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Analysis Frame
Summary
In this page we introduce the analysis covered in the frame.
First the conclusions of the analysis are listed. These
imply a need to solve a strategic dilemma.
The analysis associates trends
in the environment including:
Key influences
within the health care network are highlighted.
Both power and
Longview analysis are discussed.
Amplifiers are reviewed.
The analysis leverages an assessment
of the US health care network outlining its long term
shape and key variables including: tax policy, power of the
elites, mass production transactional health care
architecture; based on Dorner's
methodology. The goal of the
generated web structure
is to allow the reader to follow either:
The generated web
structure includes:
- Frames is a set of HTML files grouped together by a common theme in a dark web.
-
Each page of a frame aims to include only information, and
links, relevant to the specific focus of the web page. A
frame of pages allows different points of focus to be
constructed, each linked together to provide the reader with a
paced and, hopefully, comprehensive perspective. Other
pages of a frame can be reached by clicking the within-frame
navigation buttons.
- providing a list of pages oriented around a particular
perspective: the business, its customers, competitors
etc.
- Agents - addressable,
action oriented, including: Hospitals: Geisinger,
Mount
Sinai Health; Insurers: Aetna, UHG;
New entrants: Amazon,
CVS; Government:
H.H.S. is the U.S. Department of Health and Human Services. &
its secretary,
C.M.S. is the centers for Medicare and Medicaid services. and its
administrator,
F.D.A. Food and Drug Administration. and its
commissioner;
etc. associated with a model description and PEST is: Politics, Economics, Sociology-Culture, Technology; signals and actions, complex adaptive effects on the business environment.
links
- Glossary - evolvable baseline terms: 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.
, 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.
, Economics is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics. ,
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. , 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. ,
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.
,
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). ; for example.
- PEST - historic details.
Introduction
This AWF is the adaptive web framework. generic analysis
of the US health care network, written from the perspective of a
hospital system, and structured to leverage complex adaptive system
(CAS) theory, is generated from the demo source provided
with AWF. The source data should be replaced by your
enterprise's particular details, situation, models and their
implications. We hope our analysis will provide an open
template source for you to customize and replace as you see fit,
providing a useful shape to your analysis frame is a set of HTML files grouped together by a common theme in a dark web. -
Each page of a frame aims to include only information, and
links, relevant to the specific focus of the web page. A
frame of pages allows different points of focus to be
constructed, each linked together to provide the reader with a
paced and, hopefully, comprehensive perspective. Other
pages of a frame can be reached by clicking the within-frame
navigation buttons.
but with details
that are soon replaced with your creative private
alternatives.
Our main conclusions are:
- The US patient base is becoming older, and less healthy,
developing complex conditions that require chronic and acute
health care services. But the majority of people are also
getting poorer.
- Traditional acute care hospitals are platforms 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.
which
include a variety of, cross-subsidized, transactional
operations. High market share and market segmentation
opportunities empower platform businesses. These
traditional hospitals are being forced by legislation, regulation
and the indirect impacts of the competitive strategy of integrated
payer providers to improve end-to-end
customer focused processes. The integrated 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.
providers are
leveraging
technology to improve quality, reduce costs and line
extend from acute
care into chronic
and 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. care
in the community. But, due to network
effects & switching costs of insurance, it is difficult for an
integrated payer provider to invade a new geography.
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 treatment volume
is being targeted by 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. .
- Powerful 'new' entrants: Aetna +
CVS health, Amazon, UHG, Walmart; are
attacking the health care market with efficient community
based chain
business models, that aim to replace the patient's 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.
relationship and disrupt
that business.
- Successive governments have
supported the economic
forces that are undermining the health of the majority of
Americans. But they differ in their approach to
public finance of safety net services and treatment
expenses. There is agreement that health care cost impacts
on business must be constrained. The legislation: HIPAA is the Health Insurance Portability and Accountability Act of 1996. It added part C (administrative simplifications) to the SSA.
- CFR 45CFR 160.103 is the general provisions section of the regulations. HIPAA Transactions and Code Sets Standards regulations 45CFR 162.923(a) Covered entities must use adopted transaction standards for inter and intra covered entity transactions.
- HIPAA only applies to health care providers, health insurers, clearinghouses of health care data, and their BAs.
- Initially HIPAA was designed to specify a secure standardized MPI. Late in the development of the legislation the MPI was viewed as too risky and was removed from the legislation.
- The law does not prohibit health care providers from sharing information with family, friends or caregivers unless the patient specifically objects. Providers can use 'professional judgement' to disclose information to a relative or friend if it is in the best interest of an incapacitated patient.
- It is also allowed to share general information about a patient's condition and location in a facility.
- Family members can provide information.
- Caregivers who are a patient's personal representative, such as: a health care proxy or guardian or with power of attorney; or who have had the patient authorize the release of information must be provided with it.
- HHS office of Civil Rights enforces HIPAA but typically they try to fix problems rather than applying penalties.
, 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. , 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. ; and associated
regulations, are reducing government and employer healthcare
spending and hospital revenues.
- 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!
technology
has enabled Geisinger's
vision of an end-to-end efficient care bundle. And
influenced other health systems 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.; strategies and
driven associated regulations.
- A high technology amplifier is
significantly affecting health care through increased leverage
of robots, and cloud
services. 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.
analytics may help health care impact subscriber
driven costs but that is less obvious. The HITECH act 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. , HIPAA is the Health Insurance Portability and Accountability Act of 1996. It added part C (administrative simplifications) to the SSA. - CFR 45CFR 160.103 is the general provisions section of the regulations. HIPAA Transactions and Code Sets Standards regulations 45CFR 162.923(a) Covered entities must use adopted transaction standards for inter and intra covered entity transactions.
- HIPAA only applies to health care providers, health insurers, clearinghouses of health care data, and their BAs.
- Initially HIPAA was designed to specify a secure standardized MPI. Late in the development of the legislation the MPI was viewed as too risky and was removed from the legislation.
- The law does not prohibit health care providers from sharing information with family, friends or caregivers unless the patient specifically objects. Providers can use 'professional judgement' to disclose information to a relative or friend if it is in the best interest of an incapacitated patient.
- It is also allowed to share general information about a patient's condition and location in a facility.
- Family members can provide information.
- Caregivers who are a patient's personal representative, such as: a health care proxy or guardian or with power of attorney; or who have had the patient authorize the release of information must be provided with it.
- HHS office of Civil Rights enforces HIPAA but typically they try to fix problems rather than applying penalties.
and the ACA
have entrenched 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 and their developers, particularly Epic and Cerner, into the core
of the hospitals' 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.;
infrastructure. The evolved amplifier the government setup
to get EHR systems deployed has set up EHR data silos which
provide the developers and hospitals with significant power over
patient data. But these health records, and Epic and
Cerner's business model's do not reach across the whole
continuum of care to low cost 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.
:
home care agencies and outpatient rehabs; that can't support
Epic and Cerner's current margins. These PAC providers
appear essential to making FFV profitable and so they must be
integrated into each episode of care and the financial flows.
- Biotechnology advances based on low cost gene sequencing and
supporting analytics combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes. may turn health care network's
patient data into a powerful diagnostic aid. Hospitals
must also develop strategies for the potential support of these
diagnoses by augmented intelligence systems like IBM's Watson. 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.
analytics
and artificial intelligence can transform the hospitals'
pathology expertise and sample bases into new sources of
value. Immunotherapy is indirect treatment of disease by altering the immune system. Targeted diseases include: cancers -- immuno-oncology, organ transplants.
supports transformative treatments.
- DeepMind
wins protein, a relatively long chain (polymer) of peptides. Shorter chains of peptides are termed polypeptides.
folding modelling competition at
Critical Assessment of Structure Prediction contest.
Academic protein scientists and Pharmaceutical giants: Merck, Novartis; are seen
lagging in applying deep learning is an artificial intelligence approach where engineers deploy data into deep neural networks.
to protein structure work (Feb
2019)
- Google
demonstrates interpretability is scientific understanding and technology that shows how 'neurons' in a deep neural network arrive at their decisions
decision
making integrates situational context, state and signals to prioritize among strategies and respond in a timely manner. It occurs in all animals, including us and our organizations:
- Individual human decision making includes conscious and unconscious aspects. Situational context is highly influential: supplying meaning to our general mechanisms, & for robots too. Emotions are important in providing a balanced judgement. The adaptive unconscious interprets percepts quickly supporting 'fast' decision making. Conscious decision making, supported by the: DLPFC, vmPFC and limbic system; can use slower autonomy. The amygdala, during unsettling or uncertain social situations, signals the decision making regions of the frontal lobe, including the orbitofrontal cortex. The BLA supports rejecting unacceptable offers. Moral decisions are influenced by a moral decision switch. Sleeping before making an important decision is useful in obtaining the support of the unconscious in developing a preference. Word framing demonstrates the limitations of our fast intuitive decision making processes. And prior positive associations detected by the hippocampus, can be reactivated with the support of the striatum linking it to the memory of a reward, inducing a bias into our choices. Prior to the development of the PFC, the ventral striatum supports adolescent decision making. Neurons involved in decision making in the association areas of the cortex are active for much longer than neurons participating in the sensory areas of the cortex. This allows them to link perceptions with a provisional action plan. Association neurons can track probabilities connected to a choice. As evidence is accumulated and a threshold is reached a choice is made, making fast thinking highly adaptive. Diseases including: schizophrenia and anorexia; highlight aspects of human decision making.
- Organisations often struggle to balance top down and distributed decision making: parliamentry government must use a process, health care is attempting to improve the process: checklists, end-to-end care; and include more participants, but has systemic issues, business leaders struggle with strategy.
in hidden layers of a visual neural
network are representational models that achieve high performance on difficult pattern recognition problems in vision and speech. But they need specialized training methods such as greedy layerwise pre-training or HF optimization. Researchers are gaining access to the participation of the individual 'neurons' using: visualization, attribution, dimensionality reduction, interpretability; (Mar 2018) (Mar
2018)
- Hospital
suppliers, including the big pharmaceutical and biotechnology
companies, are:
- Still being supported by legislation &
associated regulatory and structural constraints on CMS is the centers for Medicare and Medicaid services. 's power to price
treatments (1979
court injunction on 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.
pricing
visibility until Mar
2014, CMS PPS is Prospective payment system a method of CMS reimbursement in which a Medicare payment is made based on a predetermined fixed amount. The amount is derived based on the classification system of that service (such as a diagnosis related group for an inpatient hospital service). CMS uses separate PPSs for reimbursement to acute inpatient hospitals, HHAs, hospice, hospital outpatients, inpatient psychiatric facilities, IRF, LTCH and SNFs.
product model), medical equipment and drugs (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.
). The
pricing of valuable new drugs is still
a huge issue. Generic supplies suffer from structural
shortages
(May
2016). A grand
bargain uses the US economic is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics. and
political might to drive their products across the globe in
exchange for some level of cooperation on R&D and pricing
for the home market. But there are outliers such as Valeant,
Questcor,
Lannett &
even Shire, that
have moved, or intend to move, their tax base from the US even
as they leverage Hedge
Fund and Wall Street
Capital. And the global capital system, described by Piketty,
is encouraging more companies to switch to low tax
domiciles.
- Providing health care providers 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).
which are core to the modern practice of surgery including
post-operative recovery. But they also supply them to
the food industry. And through conflicts between
countries about which antibiotics are to be held back as a
last resort for cases of broad antibiotic
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%. , it is likely that surgery quality may be
threatened (May
2016).
