to be very high and this has not proved possible as of 2015.
- The newly delivered DNA must remain intact and be replicated and transcribed. This has not proved to be the case.
- The process has not been able to avoid an immune response. Gene therapy has consequently been of limited value for cystic fibrosis.
- Hemophilia A and B; virus delivered in vivo therapies enter final stage trials (Aug 2018)
- ADA based SCID was the first human treatment with gene therapy. A normal ADA gene was inserted ex vivo into immune system cells. Initially the updated cells did not live as long as needed.
- Sickle-cell anemia requires a non-sickle-cell trait allele of the hemoglobin gene to be vectored into the bone marrow of the affected person.
- T-lymphocyte DNA updates for: mutation induced autoimmune diseases, melanoma treatment; using gene editing delivered with an electric field.
Yescarta, is
approved is a $6.3 billion bill to increase funding for research into cancer, Alzheimer's disease and other disease, support mental health networks and adjust regulations for drugs and medical devices. The act does not constrain drug prices. It is funded with money taken from a preventative health care fund. It aims to: - Expand the funding of the NIH.
- Allocates an additional $4.8 billion over 10 years. Much of the expanded funding is focused on Alzheimer's and cancer. This funding will still have to be appropriated by Congress.
- Empowers the NIH:
- Provides them with authority to finance high-risk, high-reward research using special procurement procedures instead of grants and contracts,
- Requires the director to establish "Eureka prizes" for biomedical research and treatment improvements.
- Advances the Precision Medicine Initiative,
- Support the moonshot to cure cancer.
- Align the federal drug regulatory structure with the processes of the biotechnology industry. Critics argue it lowers drug and device approval standards, and raises the influence of surrogate endpoints.
- The F.D.A. is allocated half a billion dollars to help staff the expedited processes.
- It provides an expedited pathway for breakthrough medical technologies (offering options for life-threatening conditions with few treatment options).
- F.D.A. must consider the least burdensome means to show device safety.
- Streamline the mental health network. It strengthens the enforcement of the mental health parity law.
- Creates the Presidentially appointed position of assistant secretary for mental health and substance use.
- Directs federal agencies to step up enforcement of laws that require equal insurance coverage for mental and physical illnesses.
- Stem the problem of opioid drug abuse with a $1 billion investment that will allow expanded access of treatment programs.
by F.D.A. Food and Drug Administration. , for adults
with CD19 expressing aggressive forms of NHL is non-Hodgkin lymphoma, It is: - A group of blood cancers that include all (> 60) types of lymphoma except HL.
- Risk factors include: poor immune function, autoimmune disease, Helicobacter pylori infection, hepatitis C, obesity, Epstein-Barr virus infection, HIV infection, radiation therapy, chemotherapy, PCBs, dioxin, phenoxy herbicides.
(Oct
2017)
- AstraZeneca's
Crestor
revenues already impacted by generics, when its Mystic
lung cancer affects 200,000 Americans each year. Inflammation is a driver of lung cancer spread (Aug 2017). All these cancers are carcinomas. There are two main hystological types:
- Non-small-cell carcinomas are of three sub-types:
- Adenocarcinomas (40% of lung cancers) are typically peripherally situated and mostly induced by smoking.
- Squamous-cell carcinomas (30% of lung cancers) arise in the large bronchi an are highly correlated with smoking.
- Large-cell carcinomas (5 to 10% of lung cancers).
- Small-cell carcinomas.
drug fails trial primary endpoint, putting the company under
more pressure. Collaborates with Merck (Jul
2017)
- Novartis's biologic are drugs made in living cells. Typically they are proteins developed using genetic engineering to develop the cellular host, and to customize animal source, DNA to produce human target proteins. Such biologics partially solve the problem of previous protein sources, extracted from animals or human sources, of contamination and immune responses. The strategy is very effective for blood transported proteins such as antibodies (MABs), hormones and blood factors. But intra-cellular proteins still demand delivery and accurate cell targeting. This creates analogous problems to those of gene therapy.
CAR is chimeric antigen receptor. Killer T lymphocytes are genetically engineered to produce a novel protein, composed of pieces from different parts of the immune system such as: antibody components to construct a new receptor binding site on the T cell that targeted an antigen exposed on the cell surface of cancer cells, and two receptor associated signals that switch the T-cell into kill mode and sustain it in that mode. Small clinical trials of CAR-T cells have shown substantial remissions among patients with various blood cancers (Aug 2016, Jul 2017, Oct 2017, Nov 2017). But there are severe side effects. -T Tisagenlecleucel
treatment for CD19 expressing unresponsive B-cell acute
lymphoblastic leukemia is a group of cancers of blood forming tissues: bone marrow, lymphatic network; where abnormal white blood cells are generated. One type of leukemia is induced when TAD boundaries near the TAL1 gene fail allowing promotors from across the TAD border to distort the operation of the TAL transcription factor. Mutation clusters common in leukemia have been identified in CHIP. ,
developed at University
of Pennsylvania & deployed at Children's
hospital of Philidelphia & Duke University,
based on research part funded by the Leukemia
& Lymphoma Society recommended for approval by F.D.A. Food and Drug Administration. panel (Jul
2017)
- University
of Pennsylvania's research version of Novartis CAR is chimeric antigen receptor. Killer T lymphocytes are genetically engineered to produce a novel protein, composed of pieces from different parts of the immune system such as: antibody components to construct a new receptor binding site on the T cell that targeted an antigen exposed on the cell surface of cancer cells, and two receptor associated signals that switch the T-cell into kill mode and sustain it in that mode. Small clinical trials of CAR-T cells have shown substantial remissions among patients with various blood cancers (Aug 2016, Jul 2017, Oct 2017, Nov 2017). But there are severe side effects. -T treatment Kymriah,
manufactured by the university and used at the Children's
Hospital of Philadelphia to treat B cell ALL is acute lymphocytic/lymphoblastic leukemia. The cancer starts in the lymphocytes of the bone marrow. Too many lymphocytes are produced instead of mature white blood cells. In 2010 combination chemotherapy, including 6-mercaptopurine, cures 85 to 90% of children suffering from ALL. , resulted in one leukemia is a group of cancers of blood forming tissues: bone marrow, lymphatic network; where abnormal white blood cells are generated. One type of leukemia is induced when TAD boundaries near the TAL1 gene fail allowing promotors from across the TAD border to distort the operation of the TAL transcription factor. Mutation clusters common in leukemia have been identified in CHIP.
cell
being reengineered along with the T-cells or T lymphocytes, are produced in the thymus & tonsils, and include a T-cell receptor. Alpha beta T cells participate in the adaptive immune system. Gamma delta T cells present antigens to other T cells. CD4+ Helper T cells are activated by MHC class II molecules. They generate cytokines to regulate the immune response. Cytotoxic T cells (CD8+ receptor) destroy virus-infected cells and tumor cells. They can be inactivated to prevent autoimmunity. Memory T cells are formed when undifferentiated T cells are presented with antigen on MHC molecules located on an APC. They are long lived and replicate widely when they detect antigen. Regulatory T cells (suppressor and helper T cells) shut down T cell controlled immunity at the end of an immune reaction. Natural killer T cells respond to CD1d presented glycolipid antigens. MAIT cells defend against microbial infection with targeting by MR1. , and
deployed into the patient, who then died from the CAR-T
resistant leukemia (Oct
2018)
- NCI is the national cancer institute.
research by Stanford
SOM's
Dr. Mackall, reported in Nature Medicine, targets tumor: Leukemia is a group of cancers of blood forming tissues: bone marrow, lymphatic network; where abnormal white blood cells are generated. One type of leukemia is induced when TAD boundaries near the TAL1 gene fail allowing promotors from across the TAD border to distort the operation of the TAL transcription factor. Mutation clusters common in leukemia have been identified in CHIP. , Lymphoma is when lymphocytes continue reproducing, and do not die - a blood cancer. ; cell
surface protein CD22 with CAR is chimeric antigen receptor. Killer T lymphocytes are genetically engineered to produce a novel protein, composed of pieces from different parts of the immune system such as: antibody components to construct a new receptor binding site on the T cell that targeted an antigen exposed on the cell surface of cancer cells, and two receptor associated signals that switch the T-cell into kill mode and sustain it in that mode. Small clinical trials of CAR-T cells have shown substantial remissions among patients with various blood cancers (Aug 2016, Jul 2017, Oct 2017, Nov 2017). But there are severe side effects. -T,
while Stanford
& Seattle
Children's are testing a CAR-T targeting both CD19 &
CD22 (Nov
2017)
- UCSF
study finds colorectal is also called colon cancer. It:
- Follows a slow, many yearlong, progression from a benign
polyp to a localized cancer to an invasive one. Two
bacteria: Bacteroides fragilis, Escherichia coli variant;
from the gut microbiome have
been implicated in the early stages of tumor induction (Feb
2018). It
- Is often associated with Ras
mutations and the high risk allele TCF7L2.
30 to 50% of colon cancers have KRAS
mutations. Intensive medical surveillance and
removal of polyps can be lifesaving for those at high
risk. Types of colon cancer include the single gene
mutation hereditary: FAP, HNPCC;
- Is linked to obesity.
and prostate is cancer of the prostate gland. Genomics detected several common DNA variants associated with increased risk of prostate cancer. Dr. Francis Collins explains that a cluster of these risk variants lies in a stretch of 1 million DNA base pairs on chromosome 8. The cluster contains seven or more risk variants, each of which can raise the risk of prostate cancer by 10 to 30%. The high risk variants occur more frequently in African-American men than European or Asians. African-Americans die from prostate cancer at more than twice the rate of Europeans. Research in mice may explain a link between obesity and prostate cancer (Jan 2018). The average diagnosis is at age 66. Worldwide in 2012 there were 1.1 million cases from which 307,000 died. A common life-saving (Feb 2017) treatment is androgen deprivation therapy, but it has worrying side effects. Various classically defined types of cancer can occur. The most common is adenocarcinoma associated with the epithelial gland cells that generate seminal fluid. Epithelial cell differentiation potency makes these significant cancer agents. Other very rare types of cancer that can start in the prostate are: - Sarcomas
- Small cell carcinomas
- Neuroendocrine tumors
- Transitional cell carcinomas
cancers is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016). remotely
inhibiting the immune
system has to support and protect an inventory of host cell types, detect and respond to invaders and maintain the symbiont equilibrium within the microbiome. It detects microbes which have breached the secreted mucus barrier, driving them back and fortifying the barrier. It culls species within the microbiome that are expanding beyond requirements. It destroys invaders who make it into the internal transport networks. As part of its initialization it has immune cells which suppress the main system to allow the microbiome to bootstrap. The initial microbiome is tailored by the antibodies supplied from the mother's milk while breastfeeding. The immune system consists of two main parts the older non-adaptive part and the newer adaptive part. The adaptive part achieves this property by being schematically specified by DNA which is highly variable. By rapid reproduction the system recombines the DNA variable regions in vast numbers of offspring cells which once they have been shown not to attack the host cell lines are used as templates for interacting with any foreign body (antigen). When the immune cell's DNA hyper-variable regions are expressed as y-shaped antibody proteins they typically include some receptor like structures which match the surfaces of the typical antigen. Once the antibody becomes bound to the antigen the immune system cells can destroy the invader. via a PD-L1 is programmed death-ligand 1, is a ligand for PD-1.
message, where the signal, is an emergent capability which is used by cooperating agents to support coordination & rival agents to support control and dominance. In eukaryotic cells signalling is used extensively. A signal interacts with the exposed region of a receptor molecule inducing it to change shape to an activated form. Chains of enzymes interact with the activated receptor relaying, amplifying and responding to the signal to change the state of the cell. Many of the signalling pathways pass through the nuclear membrane and interact with the DNA to change its state. Enzymes sensitive to the changes induced in the DNA then start to operate generating actions including sending further signals. Cell signalling is reviewed by Helmreich. Signalling is a fundamental aspect of CAS theory and is discussed from the abstract CAS perspective in signals and sensors. In AWF the eukaryotic signalling architecture has been abstracted in a codelet based implementation. To be credible signals must be hard to fake. To be effective they must be easily detected by the target recipient. To be efficient they are low cost to produce and destroy.
is not on the surface of the cancer cells, explaining how these
cancers have undermined current immunotherapy is indirect treatment of disease by altering the immune system. Targeted diseases include: cancers -- immuno-oncology, organ transplants.
drugs uses the immune system to treat cancer. Cancer cells often have different molecules on their cell surface. Studies have shown that genetic signatures of tumors can help predict which patients will benefit from treatment with PD-1 checkpoint inhibitors. Checkpoint inhibitor based treatments aim to make the immune system target these antigens. Clinical trial results indicate they are prolonging lives - even if only by a few months. They have reduced side effects relative to generic chemo therapy. There are three main strategies: cellular, antibody and cytokine. - Antibody therapies target receptors including CD20, CD274, CD279 and CTLA-4. These therapies include MABs: Alemtuzumab, Ofatumumab, Rituximab; and may induce checkpoint inhibition.