This leads to all health care providers having to solve a strategic
dilemma. Do they:
- Aggressively move into the unproven, high risk and complex 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. arena.
- Push to build multi-year relationships with subscribers and
their payers 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.
, like
Intermountain's
Selecthealth Share
or Vivity (Sep
2014).
- Invest further in gaining
the power to control narrow network - 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).
access 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,
independent specialists and profitable subscribers (Apr
2016).
- Understand losses from referral outside of
network.
- 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)
- Constrain access to the genomic combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes. and 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!
data about their
patients and subscribers.
- Focus resources on infrastructure to support doctors
specialized offers for the wealthy is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker. It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche. , assuming inequality increases
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.
deteriorates.
- Match infrastructure to areas which can differentially
service the wealthy, directly or via close by transportation
hubs: Boston
Children's (Jun
2016).
- Leverage Wall Street
- Leverage Internet marketing
- Continue as they are:
- Focused on:
- high profit 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.
treatment,
- Encouraging hospital use with personal 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).
linked to treatments (PGD is pre-implantation genetic diagnosis which enhances IVF. After IVF at the eight-cell stage one cell is removed to perform sensitive DNA testing. This allows identification of problematic -- or undesired -- characteristics which can be used to screen which embryo to implant. PGD was initially developed to help prevent severe recessive diseases: Tay-Sachs, Fanconi anemia. Then its use was broadened to include: Cystic fibrosis, Adult-onset conditions: BRCA1. ),
- Trying to drive down costs by replacing costly staff with
less skilled alternatives and robots,
- Pressure failing competitors with capital investments in
infrastructure they must match,
- Cope with quality
issues of too many specialists, Minimize payment risk is either:
- Restrictive cardiomyopathy, a rare disease where scar tissue makes the heart muscle rigid and reduces the efficiency. Or
- Revenue Cycle Management aligns treatment with reimbursement. Customer service will be involved. IT will architect the core billing, decision support and ad-hoc services, constructed by RCM vendors, into systems to support RCM. The Hospital's central business office will aim to maximize cash recoveries. As per Deming, mistakes in the RCM pipeline result in rework and lost cash flow and revenue of between 4 - 12%. The staff must be trained and fully engaged in the design and operation of the pipeline. The front end processes are best placed to capture all the information needed to make the cycle successful. The activities include:
- Scheduling and Appointments - where visits and procedures are booked and demographic and insurance information is collected. If this information is incorrect it is likely the claims will not forward to third party payers. When resources and their states are accurately known an optimal set of plans can be constructed to efficiently and effectively flow patients through the system. But that is difficult to guarantee because of a number of interrelated problems:
- Scale - as the number of resources increases the ability of a central scheduling system to represent all of them accurately and reliably becomes impossible.
- Ubiquity - a CAS strategy for ensuring availability is to have an over-abundance of equivalent resource that can be used for schedule allocation. But often these resource levels are set by local decision makers who all respond at about the same time to imposed funding changes. The effect is to suddenly and unpredictably undermine the guarantee of over-abundance. Sometimes the assumption of equivalence also fails as in the desire of a patient to see only a specific surgeon.
- Changes can ripple through the plans requiring coordination meetings and notifications or guaranteed receipt of status updates.
- Verification checks for:
- Referral - Is there PCP authorization? Is the PCP referred service covered by the patient's plan,
- Authorization - obtain Insurance authorization if required, and
- Pre-certification - is there 'need' for inpatient care or other care before admission by the MCO. Otherwise could introduce problems including not obtaining/verifying the insurance name, number and eligibility, not securing pre-certification and pre-authorization with time limits, not copying the insurance card, not checking for secondary coverage, not detecting expired referral or authorization,
- Pre-registration - provide advice about their financial obligations and what documents to bring to the procedure. If there is a copay or an outstanding payment to be paid these should be processed,
- Registration - some patients are scheduled outside of the main admitting process (by OP clinic or E.D.) and this must be detected and the scheduling verification and pre-registration process be performed,
- Time of service payments - co pays and self pays,
- Coding - identify diagnosis (ICD 9 -> ICD-10 codes) and treatment (CPT) activities and charges for the episode. More than 80% of hospital cases are coded in error.
- Demographics and billing data entry - enter charges and adjust capitated charges,
- Patient statements - submit primary and secondary claims (following HIPAA formats) with or without involvement of a clearinghouse, produce patient statements including time of service, outstanding balance, charged amount with codes, insurance details, forms used (UB 92/04 and HCFA 1500). A paper based claims filing has a rejection rate of 30%. Duplicate claim payment rates of 1 - 2% of medical expenses are common. Duplicate claims detection is often not part of the process. Payer's goals are in conflict with Provider goals.
- Collections and payment posting - Post all payments and adjustments and deposit money into the bank,
- Denials and appeals - resubmission and appeal of claims, denial analysis and bad debts and write offs. To reduce denial rates and appeals the reimbursement contracts payer processes and actual denials must be analyzed and understood.
- Account follow up - Patient inquiries, resubmission of claims and issue refunds.
- Financial counseling;
,
Manage penalties, Lobby for more 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.
;
while
- Undermined by government cost/margin (price) control
measures: 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. , CMS 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. pressure;
- Paying for 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!
infrastructure without obtaining the quality transformation
and
- Watching as new entrants, including retailers, and
alternative business models attack their profit, independent
specialist/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
subscriber bases.
- Maternity - advanced NICU is neonatal ICU also called an intensive care nursery. support (Dec
2018) and leverage value of IVF is in vitro fertilization. In the US, in 2018, multiple eggs are deployed during the IVF procedure to maximize the chance of pregnancy. This practice is driven by the metrics promoted by the CDC. However, multiple eggs increase the likelihood of multiple births, significantly raising the risk of problems for newborn and mother. In other advanced economies single egg IVF is encouraged. More women are delaying having children for education and career goals, with the assumption that they can use IVF if necessary to ensure pregnancy. But the failure rate becomes 70% to 80% for women over 40 (Oct 2016).
/PGD is pre-implantation genetic diagnosis which enhances IVF. After IVF at the eight-cell stage one cell is removed to perform sensitive DNA testing. This allows identification of problematic -- or undesired -- characteristics which can be used to screen which embryo to implant. PGD was initially developed to help prevent severe recessive diseases: Tay-Sachs, Fanconi anemia. Then its use was broadened to include: Cystic fibrosis, Adult-onset conditions: BRCA1. .
- 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).
.
- Medical/Surgical 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.
.
- Urology, Colonoscopy & eye specialist driven
procedures.
- Orthopedic is the treatment of the musculoskeletal system which supports multi-cell higher animals and allows them to move about: including correcting deformities, breaks, tears, compression, tendonitis, disc failures, misalignment, fusion to treat damaged discs.
inpatient, outpatient & rehabilitation.
Because others will choose a strategy to follow and what not to
do.
The analysis:
- Applies models to the data
gathered about the business
environment; customers (patients), competitors, suppliers
and governments power
and the amplifiers
driving the business.
- Presents a high level view of the situation based on the
conclusions of the modelling.
Trends in the
Environment
Major US is the United States of America. spending
programs reflect the New Deal was FDR's political platform to help the poor, support the economy and reform the banking system. The architects included Henry Morgenthau, Harry Hopkins, and Frances Perkins, who leveraged Al Smith's social welfare reform program plan. The New Deal: - Included liberal legislation: Emergency Banking Relief Act, Banking Act, SSA, Securities Act, Securities Exchange Act, National Housing Act, NIRA, National Labor Relations Act, FLSA, RTAA, Wealth Tax Act;
- Used Presidential executive orders,
- Enhanced the role of federal government in promoting economic growth with programs supporting:
- Reformed trade policy with the RTAA.
- Blocked deflation by limiting economic competition with the NRA.
- Rural standard of living through electrification with the REA and TVA.
- Reduced unemployment with the WPA and CCC.
- Made taxation progressive through the Wealth Tax Act, capturing private wealth and allowing income to flow to the emergent middle class.
policies of FDR is President Franklin Delano Roosevelt. He is notable for his contributions to the US CAS: - New Deal strategies including:
- Lend-lease which pushed the US and Japan into World War 2 and helped the US to become the world's predominant military power.
- Bretton Woods's agreement which economically constrained any politically driven collapse of the world economy after the war and helped the US to become the world's predominant economic power.
: SSA is the social securities act of 1935 was part of the second New Deal. It attempted to limit risks of old age, poverty and unemployment. It is funded through payroll taxes via FICA and SECA into the social security trust funds. Title IV of the original SSA created what became the AFDC. The Social Security Administration controls the OASI and DI trust funds. The funds are administered by the trustees. The SSA was amended in 1965 to include: - Title V is Maternal and child health services.
- Title XVIII is Medicare.
; and LBJ is President Lyndon Baines Johnson. : 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.
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. ; along with
Defense. Since the 1930s the US corporate elite have adopted long term strategies to undermine the New
Deal while 'liberals' have worked to maintain this public
spending. From the 1980s both Democratic and Republican
parties have converged
on a globalized, financial services and high technology based
strategy. But the escalating cost of US health care and
the retirement of the baby boomers demanded action.
Since the Nixon presidency the USA has indirectly integrated its
education, energy, food (the omnivore's dilemma), raw
materials, 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.
, health care, financial services
(abandoning
Bretton Woods), real-estate,
News/film/broadcasting, advertising (critical
condition) and political strategies. During the Reagan
presidency a
further shift in strategy was initiated that has over time
removed many of the previous constraints on free flow throughout the
global network of nation states centered on the US is the United States of America. . The strategy is
supported by tax
& budget amplifiers. Gingrich & Clinton
completed the process: NAFTA is the North American Free Trade Agreement between the U.S., Canada and Mexico. .
Global and US limits (Dodd-Frank is the 2010 Dodd-Frank Wall Street Reform and Consumer Protection Act. Its titles include: - Financial Stability creates the FSOC and OFR.
- Orderly Liquidation Authority
- Section 619 is the Volcker Rule: prohibitions on proprietary trading and certain relationships.
- Transfer of Powers to the Comptroller, the FDIC, and the Fed
- Regulation of Advisers to Hedge Funds and Others - which updated the powers of the Investment Company Act.
- Insurance
- Improvements to Regulation
- Wall Street Transparency and Accountability
- Payment, Clearing and Settlement Supervision
- Investor Protections and Improvements to the Regulation of Securities
- Bureau of Consumer Financial Protection
- Federal Reserve System Provisions
- Improving Access to Mainstream Financial Institutions
- Pay It Back Act
- Mortgage Reform and Anti-Predatory Lending Act
- Miscellaneous Provisions
- Section 1256 Contracts
)
on this free flow of 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).
and resources have been added back in response to the 2008 recession
(Apr
2016). 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. has been selected, by the Obama administration, for its
financial strength and legal flexibility, to help rebuild collapsed
areas of the housing market (Jun
2016). The Trump administration's NAFTA renegotiation
culminating in the USMCA is the US, Mexico, Canada agreement on trade, a revision of NAFTA, which includes: - TPP patent and intellectual property framework, but extends the length of patent protection on Biologics.
,
leveraged the 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.
intellectual property framework, extending the patent protections on
Biologics 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. (Oct
2018).
This system has unleashed powerful emergent forces including:
- Concentrating wealth is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker. It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche.
in 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.
and 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. leveraging gaps in the new regulatory structures;
which have provided
- Benefits including:
- An educated population,
- Effective waste treatment plants,
- Clean drinking water,
- Vaccines 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).
and other pharmaceuticals,
- Corn based factory farm produce and the Green
Revolution refers to a set of social technologies: new methods of cultivation; initially used in Mexico during the 1950s to 1970s and then deployed globally, during the 1970s, that increased agricultural production worldwide, and acted as a political constraint on famine and Communism. It was sponsored by Mexico, the Ford and Rockefeller Foundations, with leadership from Norman Borlaug and it built on the work of geneticist, Nazareno Strampelli. The improved production leveraged the development of:
- High yielding varieties of wheat and rice based on:
- High rates of nitrogen metabolism (cross breading, genetic engineering) allowing high yield when combined with
- Strong short stems to resist bending and
- Supplied with
- Chemical fertilizers, and agro-chemicals
- Irrigation
- Disease resistance based on cell level breeding and genetic engineering
; and
- Issues: such as
- Chronic diseases - some induced by: smoking, alcohol,
fast
food, sitting
to much;
- Epidemics is the rapid spread of infectious disease: AIDS (Oct 2016), Cholera (2010), Clostridium difficile (May 2015), Ebola, Influenza, Polio, SARS, Tuberculosis, Typhoid (Apr 2018), Malaria, Yellow fever, Zika; to large numbers of people in a population within a short period of time -- two weeks or less. Epidemics are studied and monitored by: NIAID, CDC, WHO; but are managed by states in the US. Infection control escalation is supported by biocontainment units: Emory, Nebraska. Once memes are included in the set of infectious schematic materials, human addictions can present as epidemics concludes Dr. Nora Volkow of the NIDA. CEPI aims to ensure public health networks are effectively prepared for epidemics. PHCPI aims to strengthen PCPs globally to improve responsiveness to epidemics. GAVI helps catalyze the development and deployment of vaccines. Sporadic investment in public health enables development of conditions for vector development: Mosquitos. The increasing demands of the global population are altering the planet: Climate change is shifting mosquito bases, Forests are being invaded bringing wildlife and their diseases in contact with human networks. Globalized travel acts as an infection amplifier: Ebola to Texas. Health clinics have also acted as amplifiers: AIDS in Haiti, C. diff & MRSA infections enabled & amplified by hospitals. Haiti earthquake support from the UN similarly introduced Cholera.
,
- Climate change (VW Sep
2105)
- 13 US is the United States of America. government
agencies issue a detailed report showing current climate change
trends will reduce the US is the United States of America.
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.
10% by
2100. Global supply chains will be impacted: flooding
stopping manufacturing etc. slowing US supplies.
Increasing poverty will reduce the opportunity in foreign
markets. Agriculture will be impacted by: heat, drought,
wild fires, heavy rain; reducing crop yields & livestock
health, and so slowing to levels seen in 1980s. Puerto
Rico and Virgin Islands will lose fresh water supplies to
salination. Heat & vectored diseases will increase
deaths and health crisis. Hydro-power will reduce in the
Southwest & the Southeast will become prone to wild fires
without the experience to cope. Alaska will flood.
The farm bill is the US federal government's main agricultural and food policy tool. It is legislated as an omnibus bill affecting: international trade, the environment, food safety and supporting rural communities across the US; which must be renewed every 5 years, shaping the powers of the US DOA. -
designed to help with climate change mitigation of agriculture
has stalled in Congress. Trump administration policy
ignores the agencies conclusions, which will undermine its case
in court battles (Nov
2018)
- Trapped smoke plume from Paradise fire flows to California
North Bay Area, making air quality worse than Chinese &
Indian cities. Breathing the increasing volumes of fine
particle polution: smoke and increased pollen; from climate
change, results in immune 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.
responses which build tissue in lungs: causing respiratory
infections seen 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). s;
and increase likelihood of subsequent allergic include various conditions: hay fever, food allergies: MMA, Peanut; atopic dermatitis, asthma, and anaphylaxis; caused by over activity of the immune system in response to antigens in the proximate environment. Initially associated with the English upper-class, allergies have spread across the population with general adoption of: small family size, cleanliness, antibiotic use, public health programs; in line with the hygiene hypothesis, with newborns no longer getting exposed to antigens by their older siblings and proximate higher animals. events:
inflammation & constricted air flow intensifying risk 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.
& 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). .
Use P100 masks (or N95 respirators next to fire source) if must
go outside, although these increase breathing stress which adds
to 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. (Nov
2018)
- C.D.C. is the HHS's center for disease control and prevention based in Atlanta Georgia.
report
indicates 3 fold increase in [detection of] Deer/Rodents/Ticks:
Anaplasmosis, in humans, is a lxodes ricinus tick vectored disease caused by Anaplasma phagocytophilum bacteria infecting neutrophils. ,
babesiosis is a parasitic disease, vectored by ticks, transmitting babesia protozoa blood parasites in the human infection. , Heartland virus is a Lone Star Tick vectored phlebovirus infection in humans. The host is not known. ,
RMSF is Rocky Mountain Spotted Fever, a tick vectored, rickettsia bacterial infection. , Rabbit fever is a tick vectored rodent hosted Francisella tularensis bacterial infection, causing fever, skin ulcers and enlarged lymph nodes in humans. ,
Powassan virus is a tick vectored flavivirus disease in humans. ,
Lyme is an Ixodes scapularis tick vectored Borrelia burgdorferi bacterial infection, initially noticed for inducing "Lyme arthritis" in patients living along the US northeastern seacoast and in Wisconsin. Hundreds of cases, often with the annular red pattern centered on the bite, were subsequently reported by the CDC including at Lyme and on nearby Shelter Island. Ecologist Richard Ostfeld demonstrated the tick ecosystem, explains David Quammen, showing white-footed mice, and other small rodents, typically supply: the blood meal to larval ticks to energize their transformation to nymphs, along with Borrelia spirochetes. Adult ticks can feed and mate on large animals such as white-tailed deer and then drop off. The larva, which are not infected with Borrelia, are then produced in the millions. The smaller stages of the tick 'quest' nearer the ground, so they usually target small animals and birds: particularly two kinds of shrew (30% of blood meals) and white-footed mice. If the Borrelia infection exists in the shrews and especially the mice, since the mice are a very competent reservoir for Borrelia, the new generation of ticks will become infected and when the adult quests a human, in a spillover, it may induce Lyme disease. That has become more likely because there are more humans near the white-footed mice's typical forest habitats and we have been breaking these forests apart disconnecting the large roaming predators of the mice from these islands, leaving the mice to flourish whenever acorn harvests, for example, are large. ; flea: Plague is a Yersinia pestis bacterial infection of humans, typically vectored by fleas, although it can be spread through the air between humans via infected droplets. ; &
mosquito: Chikungunya is a mosquito vectored viral infection in humans, causing fever and joint pain. ,
Dengue is a mosquito vectored virus that can cause high temperature, intense joint and muscle pain, hemorrhagic fever and hence death. The number of cases has been growing sharply and spreading out beyond its traditional base in the tropics and subtropics to Hawaii, Japan and the Florida Keys. Between 50 and 100 million people are estimated to be sickened by dengue fever a year. , Zika is a Flaviviridae family virus. It came from the Zika Forest of Uganda isolated in 1947. It is related to dengue, yellow fever, Japanese encephalitis and West Nile. Zika is transmitted sexually or via a daytime mosquito vector such as the Aedes genus. It has resulted in a pandemic in South America. Zika fever has been associated with a number of troubling complications: - Guillain-Barre syndrome
- Microcephaly. The mechanism may have been identified (May 2016)
, Malaria, WNV is West Nile virus a single-stranded RNA viral disease, vectored by mosquitoes. ; based infections
in the US. Reasons include: lack of vaccines 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).
, climate
change, air travel, reforestation, lack of foxes that kill
rodents, under investment in 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.
at local & state level; with no identified solutions and
complex eco-systems (May
2018)
- Powerful recessions (ECB
Apr 2016),
- Social media impacts on personal
and societal behavior,
- Expanding national debt driven by mass-production
health care and Social Security (Jul
2016) costs,
- 911 infrastructure collapse (Jun
2016),
- War and Parasitism/Cronyism
(VW Sep
2015);
- to both the nation and the western economic is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics.
network.
As such health care strategies are best evaluated within a broader
inter-national system reflecting the influence of other nations and
state and federal actors. Internationally the 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.
of the US system by China is increasing the significance of the US
debt load. This debt load through balanced budget requirements
is impacting the states. States have responded to offshoring
of jobs by using health care as a local infrastructure for
supporting job and wealth is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker. It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche.
creation. The federal government and states with interests in
pharmaceuticals, biotechnology and medical devices must balance
global business opportunities with the cost of indirect US health
care subsidies to these industries. Trade agreements and
diverse corporate tax rates across the world structurally
affect the situation.
After many years
when health care providers had little direct competition and could
be successful by providing valued,
profitable but costly treatment of variable quality to their
local patient base, the introduction of new technological and
political forces have undermined profitability and made the health
care landscape more strategic and competitive. In particular
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.
has supported: 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).
,
reduced 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. 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.
,
constraints of 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. ,
Extending 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. to
hospitals through 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.
incentives: 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.
; limiting
demand for treatment with 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); ; resulting
in consolidation of power in the largest health care payers 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.
, 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 and health care
networks.
- 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)
The Obama White House 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.
strategy references a 2009
ITIF
benchmark of international competitiveness.
The USA is adapting 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.
to the loss of trillions of dollars in the 2008 financial
crisis. Among other impacts this undercut the wealth is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker. It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche. of the majority
of Americans.
The population of the US is also aging rapidly. Health care
provision for older people is best focused on the person rather than
on the treatment facility as has been typical in the US
system.
The US federal structure promotes competition between states based
on cost and value add. This generates the environment within
which health care niches form.
In 2014 healthcare accounts for one-sixth of the engine that drives
the US 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. .
For more than twenty years healthcare costs have grown
consistently. But 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.
is designed to change that through two conflicting mechanisms:
- Expand health coverage to millions of Americans without
insurance.
- Make the healthcare system more efficient by forcing doctors
and hospitals to deliver care in a more cost-effective
way.
Which of the two aspects has more economic effect is
contentious. While 2014
Q1 numbers include a surprise drop in healthcare spending
(only the fourth quarterly decline in 80 quarters) government
actuaries (Jul
2015, Aug
2015) predict a rise through 2024. The spending increase
will be encouraged by the 2016 US budget (Dec
2015).
- Growth in U.S. is the United States of America.
healthcare spending slowed in 2017 to 3.9% - back to levels of
2008-13: Total federal healthcare spending of $1 trillion + huge
tax subsidies for healthcare and coverage to a total of $3.5
trillion - 17.9% of the 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.