- Cellular therapies have typically involved removing the immune cells from the blood or a tumor, activating, culturing and then returning them to the patient. Trials of these CAR and TCR therapies are proceeding, with some significant problems (Jul 2016).
- Cytokine therapies enhance anti-tumor activity through the cytokine's regulation and coordination of the immune system.
- Vaccines, including Sipuleucel-T for prostate cancer and BCG, classically a vaccine for tuberculosis, which is used for treating bladder cancer.
.
Blocking the PD-L1 release from the cancer resulted in attacks
by immune cells (Apr
2019)
- Medical centers driving checkpoint
inhibitor release the immune system's checkpoints: PD-1, CTLA-4; on attacking host cells: by 1) stopping T-cell division and 2) reducing their life spans. They are used in immuno-oncology where, in 2016: They are approved for treatment of: Advanced melanoma, HL, lung, kidney, liver cancer; They have a general success rate of 20 - 40% and higher for melanoma. Checkpoint inhibitors work best for tumors that have many mutations: melanomas, lung and bladder cancers. They are enhanced by adjunct treatments that kill tumor cells generating debris to stimulate the immune system. The drugs include: ipilimumab (CTLA-4 inhbition), nivolumab, pembrolizumab, atezolizumab (PD-1 inhibitors); They are costly and often have high copayments. They cause auto-immune side effects including inflammation, rheumatoid arthritis and damage to glands: Adrenal, Thyroid, Pituitary. Powerful steroids such as prednisone can help reduce the inflammation. Damaged glands require sustained hormone treatment. Checkpoint inhibitor research is funded by the CRI. trials (Aug
2016)
- BMS checkpoint
inhibitor release the immune system's checkpoints: PD-1, CTLA-4; on attacking host cells: by 1) stopping T-cell division and 2) reducing their life spans. They are used in immuno-oncology where, in 2016: They are approved for treatment of: Advanced melanoma, HL, lung, kidney, liver cancer; They have a general success rate of 20 - 40% and higher for melanoma. Checkpoint inhibitors work best for tumors that have many mutations: melanomas, lung and bladder cancers. They are enhanced by adjunct treatments that kill tumor cells generating debris to stimulate the immune system. The drugs include: ipilimumab (CTLA-4 inhbition), nivolumab, pembrolizumab, atezolizumab (PD-1 inhibitors); They are costly and often have high copayments. They cause auto-immune side effects including inflammation, rheumatoid arthritis and damage to glands: Adrenal, Thyroid, Pituitary. Powerful steroids such as prednisone can help reduce the inflammation. Damaged glands require sustained hormone treatment. Checkpoint inhibitor research is funded by the CRI. trials (Jul
2016, Jan
2017)
- BMS/NCI is the national cancer institute.
funded PD-1 is programmed cell death protein 1 (CD279) is encoded by the PDCD1 gene. It is a cell surface receptor that belongs to the immunoglobulin superfamily. It is expressed on T-cells and pro-B cells. It acts as an immune checkpoint preventing the activation of T-cells to help self-tolerance and reduce autoimmunity. When it fails people can suffer from: Lupus, Crohn's disease, Rheumatoid arthritis. PD-1 inhibitor drugs activate the immune system to attack tumors. PD-1 inhibitors are being approved for Melanoma and squamous-cell form of lung cancer. checkpoint
inhibitor release the immune system's checkpoints: PD-1, CTLA-4; on attacking host cells: by 1) stopping T-cell division and 2) reducing their life spans. They are used in immuno-oncology where, in 2016: They are approved for treatment of: Advanced melanoma, HL, lung, kidney, liver cancer; They have a general success rate of 20 - 40% and higher for melanoma. Checkpoint inhibitors work best for tumors that have many mutations: melanomas, lung and bladder cancers. They are enhanced by adjunct treatments that kill tumor cells generating debris to stimulate the immune system. The drugs include: ipilimumab (CTLA-4 inhbition), nivolumab, pembrolizumab, atezolizumab (PD-1 inhibitors); They are costly and often have high copayments. They cause auto-immune side effects including inflammation, rheumatoid arthritis and damage to glands: Adrenal, Thyroid, Pituitary. Powerful steroids such as prednisone can help reduce the inflammation. Damaged glands require sustained hormone treatment. Checkpoint inhibitor research is funded by the CRI. immuno-oncology uses the immune system to treat cancer. Cancer cells often have different molecules on their cell surface. Studies have shown that genetic signatures of tumors can help predict which patients will benefit from treatment with PD-1 checkpoint inhibitors. Checkpoint inhibitor based treatments aim to make the immune system target these antigens. Clinical trial results indicate they are prolonging lives - even if only by a few months. They have reduced side effects relative to generic chemo therapy. There are three main strategies: cellular, antibody and cytokine. - Antibody therapies target receptors including CD20, CD274, CD279 and CTLA-4. These therapies include MABs: Alemtuzumab, Ofatumumab, Rituximab; and may induce checkpoint inhibition.
- Cellular therapies have typically involved removing the immune cells from the blood or a tumor, activating, culturing and then returning them to the patient. Trials of these CAR and TCR therapies are proceeding, with some significant problems (Jul 2016).
- Cytokine therapies enhance anti-tumor activity through the cytokine's regulation and coordination of the immune system.
- Vaccines, including Sipuleucel-T for prostate cancer and BCG, classically a vaccine for tuberculosis, which is used for treating bladder cancer.
study by MD
Anderson's Dr. Hussain Tawbi reports Opdivo & Yervoy combination
used to treat melanoma is a cancer of the melanocytes. It is a less common form of skin cancer but is the most deadly once it has invaded deeply into layers of skin. It is primarily caused by UV light. It is tied to mutations in the signalling pathway (BRAF) and regulatory genes (P53) with a key dependency on crestin reactivation (Jan 2016).
(and likely other cancers of 200,000 people a year) patients
with consequent metastatic brain cancers, at 28 AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017); s: MS-KCC;
find survival rate expands beyond a year, like Jimmy Carter
after he was treated with Keytruda.
But 50% of patients had significant side effects of which 20%
quit the treatment (Aug
2018)
- Opdivo fails
broadly targeted advanced lung cancer affects 200,000 Americans each year. Inflammation is a driver of lung cancer spread (Aug 2017). All these cancers are carcinomas. There are two main hystological types:
- Non-small-cell carcinomas are of three sub-types:
- Adenocarcinomas (40% of lung cancers) are typically peripherally situated and mostly induced by smoking.
- Squamous-cell carcinomas (30% of lung cancers) arise in the large bronchi an are highly correlated with smoking.
- Large-cell carcinomas (5 to 10% of lung cancers).
- Small-cell carcinomas.
trial (Aug
2016)
- NCI is the national cancer institute.
sponsored Washington
University School
of Medicine designed clinical trial - BMS Opdivo treatment
of HTLV-1 is human T-cell leukemia virus type 1, a human retrovirus, which causes adult T-cell leukemia/lymphoma and a demyelinating disease. It infects millions of people in: Japan, Africa, South America, Caribbean, Australia; but only 5% of those infected develop the cancer. It is transmitted between humans by: sex, breast-feeding, needle-sharing, transfusions, and transplants. virus
induced adult T-cell leukemia is a group of cancers of blood forming tissues: bone marrow, lymphatic network; where abnormal white blood cells are generated. One type of leukemia is induced when TAD boundaries near the TAL1 gene fail allowing promotors from across the TAD border to distort the operation of the TAL transcription factor. Mutation clusters common in leukemia have been identified in CHIP. -lymphoma is when lymphocytes continue reproducing, and do not die - a blood cancer. , an immuno-oncology uses the immune system to treat cancer. Cancer cells often have different molecules on their cell surface. Studies have shown that genetic signatures of tumors can help predict which patients will benefit from treatment with PD-1 checkpoint inhibitors. Checkpoint inhibitor based treatments aim to make the immune system target these antigens. Clinical trial results indicate they are prolonging lives - even if only by a few months. They have reduced side effects relative to generic chemo therapy. There are three main strategies: cellular, antibody and cytokine. - Antibody therapies target receptors including CD20, CD274, CD279 and CTLA-4. These therapies include MABs: Alemtuzumab, Ofatumumab, Rituximab; and may induce checkpoint inhibition.
- Cellular therapies have typically involved removing the immune cells from the blood or a tumor, activating, culturing and then returning them to the patient. Trials of these CAR and TCR therapies are proceeding, with some significant problems (Jul 2016).
- Cytokine therapies enhance anti-tumor activity through the cytokine's regulation and coordination of the immune system.
- Vaccines, including Sipuleucel-T for prostate cancer and BCG, classically a vaccine for tuberculosis, which is used for treating bladder cancer.
checkpoint
inhibitor release the immune system's checkpoints: PD-1, CTLA-4; on attacking host cells: by 1) stopping T-cell division and 2) reducing their life spans. They are used in immuno-oncology where, in 2016: They are approved for treatment of: Advanced melanoma, HL, lung, kidney, liver cancer; They have a general success rate of 20 - 40% and higher for melanoma. Checkpoint inhibitors work best for tumors that have many mutations: melanomas, lung and bladder cancers. They are enhanced by adjunct treatments that kill tumor cells generating debris to stimulate the immune system. The drugs include: ipilimumab (CTLA-4 inhbition), nivolumab, pembrolizumab, atezolizumab (PD-1 inhibitors); They are costly and often have high copayments. They cause auto-immune side effects including inflammation, rheumatoid arthritis and damage to glands: Adrenal, Thyroid, Pituitary. Powerful steroids such as prednisone can help reduce the inflammation. Damaged glands require sustained hormone treatment. Checkpoint inhibitor research is funded by the CRI. treatment, failed (Jun
2018)
- Atopic
dermatitis, is also called eczema is a long lasting inflammation of the skin. It can be successfully treated with dupilumab. (Eczema) biologic are drugs made in living cells. Typically they are proteins developed using genetic engineering to develop the cellular host, and to customize animal source, DNA to produce human target proteins. Such biologics partially solve the problem of previous protein sources, extracted from animals or human sources, of contamination and immune responses. The strategy is very effective for blood transported proteins such as antibodies (MABs), hormones and blood factors. But intra-cellular proteins still demand delivery and accurate cell targeting. This creates analogous problems to those of gene therapy.