; total 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. spending,
for 70 million people, increased 2.9% to $582 billion, vs. 4.2%
in 2016, 9% in 2015, 11.8% in 2014; federal Medicaid payments
increased < 1%, vs. 4.6% in 2016; 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.
spending
growth slowed with a shift to 1/3 using private 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, which use 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.
and less hospital services, Growth in hospital prescribed drugs
slowed, Growth in retail spending on prescription drugs was 0.4%
(totaling $333 billion), Drug prices - generics declined,
brand-name drug increases slowed, pain killer prescription
volume growth slowed; household spending grew 3.8%, vs. 4.8% in
2016, Out-of-pocket spending grew 2.6%, vs. 4.4% in 2016, to
$365.5 billion. 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 spending grew rapidly in 2014/15: Medicaid expansion,
Added public insurance coverage; 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.
drugs also generated high spending in 2014/15; Health insurance
coverage dropped slightly in 2017 & more people selected 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. s (Dec
2018)
Congressional Democratic proposals aim to drive the health care
agenda for 2020:
- 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.
for
all proposals induce health care (hospitals,
PhRMA)
and health
insurance (fear powerful new competitor taking profits)
industries to respond, with advice from Forbes Tate,
to setup Partnership
for America's Health Care Future with Hillary Clinton's
Lauren Shaver in charge, which is pushing for 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
and maintaining 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 sustaining Employer
based insurance, which pays doctors and hospitals higher
fees than Medicare. ACP is the American College of Physicians.
supports Medicare buyin (Feb
2019)
Legislative challenges from Republicans to 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.
proceed:
- Republican led Congress developed a small government tax bill
that will need reduced health care funding to limit expansion of
the national debt.
- Tax bill written by Kevin Brady, passes Senate 51-48 allowing
House to vote to send it to President Trump's Desk. The
bill sets up an evolved amplifier.
It contains: Removal 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.
individual mandate pushing insurers out of the markets as risk
pools collapse, Opening of the Arctic Wildlife Refuge for oil
& gas drilling, $1.5 trillion allowed deficit justifying 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.
defunding, limits to state & local tax deductions impacting
large Democratic states: California, New York, New Jersey; of
$10,000, Top corporate tax rate reduced from 35% to 21%,
Individual rates reduced from 39.6% to 37% but with sunsets in
2025, Inheritances of $22 million shielded from tax,
Pass-through businesses able to deduct 20% of their business
income (Dec
2017)
- President Trump will sign the legislation
The legal challenges from Republicans to 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.
proceed:
- King v. Burwell
was rejected by the Supreme Court (Jun
2015)
- House of Representatives v. Burwell
(Aug
2015, Sep
2015)
- Texas, along with 19 other states, argues removal of the
revenue collecting aspects of the individual mandate makes key
parts of 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.
unconstitutional. Trump DOJ - U.S. Department of Justice. concludes it cannot
defend the constitutionality of the ACA pre-existing conditions
clauses (Jun
2018)
- Texas federal judge Reed O'Connor invalidates 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.
as
unconstitutional. President Trump is pleased but the White
House notes the ACA continues in effect until appeals are
resolved (Dec
2018)
- Trump administration DOJ - U.S. Department of Justice.
shifts position 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.
:
now agrees with Texas (Jun
2018, Dec
2018) that the ACA is completely unconstitutional (Mar
2019)
The reduced wealth is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker. It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche. and aging of the
US population, is forcing state politicians to look for effective
ways to restrict 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.
spending
on the elderly. Given the power
of the nursing home lobby and other political risks they are
leveraging funding of private long-term care alternatives (indirection)
to mitigate financial 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.
as 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. via global 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. (flexibility).
But the scenario
is becoming analogous to the psychiatric hospital closures of
the 70s and 80s where the lower cost community services promoted as
replacements rapidly lost funding. The mentally ill had been
forced to self-medicate and many ended up in the prison
system.
- 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.
access
restrictions have proved fatal: Tennessee; while
expansion has reduced mortality Chicago's
Baicker & Harvard's
Sommers & Epstein found (Jan
2018)
- Trump CMS is the centers for Medicare and Medicaid services. administrator
Verma, 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.
director Neale, leverages work as a health improvement benefit
to justify Medicaid funding of States: Arizona, Arkansas,
Indiana, Kansas, Kentucky,
Maine, New Hampshire, North Carolina, Utah, Wisconsin; waivered
eliigibility work requirements; angering Medicaid beneficiary
advocates: CBPP;
(Jan
2018)
- Kentucky applies work requirements 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.
Waiver,
but advocates for the poor: NHLP;
said they would oppose it with legal action (Jan
2018)
- CMS is the centers for Medicare and Medicaid services. administrator
Verma agrees Arkansas can implement 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.
work
requirements, but delays allowing the state to roll back
Medicaid expansion (Mar
2018)
Puerto Rico's situation
is particularly difficult. Its bilingual health care
workers are leaving the depressed health care sector for higher
paying US mainland jobs.
The Obama administration proposes US Congress support Puerto Rico's
Medicare flows which is 20% of Puerto Rico's cash flow but Congress
is cool to the proposal.
Aging ensures heart
disease, 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). ,
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
and 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). will
complicate the health care of a significant percentage of the US
population. That presents opportunities (Mar
2016) and problems for chronic 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. new entrants such as Wal-Mart.
Aging tends to increase the number of problems that each patient has
but it should also alter the treatment strategies. For
example:
- Chronic
kidney disease or CKD is
- Where there is permanent damage to the Kidneys. Diabetes and high blood pressure are the
leading causes of CKD. This has driven up the
percentage of American's suffering from CKD.
- CKD is diagnosed via a GFR
of less than 60, or another marker such as protein in the
urine, for atleast three months.
- The disease, classed as having five stages, causes no
symptoms until the later stages. The fifth stage of
CKD is ESRD. CKD is
associated with: Atherosclerosis,
Cardiovascular
disease, Iron
deficiency anemia from reduced EPO
synthesis, Fluid volume overload, Hyperphosphatemia, Hypertension, Metabolic
acidosis, Mineral bone disorder, Potassium accumulation,
& Urea accumulation.
affects 50 percent of the elderly and the
diagnosis encourages them to demand treatment but it is not
likely to reach stage 5 and kill them so why treat it? Maybe due
to its effects on cardiovascular
disease 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).
. (Sep
2015)
- 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)
Waiting behind these diseases are the neuro-degenerative diseases: 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. ;
as discussed
by Stanley Prusiner which, in 2014, have no treatments and an
empty drug pipeline.
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 Jul
2015 decision to test a blend of 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 and
medical treatment may improve end of life care and help manage
costs.
But hospices found to overbill 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.
(Apr
2016)
- 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)
Public health and health care
Societies have to decide how much to invest in 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.
and
safety net programs to improve the health of 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. individuals
relative to health
care oriented strategies (Dallas Parkland
Health's Mobile clinics may help hospitals manage these costs
May
2016). Current analysis suggests safety net programs are
more efficient at limiting health care costs. They also depend
on effective prophylaxis in public health to control the risks of an
increasingly connected world. CDC is the HHS's center for disease control and prevention based in Atlanta Georgia. 's Ebola
response to 2014 outbreak initiated in West Africa suggests
significant short comings. The 2016 US Budget, agreed in 2015,
allocated money for antibiotic 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).
research to the previously budget
constrained 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. and
to BARDA.
Bubonic plague is a Yersinia pestis bacterial infection of humans, typically vectored by fleas, although it can be spread through the air between humans via infected droplets.
research (Jul
2015) suggests small genetic changes can change the fatality
and infectiveness of bacteria.
Howard
Friedman and Leslie Martin argue that today's health care is
far too transactional. It does not look holistically
at the mental and physical health of individuals or integrate
life paths into the treatment process.
The American poor's life expectancy is a measure of the average life time of a new born baby. Without public health assistance many children die in the first five years of life significantly lowering the life expectancy of the whole group. There are representational and data capture problems with the model: - Not knowing the risk of dying in the newborn's future, demographers use the risks present at that time to predict impacts in the future of the person. No adjustment can be made for increased wellbeing.
- Saving the lives of children has a far larger effect on increasing life expectancy than extending the lives of the elderly
- Impacts that occur in a particular year, such as a epidemic or pandemic, are treated as permanent effects for that years life expectancy even though they may be handled by public health strategies and hence be transients. For life expectancy calculations in subsequent years the impact is ignored.
- Programs that reduced the impacts of infectious diseases, such as antibiotics and vaccine deployment, have reduced the variability of life expectancy following their introduction.
- Vital registration systems gather accurate data for life expectancy. But most countries do not have the infrastructure and instead estimates are generated from demographic and health surveys.
is dropping especially in the central zone ravaged by drug taking
related deaths, but certain cities including New York and Birmingham
Alabama, are doing relatively well. (Apr
2016)
Poor Americans are suffering from more 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. (Nov
2015). Prescribing of
pain killers has been rising since 1996 but crested in May
2016.
Technology invasion
Technology is rapidly invading the health care space. Sensors
are becoming pervasive and far more capable. Agent's routine
rule based information processing and problem solving are now
accessible to support. Robots
are able to automate processes with vastly reduced error
rates. Virtual
reality is the full immersion of a human user into a virtually generated world. Hence the user is not able to interact or think about the real world at the same time. The use of sensors detecting the user's skin, eyes, ears, and other state and signal generators for touch, hearing, visuals etc. supports the transportation of the brain into an alternate situation where the user can interact. As long as the sensors are broadly detecting the state of the user's body and the signals are generated at greater than 60 per second it is a truly real experience. Unfortunately it is hard to fool gravity so these systems can induce motion sickness. Virtual reality is likely to be significant in medicine in: - Training with new tools including surgical instruments.
- Remote treatment including surgery where the feedback allows the surgeon to operate robotic instruments experiencing the remote OR.
has large backers like Facebook (Oculus) and Microsoft and
is being experimented with in supporting
robotic surgery and 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.
treatments.
But as aging and technology integrate the health care system is
being undermined by strategic traps: 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. process
inducing
more long-term acute care impacts families and 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.
.
The health care pseudo market
Frustration with the inequity of a pseudo-market:
- Discussion of single-payer.
- Search for more efficiency and effectiveness.
Constraints such as the BBA is the Balanced Budget Act of 1997. This act aimed to balance the federal budget by 2002. It was enacted using the budget reconciliation process. In part it reduced Medicare (replacing MVPS with the SGR and commissioning the MedPAC) and Hospital inpatient and outpatient payment cuts to do this. It also enacted Medicare Advantage and SCHIP. BBA mandated risk adjustment and the HCC coding payment model, through CMS rules. 's
SGR is medical Sustainable Growth Rate. It is a CMS method to control Medicare spending on physician services. It aims to ensure the yearly increase in expense per Medicare beneficiary does not exceed the growth in GDP. To do this CMS reports to the MedPAC which advises the U.S. Congress on the previous year's total expenditures and the target expenditures. The report includes a conversion factor that constrains the payments for physician services to match the target SGR. On March 1st of each year the physician fee schedule is updated accordingly. Congress can and does adjust the target SGR outside of these bounds. SGR replaced MVPS. It was introduced via the BBA. attempt to limit 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.
payments
threatening physician finance (Doc fix constraint removed Apr
2015) and forcing Congress to reduce the constraints
impacts each year. William Haseltine highlights
Singapore as a more efficient system (2000 operations in
Singapore hospitals vs 200 in US is the United States of America. ) with better planning
for the future. It spends less on health care than any
other high-income country but ranks sixth in world
outcomes. But it is a small city state. Haseltine
sees Japan's health system as a logical direction for the US to
move towards to gain more efficiency and
effectiveness.
- Singapore is a vision
of a well-functioning state and health care system: Initially
weak, it uses focus to succeed. It plans for the long
term, using cost effective public health strategies, backed up
by government funded insurance. Protected public
hospitals and clinics constrain prices in the private
sector.
- In comparison to Singapore the US system has:
- A complex 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.
political network with a diverse
set of state economies each with conflicting
goals for the various aspects of the US federation
that contributes to the health of the nation.
- Housing access has been constrained creating a two tier
system of those who own houses - mainly white and those
who could not and now do not have the capital to gain
access and so are trapped in rural and urban
ghettos.
- Food
supply that matches the housing structure.
High income housing correlates with supplies of good
food. Low income neighborhoods have limited access
to good food choices. Instead they are offered foods
enriched with fructose!
- The US 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.
is built from a patchwork of states with differing economic
strategies. Some states follow a low cost strategy
with a minimal safety net and low average salary.
Others have adopted a high cost strategy. The result
is that sections of the US population live in poor stressed 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.
conditions that undermine wellbeing indicates the state of an organism is within homeostatic balance. It is described by Angus Deaton as all the things that are good for a person: - Material wellbeing includes income and wealth and its measures: GDP, personal income and consumption. It can be traded for goods and services which recapture time. Material wellbeing depends on investments in:
- Infrastructure
- Physical
- Property rights, contracts and dispute resolution
- People and their education
- Capturing of basic knowledge via science.
- Engineering to turn science into goods and services and then continuously improve them.
- Physical and psychological wellbeing are represented by health and happiness; and education and the ability to participate in civil society through democracy and the rule of law. University of Wisconsin's Ryff focuses on Aristotle's flourishing. Life expectancy as a measure of population health, highly weights reductions in child mortality.
.
- A highly
segmented population with some segments having no
financial ability to access to the health care network:
- Super rich who can leverage the best aspects of the
US/Global system to get superb care.
- Shrinking middle class
- African-American population that has been subjected to
inhuman medical experimentation and constraints on access
to care. It still does not trust the 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.
and health care provider infrastructure (Dec
2013).
- The US spends 18% of GDP is:
- Gross domestic product which measures the total of goods and services produced in a given year within the borders of a given country (output) according to Piketty. Gordon argues to include products produced in the home & market-purchased goods and services, following Becker's theory of time use. Gordon stresses innovation is the ultimate source of all growth in output per worker-hour. GDP growth per person is equal to the growth in labor productivity + growth in hours worked per person. GDP has many problems. Gordon concludes that between 1870 and 1940 all available measures GDP is hugely understated because:
- GDP is a poor measure of:
- Value & wealth
- Who gets what
- Global supply chains
- GDP excludes:
- Reduction in infant mortality between 1890 (22%) and 1950 (1%)
- Brightness & safety of electric light,
- Increased variety of food including refrigeration transported fresh meat and processed food
- Convenience and economies of scale of the department store and mail order catalog and resulting product price reductions
- Services by house makers
- Time & health gains from having flush toilets, integrated sewer networks; rather than having to physically remove effluent and cope with fecal-oral transmission
- Leisure
- Costs & benefits of different length work weeks
- Speed and flexibility of motor vehicles - which were not included in the CPI until 1935, after the transformation had occurred. And competition from improved foreign vehicles, while it provides purchaser/user with improved standard of living (less breakdowns, repairs, etc.) is measured as reduced domestic manufacture
- Coercion and corruption to obtain resources
- Consumption impact of finite resources: coal, oil;
- Destruction impact of loss of entire irreplaceable species
- GDP includes items that should be excluded:
- Cost of waste - cleaning up pollution (single use indestructible plastic bags), building prisons, commuting to work, and cars left parked most of the time; should be subtracted
- Guanine-di-phosphate is a nucleotide base.
on health
care. 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.
is shifting the population to private insurance with high
deductibles, 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); .
While this will constrain American's use of health care
provision it will not limit cost escalation while prices
remain opaque (Aug
2013, Sep
2015).
- The ACA is designed to generate a national network with teleodynamic properties
of contension between suppliers, prividers and payers 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.
.
But the extended phenotypic
alignment (May
2016) of such a fully, and permanently, connected
network of power and profit seeking competitors will reward
large well connected nodes and undermine 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. .
- The SCOTUS decision provides some local separation from
the network as illustrated in Independence
Kansas.
- The US system includes public and private health care
components. But the regulatory environment has blunted
the impact of the large public elements allowing private
companies to gain scale, scope and influence with the
government.
- Opaque pricing including legal constraints, such as 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.
, on the public
infrastructure from competing or revealing costs and
prices.
- The ACA title
IV is ACA preventing of chronic disease and improving public health.
- Subtitle A: Modernizing disease prevention and public health systems.
- Subtitle B: Increasing access to clinical preventative services.
- Subtitle C: Creating healthier communities.
- Subtitle D: Support for prevention and public health innovation.
- Subtitle E: Miscellaneous provisions.
focuses on chronic disease management.
- An aging population is a significant demographic
shift in the U.S. too. Immigration has offset
the retirement bulge, although globalization
and offshoring have built resentment of
immigration. But the size and complexity of the US and
the inherent tension between the needs of the different
states and the nation as a whole undermines the value of a
coordinated central plan. Various laws have been
enacted to help the US health care network adapt 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.
to
these demographic changes. Most notable are the 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. 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.
. HITECH initiated a shift to 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 from
paper. The ACA undermined the 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. strategy of
many health care providers (Rural hospital impact Oct
2015), instead
encouraging them to seek cost effective ways to
profitably deliver patient focused care.
- The ACA medical
home models are primary care architectures which deliver: patient-centered, accessible, coordinated, comprehensive care of high quality and safety (Dec 2015). The models have been made more significant due to Affordable Care Act payment reform requirements. The goal is to reduce treatment costs and improve population health by reengineering of the traditional silo'd provider network. See PCMH.
and associated CMS is the centers for Medicare and Medicaid services. rules (CPC is the CMS comprehensive primary care initiative. Medicare is working with commercial and state health insurance plans and offer bonus payments to primary care doctors who better coordinate care for their patients. PCPs that participate are given resources to better coordinate primary care for their Medicare patients. ) encourage
the use of 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.
.
But even as 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. and retail
clinics bring health care closer to the communities
House Calls are missing (Oct
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)
- 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)
- And surveys, comparing access to health care in the US to a
basket of other wealthy is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker. It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche.
health care networks, show the US continuing to perform
badly. Only Canada is consistently worse (Oct
2016).
- Regulating in value. Congressional constraints on health
care market pricing have been weakened. 98% of AHA is the American_hospital association.
/ACHE is the American College of Healthcare Executives. CEOs expect to
provide cost/quality transparency data to the public.
Single-payer scenario
The National Health Service, as used in the UK, removes the threat
of financial ruin from the treatment transaction. But 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).
forces the government, who pays the bills, to confront the problem
of limiting the demands of the health care system. The
government consequently uses its power as the single purchaser to
limit its risks introducing distortions into the rest of the health
care system. And to carry out this mandate the government must
plan out the allocation of resources. This central planning
problem was discussed by Hayek in The Road To
Serfdom. It not only allocates resources unfairly but
also undermines 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.
as explained in The
Innovator's Prescription. Innovations tend to be
introduced into the US health system much faster than in the cost
constrained 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).
systems. But Democrats, such as Michael
Moore, advocate for state
based insurance plans.
Health care complex adaptive system scenario
Any alternative to central planning must confront an alternative
dilemma. Profits can be diverted from reinvestment in
efficiency and effectiveness to profit or leadership 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. Saposky observes the disconnect between power hierarchies and wisdom in apes. John Adair developed a modern leadership methodology based on the three-circles model. reward
maximization. Treatment for a catastrophic condition will be
required whenever it occurs (Kaiser).
It is likely to demand immediate access to infrastructure and
skills. A private solution to this dilemma requires a network
of providers who will be paid for the treatment transaction (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). [reengineered],
Stabilization,) by insurance, personal payment or government
reimbursement. This is the US system. Currently it is a
relatively poor performer: Wait
times. Toby Cosgrove CEO of Cleveland Clinic
argues
that transparent competition will work well by 2024 forcing disintermediation
of hospitals and consolidation down to a few hospital systems
with high leverage of transportation.
The architecture of new hospitals must also adapt 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. to support new
trends: Bigger people (Aug
2015);
Key influences
of the health care network
Legislation constrains this network, forcing the various agents to adapt 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. (Sep
2015) to gain access and participate in the
flows. 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.
has expanded the number of people (Aug
2015, Mar
2016) who use the health care network increasing
its cost base (Aug
2015) but it supports contractual limits on non-catastrophic
access to the health care provider network is the owned health system and its extended network of partners. .
This encourages
- Patients to select low cost transactions (Henry
Ford Health System) and to stay
within the contracted narrow network - 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 service providers/doctors (working as planned in 2015).
It also encourages
- Referral based integration of the network agents. But it
also enables network integration.
- Hospital mergers can be seen concentrating power by limiting
choice and accentuating brand (Jul
2014): Harvard's
Partners
HealthCare.
- Restructuring of the care - payment transaction. ACA
support of 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.
structures and startup insurance
co-ops may not be enough to overcome network effects that leave
power with large payers which have 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).
.
- 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)
- The 2015
bill to alter Medicare payments for doctors also pushes
them towards larger groups, 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.
, 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 and 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. .
- However, the ACA requires balanced treatment of mental
disorders including addictions results from changes in the operation of the brain's reward network's regulatory regions, altering the anticipation of rewards. Addictive drugs mediate the receptors of the reward network, increasing dopamine in the pleasure centers of the cortex. The learned association of the situation with the reward makes addiction highly prone to relapse, when the situation is subsequently experienced. This makes addiction a chronic disease, where the sufferer must remain vigilant to avoid relapse inducing situations. Repeated exposure to the addictive drug alters the reward network. The neurons that produce dopamine are impaired, no longer sending dopamine to the reward target areas, reducing the feeling of pleasure. But the situational association remains strong driving the addict to repeat the addictive activity. Destroying the memory of the pleasure inducer may provide a treatment for addiction in the future. Addiction has a genetic component, which supports inheritance. Some other compulsive disorders: eating, gambling, sexual behavior; are similar to drug addiction.
.
NIDA
director Nora Volkow sees this
regulatory shift as a key opportunity to counter chronic
behaviors including addictions and over eating.
For providers transaction flows depend on being part of the
contractual network (Swedish
Medical Center) and being on the referral list of the anterior
transaction in the network.
Payers 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.
are locked in to
a yearly
contracted revenue and payment stream. Intermountain
has developed a novel
approach that encourages long term contracting with its health
plan SelectHealth
(share).
But in general the yearly contract creates false, but very real and
problematic constraints:
- Payers become focused on short term health efforts. Long
term investments might benefit competitors.
- Gilead's
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.
pricing aims
to capture its revenue stream over the time of treatment
impacting payer budgets (States'
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. ) and
making the treatment price per pill astronomical. A better
goal would be for the payers to be able to agree with drug
suppliers like Gilead that they can pay the total treatment cost
for drugs like Sovaldi over a multi-year period.
- Plans are often missing leading edge coverage:
- Mindfulness is an active meditative state of non-doing, attentively seeking each 'present moment' with one's body and mind 'being' at rest and so cultivating awareness, according to Jon Kabat-Zinn. Some traditions define it as observing when the mind wanders. Others use it to refer to the floating awareness that witnesses whatever happens in our experience without judging or otherwise reacting, explain Goleman & Davidson. The thinking mind usually spends a lot of time relating to the future and past which Kabat-Zinn argues limits its ability to become fully aware of the present. In times of stress those thoughts are so overpowering that they crowd out awareness and appreciation of the present. Mindfulness shifts attention to calming internal feelings. It allows review and prioritization of thoughts as they are recognized. Major attitude based pillars of successful mindfulness are: impartial to judging, patience, a beginner's mind, trust, non-striving, acceptance of seeing things the way they are and letting go. An awareness of the body's state can be built with tools including: inquiry, naming; from Yogi's attention to:
- Breathing - which is a proxy for the environmental situation and through its rhythms is a model of our emotional state. Attention to breathing reminds people to feel their bodies too. Belly breathing is particularly relaxing.