MAB as a terminator in medication names indicates the drug is a monoclonal antibody biologic. drug treatment dupilumab is a monoclonal antibody which blocks two immune system pathways: interleukin 4 and interleukin 13; that are over produced in atopic dermatitis, by binding to the alpha subunit of the interleukin-4 receptor. It was developed by Regeneron and marketed as Dupixent. (Dupixent)
has successful trials (Oct
2016).
- The difficulty in finding patients with specific cancer
mutations leaves biotechnology & AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017);
s struggling to
increase the patient base. Early F.D.A. Food and Drug Administration. approvals become
significant competitive advantages:
- Dana-Farber's
Matthew Meyerson & University of British Columbia's Robert
Holt found Fusobacterium, always in mouth, is found with colon cancer is a major hereditary cancer also called colorectal cancer. It:
- Follows a slow, many yearlong, progression from a benign polyp to a localized cancer to an invasive one. Two bacteria: Bacteroides fragilis, Escherichia coli variant; from the gut microbiome have been implicated in the early stages of tumor induction (Feb 2018). It
- Is often associated with Ras mutations and the high risk allele TCF7L2. 30 to 50% of colon cancers have KRAS mutations. Intensive medical surveillance and removal of polyps can be lifesaving for those at high risk. Types of colon cancer include the single gene mutation hereditary: FAP, HNPCC;
- Is linked to obesity.
tumors including metastatic. If the bacterium is killed
with antibiotics are compounds which kill bacteria, molds, etc. Sulfur dye stuffs were found to be effective antibiotics. The first evolved antibiotic discovered was penicillin. Antibiotics are central to modern health care supporting the processes of: Surgery, Wound management, Infection control; which makes the development of antibiotic resistance worrying. Antibiotics are: - Economically problematic to develop and sell.
- Congress enacted GAIN to encourage development of new antibiotics. But it has not developed any market-entry award scheme, which seems necessary to encourage new antibiotic R&D.
- Medicare has required hospitals and SNFs to execute plans to ensure correct use of antibiotics & prevent the spread of drug-resistant infections.
- C.D.C. is acting to stop the spread of resistant infections and reduce unnecessary use of antibiotics.
- F.D.A. has simplified approval standards. It is working with industry to limit use of antibiotics in livestock.
- BARDA is promoting public-private partnerships to support promising research.
- Impacting the microbiome of the recipient. Stool banking is a solution (Sloan-Kettering stool banking).
- Associated with obesity, although evidence suggests childhood obesity relates to the infections not the antibiotic treatments (Nov 2016).
- Monitored globally by W.H.O.
- Regulated in the US by the F.D.A. who promote voluntary labeling by industry to discourage livestock fattening (Dec 2013).
- Customer demands have more effect - Perdue shifts to no antibiotics in premier chickens (Aug 2015).
the tumor growth slows (Nov
2017)
- Johns
Hopkins Cynthia Sears & Drew Pardoll report gut microbiome, the trillions of bacteria and viruses that live inside higher animals' guts, on their skin etc. These bacteria and viruses seem to play a role in: immune responses, digesting food, making nutrients, controlling mental health and maintaining a healthy weight. The signals from the gut microbiota are relayed by major nerve fibers: vagus; to the central nervous system. The symbiotic relationship must be actively managed. Human armpits include glands which provide food favoring certain symbionts who build a defensive shield above the skin. In the human gut: Barriers are setup: Mucus secretions form a physical constraint and provide sites for bacteriophages to anchor and attack pathogenic bacteria; Symbiont tailored nourishment: Plant-heavy food creates opportunities for fibre specialists like Bacteroides thetaiotaomicron; is provided, Selective binding sites are provided, Poisons are deployed against the unwelcome, and Temperature, acidity and oxygenation are managed. High throughput sequencing allows the characterization of bacterial populations inside guts. Beginning at birth, as they pass down the birth canal infants are supplied with a microbiome from their mothers. If they are borne via cesarean they never receive some of the key bacteria: Bifidobaterium infantis which is also dependent on oligosaccharides in breast milk; from their mothers. A variety of diseases may be caused by changes in the microbiome:
- Eczema can be related to changes in the skin microbiome.
- Obesity can be induced by changes to the gut microbiome.
- Chronic inflammation
- Allergies
- Type 1 diabetes
:
Bacteriodes fragilis & Escherichia coli; stimulate colon cancer is a major hereditary cancer also called colorectal cancer. It: - Follows a slow, many yearlong, progression from a benign polyp to a localized cancer to an invasive one. Two bacteria: Bacteroides fragilis, Escherichia coli variant; from the gut microbiome have been implicated in the early stages of tumor induction (Feb 2018). It
- Is often associated with Ras mutations and the high risk allele TCF7L2. 30 to 50% of colon cancers have KRAS mutations. Intensive medical surveillance and removal of polyps can be lifesaving for those at high risk. Types of colon cancer include the single gene mutation hereditary: FAP, HNPCC;
- Is linked to obesity.
by invading the mucus is used to cover tissues that are exposed. It is made from mucins. Mucous membranes may secrete mucus to generate a robust barrier.
epithelium is a core cell type that lines cavities and surfaces of blood vessels and organs. All glands are constructed from epithelial cells. Epithelial cells: secrete, absorb, protect, transport and sense. They have no blood supply so they are nourished via diffusion through the basement membrane from underlying connective tissue. Epithelial cell differentiation potency makes these significant cancer agents. of
the colon, developing biofilms is a sheet of bacteria that have invaded the mucus epithelium covering an organ. ,
and damaging the DNA (DNA), a polymer composed of a chain of deoxy ribose sugars with purine or pyrimidine side chains. DNA naturally forms into helical pairs with the side chains stacked in the center of the helix. It is a natural form of schematic string. The purines and pyrimidines couple so that AT and GC pairs make up the stackable items. A code of triplets of base pairs (enabling 64 separate items to be named) has evolved which now redundantly represents each of the 20 amino-acids that are deployed into proteins, along with triplets representing the termination sequence. Chemical modifications and histone binding (chromatin) allow cells to represent state directly on the DNA schema. To cope with inconsistencies in the cell wide state second messenger and evolved amplification strategies are used.
(Feb
2018)
- MS-KCC
sets policy that all outside compensation driven by hospital
research must flow to the hospital. Vice president Dr. Gregory
Raskin: Office
of Technology Development - including hospital ventures
with for-profit companies, formerly of AllianceBernstein
VC is venture capital, venture companies invest in startups with intangable assets
arm vice president
focused on biotechnology; identifies two such cases of
compensation: Y-mAbs
developing MAB as a terminator in medication names indicates the drug is a monoclonal antibody biologic. s: naxitamab is a humanized anti-GD2 3F8 MAB (IgG1) developed by Memorial Sloan-Kettering cancer center, and commercialized by Y-mAbs Therapeutics, for treatment of high risk neuroblastoma. (F.D.A. Food and Drug Administration. breakthrough is used to speed the development and review of drugs that may demonstrate substantial improvement compared to current therapies.
status) & omburtamab is a is a humanized B7-H3 targeting MAB, developed by Memorial Sloan-Kettering cancer center, and commercialized by Y-mAbs Therapeutics, for treatment of human solid tumors: embryonal tumors, carcinomas, sarcomas and brain tumors. ;
based on MS-KCC pediatric oncologist Dr. Cheung's research
treatments, Sellas Life
Sciences Group - cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
vaccine are a core strategy of public health and have significantly extended global wellbeing over 200 years. Smallpox & polio were virtually eradicated. Recent successes include: HPV vaccine: Gardasil. They induce active acquired immunity to a particular disease. But the development and deployment of vaccines is complex: - The business model for vaccine development has been failing (Aug 2015):
- No Zika vaccine was available as the epidemic grew (Mar 2016). No vaccine for: CMV;
- Major foundations: Michael J. Fox, Gates, Wellcome; are working to improve the situation including sponsorship of the GAVI alliance. A geographic cluster is forming in Seattle including PATH (Apr 2016).
- Commercial developers include: Affiris, Cell Genesis, Chiron, CSL, Sanofi, Valeant;
- Vaccine deployment traditionally benefited from centrally managed vertical health programs. But political issues are now constraining success with less than 95-99% coverage required for herd immunity (Aug 2015, Sep 2015, Nov 2015, Nov 2016, Jul 2018).
- Where clinics have been driven into local neighborhoods health improves (Apr 2016).
- Retail clinics (Mar 2016): CVS Minute Clinics focus on vaccination.
- NNT is a useful metric for vaccine benefit. Influenza vaccine has an NNT of between 37 and 77, is cheap and causes little harm, so it is very beneficial.
- Key vaccines include: BCG, C. difficile (May 2015), Cholera (El Tor), Cervical Cancer (Gardasil HPV Jun 2018, Oct 2018), Dengvaxia (Mexico Dec 2015), Gvax, Influenza, Malaria vaccine, Provenge, Typbar-TCV (XDR typhoid Pakistan Apr 2018);
- Regulation involves: FDA (CBER), with CMS monitoring (star ratings, PACE (Aug 2016), Report cards (Sep 2015)) & CDC promoting vaccines: as a sepsis measure, To control C. difficile (May 2015);
- Research on vaccines includes:
- NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.
- NCI:
- Roswell Park clinical trial of immuno-oncology vaccine cimavax.
- Geisinger: effective process leverage in treatment.
- Stanford Edge immuno-oncology for cancer vaccines.
- P53-driven-cancer focused, gene therapy (Jun 2015).
; board
representation policies varies at Integrated systems: Cleveland
Clinic allow; AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017); s:
University
of Utah do not allow; and cancer centers: MD
Anderson allows; (Sep
2018)
- Gene therapy is the deployment of genes into patient's cells to treat or prevent diseases. It can be performed outside the body (ex vivo) or in place (in vivo). It requires a vector such as a: Virus, Ligandal style nanoparticle, electric field (Jul 2018); to perform the deployment. But viruses are: Difficult to sanitize (bringing in oncogenes etc.) and hard to target as needed, Unable to target where the DNA is deployed into the target cell chromosomes, Key targets of the immune system. The process is disease specific:
- Blood cancers: NHL; can be treated with ex vivo CAR-T (Jul 2017, Oct 2017)
- Cystic fibrosis requires a virus that infects the airways and then deploys a non-cystic fibrosis allele into the nucleus of the patient's cells. The obstacles to this process have been challenging:
- The virus must not have any problematic effects. In the case of cystic fibrosis one virus activated a cancer gene leaving several trial subjects with leukemia.
- Efficiency of delivery has to be very high and this has not proved possible as of 2015.
- The newly delivered DNA must remain intact and be replicated and transcribed. This has not proved to be the case.
- The process has not been able to avoid an immune response. Gene therapy has consequently been of limited value for cystic fibrosis.
- Hemophilia A and B; virus delivered in vivo therapies enter final stage trials (Aug 2018)
- ADA based SCID was the first human treatment with gene therapy. A normal ADA gene was inserted ex vivo into immune system cells. Initially the updated cells did not live as long as needed.
- Sickle-cell anemia requires a non-sickle-cell trait allele of the hemoglobin gene to be vectored into the bone marrow of the affected person.