- Sitting - erect with head, neck and back aligned vertically. Then attend to breathing moving back to it each time you observe the mind has wandered. When the body becomes uncomfortable, direct attention to the discomfort, observe and welcome it.
- Experience our body - rather than model, judge or hate it relative to an ideal - with a body scan.
- Hatha yoga - very slow stretching and strengthening exercises with moment-to-moment awareness supports being in your body.
- Walking meditation - Intentionally attend to the immediate experience of walking.
relief for 65 million lower back 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. sufferers (Mar
2016)
Local public
health situation (Feb
2016, Apr
2016) and associated federal, state and local political
strategies affect the risk to the hospital's patient base from:
- Acute diseases including: Dengue is a mosquito vectored virus that can cause high temperature, intense joint and muscle pain, hemorrhagic fever and hence death. The number of cases has been growing sharply and spreading out beyond its traditional base in the tropics and subtropics to Hawaii, Japan and the Florida Keys. Between 50 and 100 million people are estimated to be sickened by dengue fever a year.
(Feb
2016), Ebola is a viral disease discovered in 1976. It is an ancient virus branching 20 million years ago from other filoviruses. It mainly infects rodents and other mammals. It appears highly lethal when infecting Gorillas, and is also acute in humans, so we are not a reservoir for Ebola but a dead-end host. The death toll is very small compaired to influenza or Covid-19. A West African epidemic was probably reservoir hosted by forest dwelling bats and transferred to a boy. The 1976 northern Zaire (Yambuku) strain was able to spillover to humans with a case fatality rate of 88%. Sudan, Reston (Philippines), Bundibugyo (Uganda), and Tai Forest, Ebola like viruses have lower case fatality rates. The 1995 Zaire (Kikwit) outbreak was in a forest clearing close by a city of 200,000. A man who felled trees fell ill and died of hemorrhagic fever a week later. He had fatally infected three members of his family and ten of his friends. When it reached a local maternity hospital it infected a lab technician who was transferred to the general hospital where doctors, nurses and nuns were infected and the nuns and technician died. The CDC identified the pathogen as Ebola, which had killed 245 including 60 hospital staff members. The 2014 epidemic is seen as the result of a single infection. Evolutionary biologists consider it unlikely that natural selection will give the virus the ability to spread more easily. The size of the 2014 epidemic gives more potential for mutations but the current transmission mechanism is working for the virus so there is little obvious pressure for out-competition by a new transmission path. There are likely to be lots more viruses with similar infection model to Ebola. Typically an individual is not sick for three to five day after the onset of symptoms which can fool care givers. Then around day 5 to 7 they really crash. Their blood pressure goes down, they become stuporous to unresponsive, and they start to have renal and liver failure. This correlates with the enormous viral load (making it very contagious which is a significant risk to care givers), which is just attacking every organ in the body. Ebola patients lose enormous amounts of fluid from diarrhea and vomiting, as much as five to ten quarts a day during the worst phases of the illness which lasts about a week. Doctors struggle to rehydrate them, replace electrolytes and treat bleeding problems. Thomas Eric Duncan brought Ebola to Texas Health Presbyterian hospital, where the ED failed to identify his symptoms.
(CDC is the HHS's center for disease control and prevention based in Atlanta Georgia. response),
Zika is a Flaviviridae family virus. It came from the Zika Forest of Uganda isolated in 1947. It is related to dengue, yellow fever, Japanese encephalitis and West Nile. Zika is transmitted sexually or via a daytime mosquito vector such as the Aedes genus. It has resulted in a pandemic in South America. Zika fever has been associated with a number of troubling complications: - Guillain-Barre syndrome
- Microcephaly. The mechanism may have been identified (May 2016)
(Mar
2016); Outbreaks are often in budget constrained
areas with low income populations. Climate change is
expected to exacerbate the problems. Pharmaceutical
incentives for developing solutions may improve with
public/private finance of GAVI. 2015 US
Budget added $100 million funding to the 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. for antibiotic
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%. research, and $96 million for BARDA
to use for new drug discovery.
- Food poisoning constrained by F.D.A. Food and Drug Administration. :
- Rate and count of food poisoning is increasing in the US: 40
million cases, & 3,000 deaths each year. Problem
foods: Raw egg, undercooked meat & poultry, organisms on:
rasperries, cantaloupe, ice cream, salami, scallions, parsley,
cider, toasted oatmeal. Some steps can be taken to
minimize risk (May
2018)
- F.D.A. Food and Drug Administration. criticised,
by HHS is the U.S. Department of Health and Human Services. inspector
general, for leaving food on shelves for too long, even
after the FSMA is the Food Safety Modernization Act of 2011 which provides the F.D.A. with additional powers to police food companies.
provided it with mandatory powers (Dec
2017)
- Toxic 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.
:
Failing water supply infrastructure, Collapsing abandoned mining
and manufacturing plant, Opioid addictions results from changes in the operation of the brain's reward network's regulatory regions, altering the anticipation of rewards. Addictive drugs mediate the receptors of the reward network, increasing dopamine in the pleasure centers of the cortex. The learned association of the situation with the reward makes addiction highly prone to relapse, when the situation is subsequently experienced. This makes addiction a chronic disease, where the sufferer must remain vigilant to avoid relapse inducing situations. Repeated exposure to the addictive drug alters the reward network. The neurons that produce dopamine are impaired, no longer sending dopamine to the reward target areas, reducing the feeling of pleasure. But the situational association remains strong driving the addict to repeat the addictive activity. Destroying the memory of the pleasure inducer may provide a treatment for addiction in the future. Addiction has a genetic component, which supports inheritance. Some other compulsive disorders: eating, gambling, sexual behavior; are similar to drug addiction. , Toxic
chemicals (Jul
2016), Smoke from wild fires (Nov
2018);
- Screening, where levels are contentious (Dec
2013 (2),
Sep
2015). 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 are popular and powerful, but induce high radiation
accumulation.
- Stanford
Medical
School professor, Lei
Xing, details research in his Medical imaging,
deep learning is an artificial intelligence approach where engineers deploy data into deep neural networks.
AI & nano
medicine is the application of nanotechnology to medicine (May 2016, Feb 2019). Commercial applications are focused on research and clinical tools for drug delivery, therapies, safer and more effective in vivo imaging, neuro-electronic interfaces, other Nano-sensors, and eventually cell repair machines!! There are issues with determining toxicology etc. lab
to IEEE is the institute of electrical and electronic engineers.
nano-technology group at Varian
Medical Systems (Feb
2019)
- Verily
deploys deep
neural networks are representational models that achieve high performance on difficult pattern recognition problems in vision and speech. But they need specialized training methods such as greedy layerwise pre-training or HF optimization. Researchers are gaining access to the participation of the individual 'neurons' using: visualization, attribution, dimensionality reduction, interpretability; (Mar 2018)
to detect diabetic
retinopathy is damage to the blood vessels of the retina due to high blood sugar levels associated with type 2 diabetes. with retinal scan assistance. W.H.O. is World Health Organization a United Nations organization. reports 70
million Indians have diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. .
Technology used in Indian hospitals: Avarind Eye Hospital; and
clinics, supports the very low levels of trained doctors: 11 eye
doctors per million people, so an A.I. system may massively
improve screening. Currently needs a clear lens for the
neural networks to detect problems. Europe's regulators
have allowed the Verily system on to the market. The US is the United States of America. F.D.A. Food and Drug Administration. also approved a
system, but Verily's is still awaiting approval (Mar
2019)
- Violence: Exponential population
expansion and the increasing disparity in wealth is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker. It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche. may catalyze
an increase in terrorist and other violent acts as stressed
areas collapse.
Hospitals must ensure they can respond effectively to the
trauma.
Digital networks connecting patients to the health care network
and each other. Smart phones and appliances offering
integration with cloud based applications allowing:
Inhibition of digital data flow by:
- HIPAA is the Health Insurance Portability and Accountability Act of 1996. It added part C (administrative simplifications) to the SSA.
- CFR 45CFR 160.103 is the general provisions section of the regulations. HIPAA Transactions and Code Sets Standards regulations 45CFR 162.923(a) Covered entities must use adopted transaction standards for inter and intra covered entity transactions.
- HIPAA only applies to health care providers, health insurers, clearinghouses of health care data, and their BAs.
- Initially HIPAA was designed to specify a secure standardized MPI. Late in the development of the legislation the MPI was viewed as too risky and was removed from the legislation.
- The law does not prohibit health care providers from sharing information with family, friends or caregivers unless the patient specifically objects. Providers can use 'professional judgement' to disclose information to a relative or friend if it is in the best interest of an incapacitated patient.
- It is also allowed to share general information about a patient's condition and location in a facility.
- Family members can provide information.
- Caregivers who are a patient's personal representative, such as: a health care proxy or guardian or with power of attorney; or who have had the patient authorize the release of information must be provided with it.
- HHS office of Civil Rights enforces HIPAA but typically they try to fix problems rather than applying penalties.
,
- Silos of incompatible database schemas,
- Silo 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!
vendor
business model.
- Licensing
constraints on 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.
.
Genomic,
proteomic and medical knowledge trends - expanding set of
discoveries about cellular and system operations and pathology:
Device trends - leverage of Nano-scale
and networked sensors (IEEE nano in medicine (May
2016)), computer controls, appliance based mobility and cloud
based algorithms: laboratory
automation aims to improve the processes in laboratories. Robots and lab-on-a-chip are a key aspect. High-throughput screening and combinatorial chemistry, automated clinical and analytic testing, diagnostics, and biorepositories depend on automation. is being deployed in diagnosis by Theranos, potentially
disrupting Quest
and Lab
Corp and transforming the medical workflow as outlined by UCSF MC and
David Helfet's vision of rapid
control of hospital acquired infections. Theranos's
patented vision
of an arm patch: sensor, drug delivery system 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.
connection; is popularized in Lanier's Who Owns The Future. Google and
J. &
J. are partnering
on robot surgery.
Pharmaceutical
trends - Slow expansion of targeted treatments for micro-segmented
patient groups resulting in disruption of the block buster business
systems (although the industry has flows and court support to
sustain blockbuster model - Making Risperdal a block
buster Sep
2015) of 'big pharma' results in key advances
in:
- Biologics 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.
and
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. .
Completion of the 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.
may provide pharmaceutical
giants with global enforcement of their clinical trial
entry barrier. So US is working to remove barriers to
signing:
- US proposes to exclude tobacco companies from using legal
apparatus (Oct
2015).
- Alzheimer 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.
's
- Eli
Lilly;
- 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.
therapy with major investments from: Merck, Bristol-Myers,
Roche, AstraZeneca, Celgene,
Sanofi; and 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. of
success (Sep
2015, May
2016).
- Immune checkpoint
inhibition 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. is a broad based expansion into a new evolved
niche (Aug
2016). The strategy is driven by:
- Alignment with classical pharmaceutical business model
- CRI is the cancer research institute.
alignment
- Strategic continuation of traditional cancer therapies,
and applicable to most cancers that mutate rapidly.
- Cellular
therapies captures cells from a particular patient, modifies them, clones them and then deploys them back into the patient. Platforms include CAR and TCR. In 2016: The pricing schemes for cell therapies have not been announced but are expected to be expensive, The therapies are successful between 25 and 90% of the time for lymphoma and leukemia but patients may relapse after months or years of remission; There are a number of challenges to the approach, some of which may require treatment in an ICU, including:
- Lack of scale being specific to each patient.
- Immune system over reaction
- Neurological toxicity including cerebral edema (Jul 2016).
are personalized (Aug
2016). They have strengths and weaknesses:
- They may be able to avoid off target activity by the
activated 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.
.
- Leverage advances in gene
sequencing 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.
and 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.
.
- They currently have limited application to solid tumors
which are 90% of deadly cancers.
- They are miss-aligned with the big pharmaceutical business
model.
- 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.
:
Gilead;
where the drug
prices are impacting state budgets, but constraining
pressure from 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/drug
distributors is pushing prices down by Sep
2015).
- Atherosclerosis is the thickening of an artery wall due to invasion and accumulation of leukocytes. It is associated with lack of sleep. Sleep reduces inflammation (Jan 2019).
CETP is cholestrylester transfer protein facilitates the transfer of cholesteryl esters and triglycerides between very low density and high density lipoproteins. inhibitors -
have largely failed during late trials: Eli Lilly,
Pfizer;
- Variations
in corporate tax rates have stimulated US pharmaceutical
company inversions allows a U.S. company to move its tax domicile overseas by purchasing a foreign company. In 2015 the U.S. Treasury department adjusted the inversion rules to require 40% of the combined company is owned by the shareholders of the purchased foreign entity. In Apr 2016 they clamped down on the option to serially acquire American companies. In section 7874 of the tax code, Congress defined statutory hurdles that must be cleared to gain tax benefits: Shareholders of foreign acquirers owning less than 20% of the combined entity the inversion fails, If less than 40% and the acquirer does substantial business in the foreign jurisdiction the inversion works but with some pain, If they own more than 40% there are few negative consequences. Companies purchased serially within three years would be disregarded by the new rules. Companies invert because of lower foreign tax rates and earnings stripping. Once foreign, the parent loans the US subsidiary money. The loan repayments offset the US income and the US tax bill is vastly reduced. :
Pfizer
with Allergan; and catalyzed 'Roman empire' acquisition
oriented business models: Valeant.
As with the Roman empire as growth was impeded the Valeant
strategy collapsed (Mar
2016).
Value and visibility in drug pricing is increasing (Feb
2016). Oncologists and insurers are pushing for
visibility of costs of 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).
drugs. (Jun
2015) More pressure to amend 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.
to allow Medicare to
negotiate prescription drug prices (2015). 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. recommends that
Congress incent private insurers to constrain prescription drug
price increases (Apr
2016).
But compounding
pharmacies make unique prescription drugs to order when doctors conclude that standard formulations are not effective treatments. have been leveraging a 2012 change of industry
standards that allowed them to start billing for each ingredient in
a prescription. Pharmacy benefits managers have noticed
increases in the number and cost of ingredients submitted per
prescription.
And controlled drug distribution channels, such as specialty
pharmacies dispense specialty medications. They aim to save health plans money by: teaching patients how to apply their medicines and deal with side effects, ensure they take the full course and limit waste. These specialized channels can be used by drug companies to limit competition to their drugs since access in constrained. Generic drugs rebranded as specialty medications may escape competition, remove copayment and formulary exclusion sales inhibitors and obtain considerable pricing power. , allow pharmaceutical owners to bundle low price
generic drugs as specialty
medications 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). with high prices, limited generic competition and
profit amplification from the MMA (Sep
2015). These channels have started to incent the
patients of specialty medications (Hemophiliacs
Jan 2016).
Trial
trends - CAS
agents,
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. models,
expanded informatics and targeted cellular markers make for faster,
cheaper, smaller [and more questionable] (Aug
2015, Sep_2015)
trials:
- I-SPY 2 is the investigation of serial studies to predict your therapeutic response with imaging and molecular analysis 2. It aims to significantly reduce the cost, time and number of patients required for efficiently bringing new drug therapies to breast cancer patients who need them urgently.
- It:
- Uses tissue and imaging markers from individual cancer patients' tumors to determine eligibility, guide/screen promising new treatments and identify which treatments are most effective in specific tumor subtypes.
- The trial's adaptive design allow the I-SPY 2 team to 'learn as we go,' enabling researchers to use data from patients early in the trial to guide decisions about which treatments might be more useful for patient who enter the trial later. I-SPY 2 provides a scientific basis for researchers to eliminate ineffective treatments and graduate effective treatments more quickly.
- The I-SPY 2 neoadjuvant treatment approach, where chemotherapy is applied prior to surgery, allows the team to evaluate tumor response with MRI before removing the 'evidence'. This approach is as safe as treating after surgery, allowing tumors to shrink, and most importantly, it enables critical learning early on about how well treatments work.
- Key to the trial's distinctive design, the team will screen multiple drug candidates developed by multiple companies--up to 12 different investigational drugs over the course of the trial. New drug agents will be selected and added as those used initially either graduate to Phase III or are dropped for futility, based on their Bayesian predicted efficacy in targeted patient subgroups. Not only does this enable an enormous improvement in efficiency but, by using only one standard arm for comparison throughout the trial, it also immediately saves 35% of the costs of standard Phase III trials.
- The trial incorporates a robust informatics system that allows data to be collected, verified and shared real-time and to be accessed early and in an integrated fashion--enhancing and encouraging pre-competitive collaboration.
- By using the cellular signalling pathways as targets of 'targeted' therapies. In I-SPY 2 the pathway information forms the basis of rationalized therapeutic guidance for patient selection, stratification and further exploration to find response-predictive biomarkers. From an overview of gene mutations, gene copy number, gene expression as mRNA and protein and protein phosphorylation of both tumor and background tissue and blood a patient and tumor sub-group specific set of diagnostics and therapies. The biomarkers include:
- Standard, FDA approved, biomarkers to determine patient eligibility and allow randomization.
- CLIA biomarkers to aid hypothesis testing.
- Exploratory biomarkers to aid hypothesis generation.
- I-SPY 2 adaptively randomizes its iterative allocation of the initial/current patient population to either:
- Existing standard of care or
- Various experimental arms which eventually should graduate to phase III, or be abandoned, for some patient subgroup. Abandoned arms are replaced by alternative experimental regimes in a new randomized arm. Deciding to graduate or abandon uses Bayesian modeling. That requires (1) a reasonable model that allows simulation to assess behavior and (2) a simulation. Want to favor treatments that, on average, have superior interim results for specific biomarkers (patient segments). Aim to graduate experimental treatments with the largest signature that is likely to benefit. Graduate small signatures if it is unlikely that a larger signature benefits. Want to evaluate many drugs and combinations.
- I-SPY 2 collects data from each patient:
- Biomarkers (HR+/-, HER2+/-, MP1/2) -> 2(8) combinations but treated as 10 subgroups (1. All, 2. HR+, 3. HR-, 4. HER2+, 5. HER2-, 6. MP2, 7. HR-HER2-, 8. HR-HER2+, 9. HR+HER2+, 10. HR+HER2-;
- MRI volume at baseline, 2, 4 & 6 months;
- pCR at 6 months;
- Treatment.
- I-SPY 2 benefits:
- Reduce the cost of bringing a drug from discovery to market.
- Reduce the time to conclusive results.
- Reduce the number of patients needed to enroll in the trial. There is a tenfold reduction for Phase III.
- Improve the pace of innovation.
- Improve the success rate of Phase III trials (85% vs. 25%)
- Improve pre-competitive collaboration for applying molecular and protein pathway profiling and imaging in clinical trials.
- Improve the efficiency of drug evaluation and approval in concert with the FDA, and provide support for innovation in regulatory decision-making.
demonstrates the potential to reduce cost, time and number of
patients required in 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)
drug trials.
- Paxil is unsafe for teenagers; trial re-analysis concludes (Sep
2015)
- Trials funded by pharmaceutical companies and constrained by F.D.A. Food and Drug Administration. typically lock
in treatment protocols. A UK is the United Kingdom of Great Britain and Northern Ireland. government funded
Cambridge University study, shows Herceptin: breast tumors grow rapidly because they respond via the human EGF receptor (HER), coded for by the gene 'Her2', to cell growth signal epidermal growth factor (EGF). Herceptin inhibits the growth of the Her-2+ tumors by inhibiting the EGFR.
treatment for early stage 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)
works best after 6 months, rather than the current 12 month
protocol (May
2018)
Limited support for integrating the trends into better practice -
vision 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!
as the
interface to enhanced planning, execution and learning:
- EHR have been driven into the health care network. But
our analysis suggests the
process adopted has limited the immediate potential for emergent
amplification of the new infrastructure. Instead extended
phenotypic alignment will increasingly occur.
Further the way they are used is typically counterproductive (Oct
2014)
Increasing sensing of patient populations:
Providing data for cloud based applications to analyze at the
population level.
- IBM's Watson
and alternative big
data approaches (Epic
(Healtheway), Cerner
(CommonWell),
FlatIron, Allscripts
(dbMotion)) aim to
improve diagnosis by associating all instances of a situation
from historic data sources and then resolving them appropriately
and insightfully to the individual (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 be
successful silos of health data, see UPMC, will need to be
integrated together.
- 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.
results in vast expansion of potential for false positives are correlations between a random variable and markers of some event of interest. Over a statistically significant period the correlation of a false positive will fail but in small sample sizes it may hold. Identifying a statistically significant period is non-trivial. As more data becomes available via the web and it is applied in BI the problem of false positives will become more significant.
and regression-to-the-mean is an artifact of limited sampling in a statistical study. In a short time period exceptional scores are possible. But as more samples are taken the results will shift back to the mean. Two illustrative examples are Kahneman's explanation of Israeli fighter pilot trail scores and Deming's paddle wheel. .
Continued confusion about the difference between the realms of
physical processes, chaos,
and complexity.
Aetna has discontinued
its CarePass
personalized health data platform.
Robots are getting more
deployable, cheaper and more effective supporting better processes
in:
- Drug delivery
- Pharmacy
- Surgery
- Delivery (reducing transportation costs: Aethon Tugs
at UCSF)
Training is being supported by more sophisticated simulations.
Already movie methods including computing, 3D printing and new
materials are delivering realistic mannequins. Eventually VR
may replace the use of real materials in training.
- Movie special effects companies provide realistic artificial
patients for surgery practice (Nov
2015).
A driving forces assessment highlights the most influential and
unpredictable forces in the global environment.
High impact:
- P2, P4, P9, P10, P11, P12
- E4, E7, E9, E10, E13, E15, E16, E18, E19, E20, E23,
E24,
E25
- S7, S11
- T2, T5, T8, T10, T14
|
High impact and uncertainty:
- P1, P13
- E1, E6, E8, E12, E14, E17, E21,
E22
- S3, S5, S6, S8, S9, S14
- T1, T3, T4, T6 , T7, T12, T13
|
Low impact and uncertainty:
|
High uncertainty:
|
To be ranked by Importance & Uncertainty, Political, Economic is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics. ,
Socio-Cultural and Technology factors in 2013 are:
- P1: Deregulation
- P2: Globalization and extended phenotypic
alignment. Disruption, low
cost and differentiation implications. Power shifts to the
rich and the separated militias.
- P3: GATT and regional trade deals
- P4: Anti-trust - Microsoft, IBM &
AT&T
- P5: Intellectual property rights
- P6: Euro
- P7: China successfully
pairing communist government with Free Capital 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.