- T-lymphocyte DNA updates for: mutation induced autoimmune diseases, melanoma treatment; using gene editing delivered with an electric field.
department
- Beta thalassemia studies
- Cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
and founding
Juno
- Kite Pharma
is a close partner of the NCI is the national cancer institute.
leveraging public research investments in CAR is chimeric antigen receptor. Killer T lymphocytes are genetically engineered to produce a novel protein, composed of pieces from different parts of the immune system such as: antibody components to construct a new receptor binding site on the T cell that targeted an antigen exposed on the cell surface of cancer cells, and two receptor associated signals that switch the T-cell into kill mode and sustain it in that mode. Small clinical trials of CAR-T cells have shown substantial remissions among patients with various blood cancers (Aug 2016, Jul 2017, Oct 2017, Nov 2017). But there are severe side effects. s. N.I.H. is the National Institute of Health, Bethesda Maryland. It is the primary federal agency for the support and conduct of biomedical and behavioral research. It is also one of the four US special containment units of the CDC. should ask for
more says Rachel
Sachs, like Sloan-Kettering
and Hutchinson
get from Juno
(Dec
2016)
- Clinical genetics
testing uses genomic analysis to diagnose genetic disorders - for example Genomic Health's Oncotype DX & Agendia's MammaPrint. The desire to see the genetic risk factors identified by such tests should depend on the risk * burden * Possibility of intervention. Early tests look at only single gene mutations, but big data research tools are showing promise with large gene algorithms (Aug 2018). Genomic testing can be performed direct-to-consumer. Data is being collated on the genetic components of most diseases to enable more sophisticated diagnosis in the future such as the OPHG (EGAPP initiative), USPSTF recommendations and NCBI (Genetic test registry). While there is only limited identification of the significant mutations and limited patient bases misdiagnosis is a problem (Aug 2016).
service
- Sloan-Kettering's Peter Bach
- Talks about cost
of drugs for hepatitis C is a virus which destroys the liver during infection. In 2016 it affects 185 million people worldwide. Once the virus genome was sequenced in 1989 Dr. Bartenschlager and Dr. Rice worked to replicate the virus in the laboratory. Rice realized the genome sequence was missing details that stopped the lab replication. Bartenschlager was then successful at replicating the virus in cells in his laboratory. The replication technique allowed Pharmasset's Dr. Sofia to develop a new hepatitis C drug, by enhancing an RNA-polymerase inhibitor with a coat that allowed the drug to enter the liver, where the coat was destroyed and the polymerase inhibitor was activated. With high concentrations of the drug, sofosbuvir, in the liver it could eradicate the hepatitis C virus. Sovaldi was the first sofosbuvir approved by the F.D.A.
- Personalized
medicine is a medical strategy where decisions, practices, and products are tailored to the individual patient. Research is looking at the impact of providing potentially deleterious genomic testing information to people: The REVEAL study found no increased anxiety induced by hearing that one's genome implied increased risk of developing late onset Alzheimer's disease. The take-up of personalized medicine benefits from the focus on genomics, enabled by next generation sequencing of DNA, and detailed by the NIH director Francis Collins and includes:
- NCCN intensive cell therapies
- Direct to consumer genomic testing
- Direct to consumer diagnostics
- Pharmacogenomics tailored drug treatments reducing the risk and cost of adverse drug reactions.
& immunotherapy is indirect treatment of disease by altering the immune system. Targeted diseases include: cancers -- immuno-oncology, organ transplants.
clinical trials are constrained by: Limited patient base argue:
Yale CC,
MS-KCC,
Genentech;
Companies with me-too products requesting trials -- a situation
companies with F.D.A. Food and Drug Administration.
approval: Merck; are
happy to see. Targeted therapies: GSK, Pfizer, Loxo Oncology;
have even less potential patients which is a concern at Fred
Hutchinson (Aug
2017)
- Department of surgery
- Outpatient surgery center
- Pathology
& Computational
pathology
- Memorial
Sloan-Kettering sponsored AI startup, Paige.AI executives
are senior executives: Klimstra,
Fuchs;
and board members: Stanley
Druckenmiller, Alexander
Robertson, Marie-Josee
Kravis, Norman
Selby; of the hospital. Paige.AI is leveraging 60
years of MS-KCC pathology data which may have broken related
party transaction federal and state laws; undermining the
hospital's tax status. ValueEdge advisors's Nell Minow is
concerned. Other medical AI product developers: Google, Microsoft,
PathAI, SpIntellx;
might benefit from access to the pathology data. Patients
were not informed that tissue images were being shared with an
outside company. MS-KCC staff pathologists felt their work
was being commercialized for private gain (Sep
2018)
- Office of Technology
Development
- MS-KCC
sets policy that all outside compensation driven by hospital
research must flow to the hospital. Vice president Dr. Gregory
Raskin: Office
of Technology Development - including hospital ventures
with for-profit companies, formerly of AllianceBernstein
VC is venture capital, venture companies invest in startups with intangable assets
arm vice president
focused on biotechnology; identifies two such cases of
compensation: Y-mAbs
developing MAB as a terminator in medication names indicates the drug is a monoclonal antibody biologic. s: naxitamab is a humanized anti-GD2 3F8 MAB (IgG1) developed by Memorial Sloan-Kettering cancer center, and commercialized by Y-mAbs Therapeutics, for treatment of high risk neuroblastoma. (F.D.A. Food and Drug Administration. breakthrough is used to speed the development and review of drugs that may demonstrate substantial improvement compared to current therapies.
status) & omburtamab is a is a humanized B7-H3 targeting MAB, developed by Memorial Sloan-Kettering cancer center, and commercialized by Y-mAbs Therapeutics, for treatment of human solid tumors: embryonal tumors, carcinomas, sarcomas and brain tumors. ;
based on MS-KCC pediatric oncologist Dr. Cheung's research
treatments, Sellas Life
Sciences Group - cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
vaccine are a core strategy of public health and have significantly extended global wellbeing over 200 years. Smallpox & polio were virtually eradicated. Recent successes include: HPV vaccine: Gardasil. They induce active acquired immunity to a particular disease. But the development and deployment of vaccines is complex: - The business model for vaccine development has been failing (Aug 2015):
- No Zika vaccine was available as the epidemic grew (Mar 2016). No vaccine for: CMV;
- Major foundations: Michael J. Fox, Gates, Wellcome; are working to improve the situation including sponsorship of the GAVI alliance. A geographic cluster is forming in Seattle including PATH (Apr 2016).
- Commercial developers include: Affiris, Cell Genesis, Chiron, CSL, Sanofi, Valeant;
- Vaccine deployment traditionally benefited from centrally managed vertical health programs. But political issues are now constraining success with less than 95-99% coverage required for herd immunity (Aug 2015, Sep 2015, Nov 2015, Nov 2016, Jul 2018).
- Where clinics have been driven into local neighborhoods health improves (Apr 2016).
- Retail clinics (Mar 2016): CVS Minute Clinics focus on vaccination.
- NNT is a useful metric for vaccine benefit. Influenza vaccine has an NNT of between 37 and 77, is cheap and causes little harm, so it is very beneficial.
- Key vaccines include: BCG, C. difficile (May 2015), Cholera (El Tor), Cervical Cancer (Gardasil HPV Jun 2018, Oct 2018), Dengvaxia (Mexico Dec 2015), Gvax, Influenza, Malaria vaccine, Provenge, Typbar-TCV (XDR typhoid Pakistan Apr 2018);
- Regulation involves: FDA (CBER), with CMS monitoring (star ratings, PACE (Aug 2016), Report cards (Sep 2015)) & CDC promoting vaccines: as a sepsis measure, To control C. difficile (May 2015);
- Research on vaccines includes:
- NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.
- NCI:
- Roswell Park clinical trial of immuno-oncology vaccine cimavax.
- Geisinger: effective process leverage in treatment.
- Stanford Edge immuno-oncology for cancer vaccines.
- P53-driven-cancer focused, gene therapy (Jun 2015).
; board
representation policies varies at Integrated systems: Cleveland
Clinic allow; AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017); s:
University
of Utah do not allow; and cancer centers: MD
Anderson allows; (Sep
2018)
- Watson
supported genomics combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes.
for oncologists with: Quest (Oct
2016), MS-KCC,
Broad Institute;
- New York Private
Equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors. Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges. Private equity companies were initially corporate raiders.
company Royalty Pharma
purchases future drug sales royalty rights from drug companies:
AstraZeneca,
Universities/Foundations: Emory, Northwestern,
UCLA,
MS-KCC,
CFF;
once the drugs: Humira,
Remicade,
Xtandi,
Kalydeco, Tysabri; are
FDA Food and Drug Administration. approved (Jul
2017).
- Constrained demand for Proton
Therapy irradiates diseased tissues, including cancers, with protons. The particles destroy the DNA of cells they interact with stopping their reproduction. The powerful control of the large charged particles allows acute focus and limited exit dosage. Cyclotrons, synchrotrons and linear accelerators are used to accelerate and control the protons. A significant drawback is the cost and size of the particle accelerator. The therapy is viewed as useful in treating children and for tumors that are proximate to sensitive organs such as eyes. Infrastructure competition driven over-deployment has resulted in business failures for the treatment centers (Apr 2018)
leaves Cancer Centers: Georgetown
University Hospital,
Indiana
University Health System, University
of Maryland MS Greenebaum
CCC, New York (Memorial
Sloan-Kettering, Mount
Sinai Health System, Montefiore Health),
Northwestern
Medical, Scripps,
Seattle cancer care alliance (Fred
Hutchinson, Seattle
Children's, University
of Washington); with costly underperforming or bankrupt is a legal status for an entity that cannot repay its creditor's loans. It holds creditor lawsuits in abeyance while the restructuring process proceeds to allow the entity to continue operations. It also has legal tools for forcing holdout creditors to accept repayments that are lower than the bond sale initially promised.
investments (Apr
2018)
- Memorial
Sloan-Kettering's chief medical officer, & esteemed
oncologist, Dr. Jose Baselga, did not disclose millions of
dollars he received from pharmaceutical and healthcare
companies: Roche/Genentech; while he
was positively reviewing their work: Zelboraf,
Perjeta
(herceptin
upgrade), PI3K is phosphatidylinosotol-4,5-biphosphate 3-kinase is a family of cellular signal transducers, phosporylating the 3' of the inositol ring of lipids. Class I PI3Ks are activated by G protein-coupled receptors & tyrosine kinase receptors. Class II PI3Ks participate in clathrin-mediated endocytosis. Class III is involved in trafficing of proteins and vesicles. They support phagocytosis. Class IV include ATM, ATR, DNA-PK and mTOR serine/threonine kinases. By helping signalling proteins to be recruited to cell membranes they support cell growth, proliferation, differentiation, motility, survival and intracellular trafficking, often by activating protein kinase B. Different isoforms regulate different aspects of the immune response, and the insulin signalling pathway. inhibitor are pharmaceuticals designed to inhibit various isoforms of PI3K, to inhibit the growth of cancers and inflammatory respiratory disease.
taselisib;
undermining other generally negative views, and publishing
related research in journals without noting payments 60% of the
time. His role at MS-KCC
may also conflict with board positions at: Mosaic
(founder), Tango
(founder), Aura,
BMS,
Varian, Foghorn,
Grail, Infinity;
Science/clinical boards: ApoGen,
Aura, Grail, Juno,
Northern
Biologics, Paige.AI,
Peptomyc, PMV, Seragon; and
consulting to: AstraZeneca,
Eli Lilly, Novartis,
Roche/Genentech; which sell to MS-KCC. Societies: ASCO
require disclosure. Journals: JAMA Internal Medicine, New
England Journal of Medicine; argue they do not have the
resources to check on author's submissions (Sep
2018)
- Fund
raising
At its core PCMH aims to focus attention on the patient, and ensure
the PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. has the support
to manage the care of a complex case. It builds infrastructure
to leverage:
- The patient's goals and desires. This includes training
the team in: asking questions and recording the discoveries (Southwestern
Vermont assessment & self-management), inspiring the
patient (Southwestern
Vermont motivational interviewing), presenting a vision of
a trusted partner/team;
- Improved access to the health network. This requires
enough resource to cover the range of times that different
patients in the patient population need (Elmhurst
access
strategy). Scheduling tools (AtlantiCare
special
care center scheduling)
aim to support making best use of the resources in coping
with unpredictable demands. 24 hour access equivalent to
rolling response center support would seem to be the
extrapolated ideal (Kaiser PCMH
strategy) but it is not trivial to make this effective,
coherent and low cost. Home visits by on call doctors
would require more PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
than exist or are being trained.
- Coordination specialists (Geisinger
proven
care navigator, BSVMG
Navigators)
to ensure that the plan of care is understood, communicated and
executed. This is key to track the various interacting
aspects of a complex illness and its treatment. But
patients do not expect or trust the new role (Trinity
clinic Navigator).
Geisinger's health plan supplies
incentives and the nurse case manager enhancing its power
and influence in the PCMH.
- Learning theory to improve the patients understanding of
clinical comments (Geisinger
PCN patient
over-optimism), their goals and strategies for wellness.
- Technology to provide:
- Consistent representation of the patient's medical state
including: diagnosis, medicines, medical history, discharge
data (UCLA
discharge times),
- Real time and queued communication media,
- Diagnostic support including help with effectively searching
and interpreting the increasing volume of scientific findings
and recommended protocols,
- Educational information,
- Support for flexible scheduling including real-time
discussion of current priorities and availability of
resources, and required diagnostic data.
There are some constraints and incoherencies in the PCMH:
- The value provided by different members of the PCMH does not
necessarily correlate with power or remuneration.
- The open access to data promoted as beneficial to making the
PCMH effective (Bon
Secours) is in contention with: privacy desires and
regulations, the risk of legal discovery for litigation, the
personality and personal goals of the individuals that make up
the group and team roles.
- Hospital
systems is the owner of a set of hospitals and other owned infrastructure and employer of direct staff. can benefit from having control over key resources
that make the PCMH work: EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses:
- The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
,
Portal provides web and or application based access to a patient's EHR based health care information and services. Specific portal services are mandated by meaningful use. They include at a minimum lab test results, problem list, medication list, and medication allergy list. , Case is defined by American Case Management Association as a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality cost effective outcomes. Case management productivity, discharge planning, utilization, coding and documentation, denials (RAC), Patient satisfaction (HCAHPS) and performance improvements are often measured to constrain overheads. Patient flows can be assessed via numbers of: admissions, observation days, patient days, outpatient visits, discharges, E.D. volumes, occupancy, and denial rates.
workers, Care
coordination aims to transfer information between the patient and each care participant as required and establish accountability by defining who is responsible for each care delivery activity, the extent of that responsibility and when that responsibility will be transferred to other care participants or the patient and family. Successful care coordination requires face-to-face interactions. It also requires aligned incentives (ACO, Bundled payments). AHRQ defines quality measures for care coordination. The situation is usually complex and adaptive due to the interactions of all the providers, settings, the patients' preferences, and the number of physical health problems, treatments, and the patients' social situation. The potentially exponential increase in complexity as the number of these factors present increases leads to patient hot spots requiring explicit proactive coordination of care. It is argued that care coordination must include six specific activities: - Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history. It needs to be updated periodically and after new diagnosis and other changes in health or functional status.
- Creation and updating of proactive plan of care
- Communication
- Facilitation of transitions: typical transition problems are detailed by Project Boost. A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff.
- Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness.
- Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.
workers, but this seems inconsistent with the
focus of the PCMH. Indeed the EHR and center of
coordination would be the PCMH. AtlantiCare shows that
with the right incentives the PCMH makes sense. Similarly
Kaiser (PCMH
strategy) can leverage their end-to-end
infrastructure/business model with one EHR accessible to all
their employees etc. They also argue that an effective
PCMH shifts health strategies away from over use of costly
specialists. But as more PCMHs are setup will the
replacement of PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
interactions with multi-specialist-skill based team meetings
sustain the effectiveness of the shift?
- The promotion of PCP is a threat to specialists. They
will work to maintain their current remunerations and access to
referrals. Specialists will respond by organizing as a super group is an integrated single practice combining independent specialists and specialist organizations with one tax identification number. They aim to improve market power for the specialists by capturing essential agents and so making the SuperGroups participation in a value delivery system necessary for the delivery of efficient, effective health care. The focus on a single specialty can improve efficiency and effectiveness. They can avoid Stark laws and Kickback statutes but are often limited in the total percentage of specialists they can encompass and may need an antitrust assessment. They can organize as centrally managed medical groups with pooled revenues or as a set of autonomous operating divisions (practices) within a group practice 'without walls' where only centralized expenses are allocated. But such organizations are often unstable due to the independent nature of the experts they leverage and constrain. And it can be difficult to build the original super group since it must combine different cultures, billing arrangements, debt profiles, payment contracts, IT systems, values and approaches to quality. or clinically
integrated network is a legally acceptable clinical integration of hospital, physicians and/or other dedicated health care providers who deliver services focused on quality, performance, efficiency and value to the patient. In comparison with a SuperGroup it also increases market power while sustaining expert agent independence. But it is hard to manage and requires significant infrastructure expense to support clinical integration and management of utilization and financial uncertainty. Initial setup will have to manage the problem of prior contracts the new members have with IPA, PHO or ACOs. An alternative to a clinically integrated network is a messenger model network. The Joint Commission specified an OPPE requirement for general performance improvement. Network providers must develop and sustain clinical initiatives that enhance access to care, clinical quality, cost control and the patient experience by:
- Coordination across the network,
- Implementing evidence-based clinical protocols,
- Improving efficiency in the delivery of care,
- Partnering with payers to develop contracts that drive definable clinical improvement and add value to patients.
. They will also benefit by
resting power from the PCP in the PCMH. The increasing lack of
PCPs helps drive a low cost PCMH strategy based on Nurse
Practitioners. Kentucky Family
Health Centers demonstrates the aim, and risks, of having
a business model leveraging the expansion and costs of Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. 's payment
stream. It replaces doctors with nurse practitioners and
is struggling with the reality of EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
.
- The increasing complexity of medicine, described in the checklist
manifesto, undermines the PCP role. For example a
PCP suggested
a basal
cell carcinoma is the most common form of cancer. It rarely metastasizes or kills unlike melanoma. It does cause destruction and disfigurement by invading surrounding tissue so it is considered malignant. There are a number of types: Aberrant, Cicatricial, Cystic, Fibroepithelioma of Pinkus, Infiltrative, Micronodular,Nodular which can become a Rodent ulcer, Pigmented, Polypoid, Pore-like, Superficial.
was a clogged pore limiting their
crediblity in constraining the use of specialist proposed
treatments.
The AtlantiCare special care center also reduces its billing costs
by being paid a flat fee
per 'hot spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community. '
patient by the sponsoring health funds. The goal of the center
is to keep the patients healthy enough they do not need hospital and
ER is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). visits. The
individual transactions at the care center are designed to be low
cost and highly flexible. More transactions must occur.
The key to success is staffs that are focused on patient
service. Patients do not get charged to visit the
center. Regular health care incents and trains the
opposite. The key requirements are:
- Open scheduling to guarantee same day access to acute
patients. A meeting where all clinicians talk about their
notes on each patient scheduled to visit that day.
- Software specialized for tracking of patients
[failure/success] in achieving their goals.
- Specific staffs were focused on helping the patients achieve
the goals.
- Health coaches who contact the patients very regularly and
help them stay on track.
- Follow up calls were made within 24 hours of a
visit.
It is not clear how AtlantiCare
becoming part of the Geisinger
health system will affect these activities.
Lehigh valley's coordination aims to support effective transfers
through the hospital stay and after discharge effectively moving the
patient to the most appropriate facility for their needs. It
leverages care coordinators and IT infrastructure including the EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
. Can the use of
coordination overcome the structural inefficiencies of not being
deployed in a team structure? It is also not clear how costs
are managed and patients are incented to focus on wellness is a health care oriented employer based strategy for reducing health care costs and encouraging wellbeing. Wellbeing has traditionally been a focus of public health. .
Specialized focused providers such as the Hospital
for Special Surgery in New York, and even Cleveland Clinic's
focused Institutes
can contract directly with employers such as Walmart,
leveraging the transport infrastructure to bring patients to centers
of excellence. 73% of AHA is the American_hospital association. /ACHE is the American College of Healthcare Executives. CEO's said they would
contract directly with employers. This pressure should
facilitate the consolidation and disruption of the profit hospital
management companies. 24*7
Branded Urgent Care is another reengineered niche undermining
the constrained hospital ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). s,
and PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. practices.
- Business
model for individual PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
collapses under
pressure from various large organizations executing acquisitions
and mergers: Apple
running own clinics for employees, Large hospitals setting up
urgent care: HCA,
Dignity Health,
Northwell
Health (GoHealth);
CVS Health & Aetna, Wal-Mart & Humana, United Health
employs 30,000 physicians and owns one of the largest urgent care is an efficient and less costly 'alternative' to the ER. There is no accepted standard. Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls. Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones. Unlike an ER they can not admit patients to a hospital. Some also offer services like pre-employment drug screening and summer camp physicals.
groups
(MedExpress);
who can leverage employed PCP prescriptions for their PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. s, driving some PCPs
to compete with urgent care: Healthy Now; and or leverage nurse
practitioners, and others to explore One Medical
& Aledade (Apr
2018)
Reengineering ED use
The high cost of ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). makes
it a major focus for improvements. NYT
Dec 2013 reports on Raleigh NC attempts to limit inappropriate
ED use by the mentally ill. And NYT
Sep 2013 op-ed notes 40 percent of ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). visits are more cost
effectively handled with home visits. Companies such as Carna are providing
doctors and nurse practitioners supported by customer care software
that uses algorithms to help differentiate between cases that are
safe to handle at home and those that require the ED. There is
also for profit competition from urgent care
clinics is an efficient and less costly 'alternative' to the ER. There is no accepted standard. Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls. Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones. Unlike an ER they can not admit patients to a hospital. Some also offer services like pre-employment drug screening and summer camp physicals. with Wall
Street financing.
But hospital systems focused
on innovation are using standalone EDs to
undermine this reengineering and capture more patients.
Specialist intuitive job shops leverage low error rates to gain
a competitive advantage
Specialists can avoid many of the complex costs associated with
general hospitals:
-
Hospitals handle patients with communicable infections. So
they must be able to implement isolation procedures, maintain
supplies of barrier gowns etc. and carefully manage waste
items. These costs are typically avoided by competitors such
as focused specialist hospitals (Texas heart
etc.) and surgical
centers.
Cancer centers: MS-KCC;
build complex relationships with scientists, federal agencies and
suppliers of specialist diagnostics and treatments.
Focused general hospitals!
The use of service
lines is a strategic focus and structuring by a general hospital to optimize for the most locally profitable areas of diagnosis and treatment such as: Cardiovascular, Neurology or Cancer; to respond to competition from specialist focused health care facilities such as the Texas heart institute and local low cost outpatient facilities. It does not abandon other services which the community as a whole needs but limits the losses they generate. A successful service line can: Diagnose and treat a high volume of service specific problems ensuring quality and efficiency, be profitable enough to gain additional investment and attract top physicians. To be effective service line strategies require: - A clear view of the hospital's competitive environment.
- Visibility of the revenue, costs (activity based rather than top down) and benefits of particular procedures and bundles of care. Cost estimates are often averaged by hospital accounting models.
- Effective management of PCP referrals to the hospital and its competitors.
- Changes to the: Organization structure, Incentive plans for doctors, Relationship with physicians (potentially including co-management) - who must own the problems of their service line, Business development, HCIT - which will need to capture all details of a service, HR who will need to support the employees during and after the transition.
to tighten the focus of a general hospital: Mayo
Clinic, Geisinger,
El Camino
Hospital; can never directly match the efficiency of a
specialist: Standalone
VASC (Aug
2016); But it fills a key need of the community
it serves. Recognition of that need can provide the
community general hospital with its own focused strategic advantages
to add to the effective execution of the service lines. The
key requirements are:
- Visibility into the local community's health care needs and
insurance status.
- Close relationships with physician specialists who can
champion and lead the service lines the community need's
support.
- Physician partnership strategies must seek out niches which
are valuable and complementary to the medical
system quality differentiation partner. This
allows for:
- Business strategy must ensure:
- Phenotypic alignment must support
the strategy. Focusing on treatment of obese is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016).
patients (Sep
2016) can leverage investments in targeted
infrastructure. But trial data on obese patients is too
limited to support the risks of treatment.
- Enough business and cost controls to drive inclusion in the
payers' narrow
networks - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans. This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans. By limiting the number of providers/doctors offered in the plans the few that are included should get more business. Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers). In large cities narrow networks are even more common. Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills. There are problems induced by narrow network constraints:
- Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts. Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running. If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016).
in this location.
- HCIT is health care information technology. The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets. Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.;
capabilities
to associate patients, PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. ,
specialists and the hospital including:
- Efficient and effective clinical capabilities reflecting both
the desired strategic direction and the clinical team's creative
feedback and best practices.
- Capabilities to iteratively align plans with reality of the
clinical setting, and business pressures.
- Financing from the local, state and federal authorities to
assist with losses generated by cost controlled but broad
community programs.
Government
sustained, safety net focus
Safety net
hospitals are hospitals which care for a financially challenged patient population. There are about 300 safety-net hospitals including: Grady memorial, Harris Health, Mcleod; in the US providing longer term care to the poor and indigent than regular for-profit and non-profit acute care hospitals. This arrangement allows the other hospitals to focus on the needs of their insured customers. Once acute treatment of a life-threatening illness, which will be funded by Emergency Medicaid, has completed, longer term treatment depends on the support of a safety net hospital. This dependency is being undermined by HRRP (Dec 2018). such as Grady
Memorial, benefit from high volumes of acute patients, helping
specialists build operational expertise.
Notable events involving these hospital networks include:
- ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
funding
adjustments and state's: Georgia's; SCOTUS refusal of Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. expansion
threatening the hospital
safety net are hospitals which care for a financially challenged patient population. There are about 300 safety-net hospitals including: Grady memorial, Harris Health, Mcleod; in the US providing longer term care to the poor and indigent than regular for-profit and non-profit acute care hospitals. This arrangement allows the other hospitals to focus on the needs of their insured customers. Once acute treatment of a life-threatening illness, which will be funded by Emergency Medicaid, has completed, longer term treatment depends on the support of a safety net hospital. This dependency is being undermined by HRRP (Dec 2018). : Grady
Memorial (Aug
2016)
- Issues identified with HRRP is the Hospital Readmissions Reduction Program of the ACA. It imposes payment penalties on high readmitting IPPS hospitals. Such hospitals with higher than expected readmissions rates will receive reduced Medicare payments for all Medicare discharges relating to three medical conditions: heart failure, acute myocardial infarction, and pneumonia. The reductions will be driven by an adjustment factor of 1% in 2013, 2% in 2014, and 3% subsequently. The incentives/penalties induce complex adaptive responses (Dec 2018)
by Harvard
cardiologist is the diagnosis and treatment of: Congenital heart defects, CAD, Heart failure, Valvular heart disease; by cardiologists.
Wadhera, Washington
St. Louis cardiologist Maddox, Beth
Israel Deaconess cardiologist Yeh; patients returning to
hospital are being processed through ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). or placed in observation means outpatient observation stay. , Safety net
hospitals are hospitals which care for a financially challenged patient population. There are about 300 safety-net hospitals including: Grady memorial, Harris Health, Mcleod; in the US providing longer term care to the poor and indigent than regular for-profit and non-profit acute care hospitals. This arrangement allows the other hospitals to focus on the needs of their insured customers. Once acute treatment of a life-threatening illness, which will be funded by Emergency Medicaid, has completed, longer term treatment depends on the support of a safety net hospital. This dependency is being undermined by HRRP (Dec 2018). are being penalized for their low income patient
bases higher readmissions have become a source of increased revenue for hospitals. But with government interested in reducing the US health care cost curve ACA's HRRP (pay-for-performance), BPCI and CTI and Interact discharge initiative have all increased the focus on unnecessary readmissions. Now the end-to-end process is under scrutiny with hospitals reengineering discharge (RED) and PAC providers using RAI and TCN. ,
readmission rates are falling but death rates are rising (Dec
2018)
Medical system for
profit differentiation strategies
HCA,
HMA
+ CYH,
LPNT,
UHS
and Tenet
(THC) strategy: These for profit hospital management companies
have leveraged FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment. into a
powerful mechanism for capturing treatment revenue. They can
benefit from ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
driven
reductions in uninsured but must develop new strategies to cope with
meaningful use is the set of standards defined by CMS Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria. It aims to ensure that ARRA subsidies for HIS are used to generate health improvements. It is staged: - 2011-2012 Data capture and sharing - Criteria focus on electronically capturing health information in a standardized format. Using that information to track key clinical conditions. Communicating that information for care coordination processes. Initiating the reporting of clinical quality measures and public health information. Using information to engage patients and their families in their care. Achieving meaningful use stage 1 requires meeting all core and selected menu objectives.
- 2014 Advance clinical processes - More rigorous health information exchange requirements. Increased requirements for e-prescribing and incorporating lab results. Electronic transmission of patient care summaries across multiple settings. More patient-controlled data. A patient portal is required. CMS hospital core measures, CMS hospital menu set measures, NPRMs of stage 2 meaningful use and certification criteria have been announced (2013).
- MU2 requires EHR systems to support direct messaging to send PHI to registered users.
- 2016 Improved outcomes - Improving quality, safety, and efficiency, leading to improved health outcomes. Decision support for national high-priority conditions. Patient access to self-managed tools. Access to comprehensive patient data through patient-centered HIE. Improving population health.
constraints, at least while the Administration and Senate are
Democratic. Counter cyclical revenue generation, growth from
the aging population demographics, and cash generation from high
priced services, along with consolidation is popular with
shareholders including hedge
funds is an investment fund that accepts investments from a limited number of accredited individual or institutional investors. Hedge funds are able to use investment methods that are not allowed for other types of fund. : Glenview.
CYH
and Tenet
both target major purchases in 2013. CYH bid for HMA was
accepted. They have the opportunity during the shift
from FFS to shared risk to push independent PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. s and specialists
towards direct employment and profit
oriented medical strategies but they may just increase the
cost structure and undermine profitability. More likely they
will consolidate, and then disintermediate is the shift of operations from one network provider to another lower cost connected network provider. The first network provider leverages the cost benefits of the shift to increase its profitability but becomes disrupted. The lower cost network provider gains revenue flows, expertise and increases its active agents. Over time this disruptive shift will leave the higher cost network as a highly profitable shell, but the agents that performed the operations that migrated to the low cost network will be ejected from the network. For a company that may imply the costs of layoffs. For a state the ejected workers imply increased cost impacts and reduced revenue potential which the state are trading off for improved operating efficiency.
to sustain profits unless constrained by the F.T.C. - is either: - Federal Trade Commission. Setup during the Wilson administration. Its powers include blocking mergers due to antitrust concerns using the powers of the Clayton act.
- Follicular thyroid cancer.
(sep
2014).
- Hedge fund is an investment fund that accepts investments from a limited number of accredited individual or institutional investors. Hedge funds are able to use investment methods that are not allowed for other types of fund.
Glenview
Capital sells off Hospital
Corporation of America & Health
Management Associates, but still suffers from investments
in hospitals: Tenet;
that have added debt from acquisitions but lost customers to
outpatient treatment and HDHP is a high-deductible health plan which has lower premiums and a higher deductable than traditional health insurance plan such as a HMO plan or PPO plan.
pressure (Sep
2017)
- Major hospital
systems is the owner of a set of hospitals and other owned infrastructure and employer of direct staff. : Dignity + Catholic
Health Initiatives, Ascension,
Advocate
+ Aurora;
plan mergers; Tenet
& Community
Health sell off poor performing hospitals & shift
further to outpatient services. All are hoping to capture
patient base before new entrents: UnitedHealth,
CVS Health, Amazon; can.
And scale may help with margin & HCIT is health care information technology. The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets. Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.;
costs.
UnitedHealth's Optum
purchases the Advisory
Board. Republican tax law suggests reduced funding
of: ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
, Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
& Medicaid is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; will all
be further impacting revenue to hospitals (Dec
2017)
- Community
Health Systems is investigated for ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016).
incentives (2013)
- Community
Health Systems to acquire Health
Management Associates (2013)
- Community
Health Systems spins off 38 rural hospitals as Quorum
Health (Aug
2015)
- 85 rural hospitals (5% of them) have closed since 2010: CHY
strategy. Less than half the US is the United States of America. 's rural counties have
a hospital that covers maternity, due to business model issues:
collapsing birth rate, specialists clustered in large cities;
which cascades added risks, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty.
:
medical visits cost more & take up more time - NICU is neonatal ICU also called an intensive care nursery. babies need to be
visited regularly increasing the impact on mother and family,
women go less often to visit doctors, more babies born
prematurely, deliveries occur outside hospital or at ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). , hospital is often a
large employer and closure impacts the community economics (Oct
2015), but eventually rebalancing occurs with urgent care is an efficient and less costly 'alternative' to the ER. There is no accepted standard. Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls. Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones. Unlike an ER they can not admit patients to a hospital. Some also offer services like pre-employment drug screening and summer camp physicals.
units opening, maternity opening at a remaining hospital in the
region, helicopters
taking serious cases to hub hospitals (Jul
2018)
- Health
Management Associates investigated by government for
alleged invalid increases in admissions via ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016).
relationships (2013)
- Hospital
Corporation of America develops SMART is substitutable medical applications and reusable technology from SMART Health IT.
clinical
trials matching at Sarah
Canon Cancer Center.
- Business
model for individual PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
collapses under
pressure from various large organizations executing acquisitions
and mergers: Apple
running own clinics for employees, Large hospitals setting up
urgent care: HCA,
Dignity Health,
Northwell
Health (GoHealth);
CVS Health & Aetna, Wal-Mart & Humana, United Health
employs 30,000 physicians and owns one of the largest urgent care is an efficient and less costly 'alternative' to the ER. There is no accepted standard. Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls. Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones. Unlike an ER they can not admit patients to a hospital. Some also offer services like pre-employment drug screening and summer camp physicals.
groups
(MedExpress);
who can leverage employed PCP prescriptions for their PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. s, driving some PCPs
to compete with urgent care: Healthy Now; and or leverage nurse
practitioners, and others to explore One Medical
& Aledade (Apr
2018)
- Healthcare is often used as a counter cyclical investment by
portfolio managers: Wellington Management (Vanguard Health Care
fund's manager) during downturns, because people still get sick
and injured during recessions. The ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
helped increase bed
and drug use; healthcare service spend increased 35% from 2010
to 2017, driving up the market value of commercial hospital
groups: HCA
- which has been expanding bed capacity; but that success helped
ensure performance of the health care sector has been relatively
poor recently. The ACA
unconstitutionality ruling, & health insurance
political shifts may also limit a counter cyclical investment
strategy (Jan
2019)
- Hospital
Corporation of America spins off rural hospitals as Lifepoint
& Triad
(1999)
CYH
has spun off its rural hospitals as Quorum Health
(Aug
2015).
Consolidation of IT infrastructure of merged provider networks is
likely judged key to removing complexity and cost and improving
flexibility and IT responsiveness to the businesses. It is not
clear that the hospital business executives will agree.
Geographic
niche hospital strategies
The traditional community hospitals: El Camino Health;
provide a platform is agent generated infrastructure that supports emergence of an entity through: leverage of an abundant energy source, reusable resources; attracting a phenotypically aligned network of agents.
supporting:
- Development of a network of businesses which could support
current, and attract new, residents with the support of the
hospital.
- A population of independent doctors who gained low cost access
to capital intensive medical infrastructure. They could
explore proximate niches enabling evolutionary
pressure to build.
But these hospital's business model may be undermined by other evolved amplifiers:
Notable events involving these hospital networks include:
- New York City Health
& Hospitals president Katz will: focus on primary
care, leverage technology: eConsult; reduce use of consultants;
to improve profitability (Jan
2018)
- Amazon, Berkshire
Hathaway, JPMorgan
Chase partnership aims to disrupt
health care; leveraging their combined consumer choice &
health insurance knowledge to enable technology to simplify
care. (Jan
2018)
- University
of Pennsylvania's Ezekiel
Emanuel argues traditional
hospital business model is under pressure (Feb
2018)
- Business
model for individual PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
collapses under
pressure from various large organizations executing acquisitions
and mergers: Apple
running own clinics for employees, Large hospitals setting up
urgent care: HCA,
Dignity Health,
Northwell
Health (GoHealth);
CVS Health & Aetna, Wal-Mart & Humana, United Health
employs 30,000 physicians and owns one of the largest urgent care is an efficient and less costly 'alternative' to the ER. There is no accepted standard. Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls. Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones. Unlike an ER they can not admit patients to a hospital. Some also offer services like pre-employment drug screening and summer camp physicals.
groups
(MedExpress);
who can leverage employed PCP prescriptions for their PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. s, driving some PCPs
to compete with urgent care: Healthy Now; and or leverage nurse
practitioners, and others to explore One Medical
& Aledade (Apr
2018)
The supportive local, state and federal regulatory environments
limited the competitive forces on the independent doctors
undermining the drive to enter additional niches and encouraging extended phenotypic alignment.
Hospitals have been encouraged to deploy conforming EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
systems through HITECH the Health Information Technology and Economic and Clinical Health Act 2009. Central to the act is the establishment of the Medicare and Medicaid EHR incentive programs which make available $27 Billion over 10 years to encourage eligible professionals and hospitals to adopt and meaningfully use certified EHR technology. It is assumed that over time use of the new infrastructure will grow exponentially. HITECH established a formal mechanism for public input into HIT policy - the HITPC and HITSC. Hitech is a key evolved amplifier driving the migration to and installation of Epic and Cerner EHR systems. financial
incentives and meaningful
use is the set of standards defined by CMS Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria. It aims to ensure that ARRA subsidies for HIS are used to generate health improvements. It is staged: - 2011-2012 Data capture and sharing - Criteria focus on electronically capturing health information in a standardized format. Using that information to track key clinical conditions. Communicating that information for care coordination processes. Initiating the reporting of clinical quality measures and public health information. Using information to engage patients and their families in their care. Achieving meaningful use stage 1 requires meeting all core and selected menu objectives.
- 2014 Advance clinical processes - More rigorous health information exchange requirements. Increased requirements for e-prescribing and incorporating lab results. Electronic transmission of patient care summaries across multiple settings. More patient-controlled data. A patient portal is required. CMS hospital core measures, CMS hospital menu set measures, NPRMs of stage 2 meaningful use and certification criteria have been announced (2013).
- MU2 requires EHR systems to support direct messaging to send PHI to registered users.
- 2016 Improved outcomes - Improving quality, safety, and efficiency, leading to improved health outcomes. Decision support for national high-priority conditions. Patient access to self-managed tools. Access to comprehensive patient data through patient-centered HIE. Improving population health.
requirements.
The EHR systems help hospitals:
- Shift away from paper records
- Centralize most of their former data silos within the EHR data
store.
- Automate medical process work flows. This aspect
developed by Geisinger,
in collaboration with Epic,
is described in detail by Dr.
Glenn Steele and Dr. David Feinberg. They show how
process quality improvements are enabled when physicians,
hospital and insurer are part of one business.
- Kaiser,
which also has its own physicians, hospitals and insurer, enthusiastically adopted the strategy.
- AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017);
s and
geographic niche hospitals, who partner with independent
physicians, must cope with anti-trust and Stark law The Stark law constrains certain physician referrals. It prohibits physician referrals of designated health services for Medicare and Medicaid patients if the physician or a family member has a financial relationship with the entity. It was written by Californian congressman Peter Stark.
constraints before they can share EHR infrastructure and
workflows. The ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
& MACRA is Medicare Access and CHIP Reauthorization Act of 2015 is designed to encourage physicians to move to FFV and to link Medicare payment to quality & value. It alters the way Medicare pays for part B physician services encouraging physicians and other ECs to conform to one of two value based payment schemes: Advanced APMs (where the EC can become a QP) or MIPS. MACRA does not apply to hospitals which have their own meaningful use. MACRA is designed to promote transformation and includes: Data reporting by ECs, New practice models, Changing clinical standards, and Physician evaluations; with hundreds of millions of dollars in penalties and bonuses. It authorizes CMS to develop and deploy new rules. It provides for PCPs in PCMHs to qualify as advanced APMs via a special lower risk pathway. It replaced the problematic physician SGR formula.
provide encouragement to independent physicians to participate
in ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. - CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
s that can
develop end-to-end quality
workflows with hospitals.
Long
Island college hospital is an example of an urban hospital
whose:
- Broad clinical skills are hard to maintain with a shrinking,
localized patient base.
- Revenue base has eroded as the affluent part of their
potential patient base is attracted to marketing and local urgent
care access points of leading health care provider
brands.
- Political
importance is significant as a major local driver of jobs,
and a issue for the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
and the State Governer Andrew Cuomo who favors a transport based
acute care strategy.
Rural hospitals are recipients of DOA - U.S. Department of Agriculture. Food, Nutrition &
Consumer Services, low cost financing.
Rural hospitals, such as Mercy Hospital
Independence Kansas, are under huge pressure from an aging
(more chronically ill and costly) shrinking population and ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
driven reductions in Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
reimbursements is the payment process for much of US health care. Reimbursement is the centralizing mechanism in the US Health care network. It associates reward flows with central planning requirements such as HITECH. Different payment methods apportion risk differently between the payer and the provider. The payment methods include: - Fee-for-service,
- Per Diem,
- Episode of Care Payment,
- Multi-provider bundled EPC,
- Condition-specific capitation,
- Full capitation.
with dozens shutting (Oct
2015).
- Arkansas,
Rural Baxter
Regional Medical Center, hovers at break even: dependent
on ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. expansion,
is center of regional economy is a human SuperOrganism complex adaptive system (CAS) which operates and controls trade flows within a rich niche. Economics models economies. Robert Gordon has described the evolution of the American economy. Like other CAS, economic flows are maintained far from equilibrium by: demand, financial flows and constraints, supply infrastructure constraints, political and military constraints; ensuring wealth, legislative control, legal contracts and power have significant leverage through evolved amplifiers. ;
Arkansas
State University-Mountain Home 2 year college focuses on
supplying the hospital with workers (Oct
2017)
- 85 rural hospitals (5% of them) have closed since 2010: CHY
strategy. Less than half the US is the United States of America. 's rural counties have
a hospital that covers maternity, due to business model issues:
collapsing birth rate, specialists clustered in large cities;
which cascades added risks, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty.
:
medical visits cost more & take up more time - NICU is neonatal ICU also called an intensive care nursery. babies need to be
visited regularly increasing the impact on mother and family,
women go less often to visit doctors, more babies born
prematurely, deliveries occur outside hospital or at ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). , hospital is often a
large employer and closure impacts the community economics (Oct
2015), but eventually rebalancing occurs with urgent care is an efficient and less costly 'alternative' to the ER. There is no accepted standard. Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls. Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones. Unlike an ER they can not admit patients to a hospital. Some also offer services like pre-employment drug screening and summer camp physicals.
units opening, maternity opening at a remaining hospital in the
region, helicopters
taking serious cases to hub hospitals (Jul
2018)
- Florida's rural Immokalee, in Collier County, needs a
hospital, with increasing: births (in ambulances|out of
hospital), baby death rate, deaths in fields and parking lots, stroke is when brain cells are deprived of oxygen and begin to die. 750,000 patients a year suffer strokes in the US. 85% of those strokes are caused by clots. There are two structural types: Ischemic and hemorrhagic. Thrombectomy has been found to be a highly effective treatment for some stroke situations (Jan 2018).
death rate,
no nearby ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). , lack of
ambulance service; only a 9 to 5 weekday federal health clinic,
regulators granted a certificate of need, but Naples
Hospital wants the patient base and is objecting to the
hospital development as rural
hospitals close (Sep
2018)
The key plans (P), flows (F), signals, is an emergent capability which is used by cooperating agents to support coordination & rival agents to support control and dominance. In eukaryotic cells signalling is used extensively. A signal interacts with the exposed region of a receptor molecule inducing it to change shape to an activated form. Chains of enzymes interact with the activated receptor relaying, amplifying and responding to the signal to change the state of the cell. Many of the signalling pathways pass through the nuclear membrane and interact with the DNA to change its state. Enzymes sensitive to the changes induced in the DNA then start to operate generating actions including sending further signals. Cell signalling is reviewed by Helmreich. Signalling is a fundamental aspect of CAS theory and is discussed from the abstract CAS perspective in signals and sensors. In AWF the eukaryotic signalling architecture has been abstracted in a codelet based implementation. To be credible signals must be hard to fake. To be effective they must be easily detected by the target recipient. To be efficient they are low cost to produce and destroy. (S), constraints (C),
infrastructure amplifiers (IA) and
evolved amplifiers (EA) through these
hospital management companies are:
- C - Regulator, such as NY DOH, limiting
access to charts of 'confidential' supplies pricing.
This is being relaxed.
- C - US Congress,
and trade deals including TPP is the Trans Pacific Partnership, a twelve country, Pacific regional, trade deal between: Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, United States, Vietnam; The U.S. aims to use the agreement to constrain competition from China. The initial 12 countries account for more than a quarter of global seafood trade and a quarter of the World's timber and pulp production. Five of the nations are among the World's most biologically diverse. The TPP includes:
- Patents and copyrights chapters.
- State-owned businesses chapter.
- Investor-state dispute settlement chapter which enforces extrajudicial tribunals for arbitrating disputes. The tribunals give investors legal recourse if a government changes policies in ways that hurt the value of their investments.
- An environmental chapter that covers illegal wildlife trafficking, forestry management, overfishing and marine protection. Environmentally destructive subsidies, such as cheap fuel for illegal fishing boats and subsidies for boat building in overfished waters are banned. The chapter enforces Cites with economic sanctions and disallows trade in wildlife taken illegally from a country.
- Requirements that member countries strengthen port inspections and document checks.
- Requirements that a country in the agreement take action if they discover contraband that has been harvested illegally, even if the product is not illegal in that country.
,
provide biologic are drugs made in living cells. Typically they are proteins developed using genetic engineering to develop the cellular host, and to customize animal source, DNA to produce human target proteins. Such biologics partially solve the problem of previous protein sources, extracted from animals or human sources, of contamination and immune responses. The strategy is very effective for blood transported proteins such as antibodies (MABs), hormones and blood factors. But intra-cellular proteins still demand delivery and accurate cell targeting. This creates analogous problems to those of gene therapy.
data
exclusivity is a regulatory protection extended to biologics which protects their manufacturer's profits from attack from biosimilars. , creating a barrier to entry for biosimilars are generic drugs made to copy biologics. They could undermine the pharmaceutical industry's biologic profit model and so are subject to trade constraints: TRIPS, TPP. by
requiring biosimilar manufacturers to fund drug trials
- C - FSMB is the Federation of State Medical Boards which is composed of the agencies that license and discipline doctors.
and its
Interstate Commission enable
access to interstate tele-health is the use of remote health care. It includes telepharmacy and clinical telehealth for stroke and psychiatry. It also includes sessions between primary care providers and patients and assisted caregiving such as medication reminders and DME usage monitors.
networks (Mayo).
- C - Medical guilds, such as the ACG is the American College of Gastroenterology. , advocating for a
hospital based yearly test, or use of an obstetrician rather
than a midwife. Enhancing this process increases revenues
significantly.
- EA - Federal
and state marketplaces enable
payer's include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
narrow networks - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans. This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans. By limiting the number of providers/doctors offered in the plans the few that are included should get more business. Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers). In large cities narrow networks are even more common. Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills. There are problems induced by narrow network constraints: - Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts. Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running. If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016).
(Wellpoint)
of hospitals and PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. s.
78% of CEOs predict they will participate.
- EA - Congress (mandate) or CMS is the centers for Medicare and Medicaid services. / FDA Food and Drug Administration. (advisory)
supporting the use of a hospital based yearly test.
Enhancing this process increases revenues significantly.
- EA - Congress (mandate in ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
) payments to
subsidize obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016).
treatments stimulating the emergence of diet clinics.
- EA - NIH is the National Institute of Health, Bethesda Maryland. It is the primary federal agency for the support and conduct of biomedical and behavioral research. It is also one of the four US special containment units of the CDC. 's NIDDK is the National Institute of Diabetes and Digestive and Kidney Diseases.
looks at
genomics of obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). .
- EA - Congress (mandate) CMS payment
levels for ESRD is end-stage renal disease. This is the last stage of CKD. It is associated with adolescents who have hypertension. There are more than 200,000 cases a year in the U.S. Richard Nixon encouraged and signed Social Security amendments that provided Medicare for anyone suffering from ESRD. There are two main treatment strategies:
- Kidney transplants allow recovery from the disease but are limited by the availability of matching donated kidneys, enabled by UNOS, and the patient's awareness of the option to have a transplant.
- Kidney dialysis performed at a dialysis center.
supporting distortions
of the dialysis Value Delivery System (VDS is value delivery system. ).
- EA - MMA is:
- The Medicare Modernization Act of 2003. It includes Medicare part D, the Medicare prescription drug benefit, which constrains Medicare from negotiation of its drug prices and created MAC and RAC. It was sponsored by Senator Bill Tauzin and implemented by Tom Scully.
- Mammalian meat allergy which is induced by a month prior tick bite that introduced the allergen alpha-gal. About 1% of bitten humans develop the allergy & prevalence is increasing. Humans & old world primates & monkeys don't make alpha-gal (Jul 2018). Symptoms can include: hives, anaphylactic shock, low blood pressure.
mandates Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
not to
negotiate for drug discounts supporting leverage of generic into
specialty
medication cost tens or hundreds of thousands of dollars a year when used to treat complex or rare diseases: cancer, rheumatoid arthritis, hemophilia, HIV. By 2015 they account for one-third of all spending on drugs in the United States and should reach 50% by 2025. With the MMA constraining Medicare drug price negotiations many old generic drugs appear to be being rebranded with controlled distribution as specialty drugs and re-priced with vast margins (Sep 2015). .
- C - Big pharmaceutical companies have the capital is the sum total nonhuman assets that can be owned and exchanged on some market according to Piketty. Capital includes: real property, financial capital and professional capital. It is not immutable instead depending on the state of the society within which it exists. It can be owned by governments (public capital) and private individuals (private capital). base to
prophylactically fund phase 2/3 vaccine are a core strategy of public health and have significantly extended global wellbeing over 200 years. Smallpox & polio were virtually eradicated. Recent successes include: HPV vaccine: Gardasil. They induce active acquired immunity to a particular disease. But the development and deployment of vaccines is complex:
- The business model for vaccine development has been failing (Aug 2015):
- No Zika vaccine was available as the epidemic grew (Mar 2016). No vaccine for: CMV;
- Major foundations: Michael J. Fox, Gates, Wellcome; are working to improve the situation including sponsorship of the GAVI alliance. A geographic cluster is forming in Seattle including PATH (Apr 2016).
- Commercial developers include: Affiris, Cell Genesis, Chiron, CSL, Sanofi, Valeant;
- Vaccine deployment traditionally benefited from centrally managed vertical health programs. But political issues are now constraining success with less than 95-99% coverage required for herd immunity (Aug 2015, Sep 2015, Nov 2015, Nov 2016, Jul 2018).
- Where clinics have been driven into local neighborhoods health improves (Apr 2016).
- Retail clinics (Mar 2016): CVS Minute Clinics focus on vaccination.
- NNT is a useful metric for vaccine benefit. Influenza vaccine has an NNT of between 37 and 77, is cheap and causes little harm, so it is very beneficial.
- Key vaccines include: BCG, C. difficile (May 2015), Cholera (El Tor), Cervical Cancer (Gardasil HPV Jun 2018, Oct 2018), Dengvaxia (Mexico Dec 2015), Gvax, Influenza, Malaria vaccine, Provenge, Typbar-TCV (XDR typhoid Pakistan Apr 2018);
- Regulation involves: FDA (CBER), with CMS monitoring (star ratings, PACE (Aug 2016), Report cards (Sep 2015)) & CDC promoting vaccines: as a sepsis measure, To control C. difficile (May 2015);
- Research on vaccines includes:
- NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.
- NCI:
- Roswell Park clinical trial of immuno-oncology vaccine cimavax.
- Geisinger: effective process leverage in treatment.
- Stanford Edge immuno-oncology for cancer vaccines.
- P53-driven-cancer focused, gene therapy (Jun 2015).
trials but
they don't see enough profits (2015)
- IA - Big data encompasses the IT systems and processes necessary to do population based data collection, management and analysis. The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass. Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms: Precision medicine, Protein folding modeling (Feb 2019) assumes coevolutionary methods can be applied to identify contact points in a protein's tertiary structure. Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure:
- Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Complex data models must include clinical aspects of the patient specific data, including disease state population wide.
- A key aspect is providing clear signals about the nature of the data using data visualization.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
tools (visualization aims to communicate information clearly and effectively via signals presented as information graphics. )
encourage prescription of drugs that maximize discounts based on
group
purchasing agreements.
- EA - State Senator sponsoring licenses for health providers (2013 Extended).
- C - State legislatures specifying that state leaders now aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group. Pinker notes the evolved pressure of social rivalry associating power with leadership. Different evolved personality types reinforced during development provided hunter-gatherer bands with alternate adult capabilities for coping with the various challenges of the African savanna. As the situation changed different personalities would prove most helpful in leading the band. Big men, chiefs and leaders of early states leveraged their power over the flow of resources to capture and redistribute wealth to their supporters. As the environmental state changed and began threatening the polity's fitness, one leader would be abandoned, replaced by another who the group hoped might improve the situation for all. Sapolsky observes the disconnect that occurs between power hierarchies and wisdom in apes. In modern Anglo-American style corporations, which typically follow Malthus, and are disconnected from the superOrganism nest site, the goal of leadership has become detached from the needs of this broader polity, instead: seeking market and revenue growth, hiring and firing workers, and leveraging power to reduce these commitments further. Dorner notes that corporate executives show an appreciation of how to control a CAS. Robert Iger with personality types: Reformer, Achiever, Investigator; describes his time as Disney CEO, where he experienced a highly aligned environment, working to nurture the good and manage the bad. He notes something is always coming up. Leadership requires the ability to adapt to challenges while compartmentalizing. John Boyd: Achiever, Investigator, Challenger; could not align with the military hierarchy but developed an innovative systematic perspective which his supporters championed and politicians leveraged. John Adair developed a modern leadership methodology based on the three-circles model.
can
nominate a number of licenses for health care
providers.
- C - State licensing requirement for health care
providers.
- C - PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
referring
patients for treatment. Expanding the number of referrals
and capturing a larger share of the referrals increases
revenues. Wal-Mart
aiming
to disrupt.
- IA - ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016).
physician-staffing
companies concentrate 25% of ED doctors and catalyze, an infrastructure amplifier.
out-of-network charges, surprise
billing is where a contracted service is used by a patient and the bill contains huge out-of-network charges from doctors who were consulting to the health care provider. The opportunity to catalyze profits for: hospitals, physician staffing companies; while coping with rural E.D. staff shortages is encouraging this situation. Examples include: E.D. billing (Nov 2016, Jul 2017) & admission to the hospitals (Jul
2017)
- C - ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016).
referring
patients to acute hospital beds (incentives 2012 HMA,
2013
CYH enhancing revenues) or for observation.
- C - Mammograms is an X-ray record of the breast used for screening and diagnosis of breast cancer. Mammograms have become progressively more sensitive allowing detection of smaller tumors. This has allowed aggressive treatment practices which may be counterproductive (Aug 2015). Mammography policies are defined by: ACOG, ACS, NCCN, USPSTF;
able to detect increasingly small abnormalities in the breast (DCIS is ductal carcinoma in situ where abnormal cells have been found piled up confined to the lining of the milk ducts of the breast. They are detectable in a mammogram and can look like cancer cells to a pathologist. The cells could be spread along the whole of the milk duct suggesting a need for mastectomy rather than lumpectomy analogous to cervical cancer treatments after a Pap test. It is now known that the DCIS may disappear over time, or stop growing and remain stable. Most women diagnosed with early stage DCIS have surgical or chemotherapy treatment, which does not alter their life expectancy (Aug 2015). No data is available detailing a correlation with breast cancer. But it is now understood that metastatic cancers are different from localized cancers. 2015)
which result in aggressive diagnosis and treatment (Aug
2015).
- C - USPSTF is United States preventative services task force. It is an independent expert panel focused on prevention and evidence-based medicine appointed by HHS. prostate is a male only gland positioned between the bladder and rectum. It generates part of the seminal fluid. It enlarges during puberty to the size of a walnut stimulated by androgens and the remains stable or grows slowly with age. The prostate includes several types of cells including the gland cells that make the prostate fluid. The Urethra passes through the middle of the prostate.
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