(Making the
world safe for markets - HBR volume 81 no 8)
- P8: (2002) Terrorism & Ethnic/religious
factional wars
- P9: 8 Billion people increasingly in cities
implies more demand for resources such as hospital beds
- P10: US democracy log jam keeps strategies
short term
- P11: US Democrats gain increasing control
from demographic shifts
- P12: 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.
and Affordable Care Act 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.
rules and incentives - resulting in: Deceleration in health
spending forcing providers to eliminate costs (Oct
2015), Provider partnering with health plans (Vivity).
- P13: Processed
food industry's dependence on sugar:
- Promotes distortions (Aug
2015),
- Promotes protection (Oct
2015, Mar
2016),
- Harvard
school
of public health/D.O.A. - U.S. Department of Agriculture.
academics were
financed clandestinely by the sugar
association to shift blame for 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). from sugar
to fat in the 1960s (Sep
2016)
- Results in enhancement of political evolved amplifiers -
Youth 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).
-> diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections.
(Mar
2016) -> 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).
bulge
- E1:
Positive
return infrastructure build out
- E2: Transaction cost economics is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics.
and the
shift from M-form to E-form business
- E3: Swarms & Communities
- E4: Financial measurement system and stock
assessment
- E5: Friction free electronic business economics is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics.
- E6: Disaggregation/rationalization of
vertical/horizontal integrated firms
- E7: Low skilled unemployed can't compete
with computers, robots,
and lower cost offshore strategies (4.3 million jobs lost for
high-school graduates & less qualified)
- E8: Malthusian down cycle promotes income
inequality
- E9: Not enough skilled IT people (3.1
million new jobs for college graduates)
- E10: Global business cycles
- E11: China as the economic is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics.
challenger of 2013
- E12: Tragedy
of the commons reflects the lack of incentive for individuals to cooperate to sustain a common good when there is no immediate disincentive, even when over time the result will be collapse of the resource base sustaining the group. Josh Greene notes the issue is how to jump-start and maintain cooperation. Sapolsky notes evolution has solved this problem by leveraging bootstrapping processes and helping groups to discourage individuals being selfish. Institutions: religion, nationalism, ethnic pride, team spirit; provide green-beard markers to support this process.
- Internet, Forests, Fish, ....
- E13: Oil sourcing food for 8 Billion
supported by US farm
bill is the US federal government's main agricultural and food policy tool. It is legislated as an omnibus bill affecting: international trade, the environment, food safety and supporting rural communities across the US; which must be renewed every 5 years, shaping the powers of the US DOA.
- E14: Internet 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.
- growth
& taxation
- E15: Pressure on low growth aspects of
enterprises
- E16: Aging of US population creates
chronic health care bulge
- E17: Human energy capture still dependent
on carbon (traditional + fracturing and horizontal drilling)
rather than wind, solar, nuclear; or carbon
sequestration.
- E18: Infrastructure investment leverage
constrained by debt reduction.
- E19: Retirement of 80% of US nurses - all
aged > 55 years
- E20: 25,000 shortage 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.
in 2020: (Nov
2016).
- E21: Will the collapse of weak hospital
systems (Oct
2015) strengthen the most powerful
- E22: Scale of employer shift of workers
health care coverage to health exchanges (Trader Joe's)
and its consequent impact on pricing, 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.
...
- E23: 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.
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);
introduce pricing pressure on providers
- E24: Payers 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.
increase
power forcing shift away from 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. , leverage RAC is recovery audit contractor program created by the MMA of 2003. It is intended to identify and recover invalid FFS Medicare claims payments. which both increase
provider risk and narrowing
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).
.
- E25: 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. remains dominant
until atleast 2020
- S1: Cyber communities
- S2: Market to one but sell to the whole
world (Getting real about virtual commerce -HBR volume 77 no 6)
- S3: Hierarchies and evolutionary
psychology asserts that human culture reflects adaptations that developed during human's long hunter-gatherer past, living on the African savanna. Its implications are described in The Adapted Mind. Subsequent studies of the effects of selection on the human genome show significant changes due to our more recent history as well.
- S4: Open source
- S5: 80 year down cycle (1980 - 2050)
- S6: Environmental stress removes glaciation
and mountain snowpack directly generating floods and lack of
water and indirectly expanding conflict
- S7: US Job skills training not focused on
transforming the unskilled while Germany use government funding
to support apprenticeships into differentiated industry
- S8: Ineffective population health care -
How fast will 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.
evolve? It needs effective incentives, analytics, and new
management, legal contracts applicable to populations
- S9: Hot spots in US population have outsize
costs complicated by housing issues, substance abuse, legal
problems, language barriers, education level and lack of contact
with 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.
.
- S10: Accountable care 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.
pushes 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.
onto providers, payers 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.
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.
- S11: Taylorism or scientific management was advocated by Fredrick Taylor. He viewed operatives as machines that were to follow precise instructions optimized by designers. Deming followers such as Toyota rejected this approach and improved quality and cost management by training the operatives and treating them as skilled 'agents' who were key to detecting problems and improving the processes they participated in.
fights
Florence
Nightingale
- S12: Stock option and venture capital is venture capital, venture companies invest in startups with intangable assets
rewards
- S13: Death decoupled from treatment
- S14: Consumer empowerment's impact on
health care and its 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.;
needs
- T1: Computerized brain which can talk
- T2: Global Network (Data, Flight, Disease,
Food, Energy, Finance: Circuit, Packet)
- T3: Standards
- T4: Genetically engineered crops with
insecticides, herbicides ingested by the food chain (Sep
2015, Oct
2015)
- T5: Data > Voice
- T6: Modularity fails when merge systems with
disjoint design rules
- T7: Complexity of growing set of scientific
data
- T8: Appliances
- T9: Moore's law, Gordon Moore characterized the two yearly doubling of the number of transistors in each new generation of integrated circuit.
at > 64
doublings (May
2016, Oct
2016)
- T10: Cloud
- T11: Immune system leverage in
medicine
- T12: Effective Process management
infrastructure for health care
- T13: Interoperable 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!
infrastructure
deployed and operational across the health care continuum and
relative power of mediation
- T14: Epic
and Cerner will
increase market share, increasing their influence on 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.;
- T15: Antibiotic
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%.
superbugs (May
2015) undermine health care processes, such as surgery and
inpatient care which depend 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).
A SWOT is used to derive the execution clusters.
2013 SWOT
Analysis
- The legislative rule changes and executive action creates
opportunities for new business strategy
Strengths:
- 1: <strength>
- 2: <strength>
- 3: <strength>
- 4: <strength>
- 5: <strength>
|
Weaknesses
|
Opportunities:
- 1: Hospital readmissions
reductions program 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)
evolved
amplifier driving effective integration of acute
care hospitals and post-acute care facilities.
- 2: Optimization of resources
required for efficiently executing operational
plans.
- 3: Well-designed checklists
support expertise during chaotic episodes.
- 4: Nano technology and
proteomics may improve sensors specificity and
association with mechanism of disease.
- 5: Often an inverse relationship
between cost of acute care and quality of that care
- 6: Widely variable outcomes in
acute care not explained by severity stratification
- 7: Geographic differences in the
frequency of acute care
- 8: 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.
power shift to
payer narrow networks forcing consolidation of
hospital systems.
- 9: A la carte payment for acute
services
- 10: Shift to 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.
requires
enhanced IOP is: - Interoperability. ONC offers a vision. Interoperability providers aim to integrate all the HCIT.
- Intraocular pressure
.
- 11: Incomplete communication
across the continuum of care
- 12: Shift to 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.
- 13: Chronic disease treatment
- 14: 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
- 15: <opportunity>VA - Department of Veterans Affairs. Includes the Veterans Health Administration.
- 16: 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.
shift to
employment
- 17: 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.
shift to 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. increases focus
on costs
- 18: 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.
shift to 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. increases focus
on provider utilization
- 19: Payer power drives 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.
.
- 20: BPCI bundled payments for care improvements is a CMS initiative to explore bundled payments. Its purpose is to incent multiple types of provider to coordinate care reducing expenses associated with care episodes. CMMI accepts providers' proposals to test the four different bundled payment models. The program consists of:
- Seeking voluntary participation in four bundled payments models.
- Model 1: 3 days pre-acute + hospital inpatient stay.
- Model 2: 3 days pre-acute + hospital inpatient stay + inpatient MD services + post-acute facility services + post-acute MD services + related readmissions.
- Model 3: Post-acute facility services + post-acute MD services + related readmissions.
- Models 1 - 3 provide retrospective reimbursement.
- Models 2 - 3 include post episode reconciliation.
- Model 4: 3 days pre-acute + hospital inpatient stay + inpatient MD services + related readmissions.
- Model 4 offers a single prospective payment.
- Acute care hospitals, physicians groups, health systems eligible for all models; post-acute facilities may participate without hospitals in Model 3.
- Physicians eligible for gain sharing bonuses up to 50% of traditional fee schedule.
- For all models, applicants must propose quality measures, which CMS will use to develop a set of standardized metrics.
- 21: Unreliable compliance with
evidence-based guidelines
- 22: 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.
integration
with health plans is too costly.
|
Threats
- 1: <threat>
- 2: Placing a menu hierarchy
between a doctor and patient reduces efficiency and
humanity.
- 3: Placing a menu hierarchy
between a doctor and patient can replace expertise and
intuition with cumbersome representations of standard
operating procedures and searches of
alternatives.
- 4: Classical symptoms map to a
variety of actual causes of disease.
- 5: <threat>
- 6: <threat>
- 7: <threat>
|
A Porter power analysis of the health care industry demonstrates
the concentration of power within the government,
and capital
markets:
Porter value delivery system relations
A significant aspect of the development of the industry is the
relationship of the various components of the US health care value
delivery system (VDS).
- Porter Power
Relationships
- Biotech
- Physicians - Porter Research 2012
suggests that survey respondents see 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 as an effective
power grab by Hospitals.
- 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.
- 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)
- 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 have low margins, political power and connections
and are large employers. There is increased competition
among providers. The pressure to integrate brings
financial uncertainty (Advocate,
Essence)
and implementation and operational 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 also
revenue, power (Mar
2013, Jan
2013, Jul
2014) and reimbursement opportunities. Hospitalists are internists based at a hospital, where they handle the care of all the patients on site. It's a recently created role developed in response to the economic pressure of managed care in the mid-1990s. Formerly doctors saw patients at the hospital in the morning before heading to the office for the next eight hours. Internists would go to a hospital if one of their patients needed them. Dr. Diane Craig argued it would be better for dedicated physicians to be available to care for hospital patients throughout the day. And hospitalists were initially very profitable for hospitals. Even though the hospitals had the additional cost of their salaries the hospitalists were able to discharge patients as soon as possible emptying beds that could be used to get more revenue. But hospitalists' Medicare treatment reimbursements are typically less than the hospital must pay them. This is the opposite of the situation with surgeons. Hospitalists are responsible for maintaining accurate metrics on their patients: readmission rates, HAI. As of 2015 there are 50,000 hospitalists. ,
under pressure from hospitals to outsource, move to unionize
at Sacred Heart (Jan 2016). Privately owned chains
have better access to 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). and
should see integration as an opportunity to leverage this
benefit. In a declining 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.
environment hospitals are likely to focus on core competences
and choose to outsource RCM is either: - Restrictive cardiomyopathy, a rare disease where scar tissue makes the heart muscle rigid and reduces the efficiency. Or
- Revenue Cycle Management aligns treatment with reimbursement. Customer service will be involved. IT will architect the core billing, decision support and ad-hoc services, constructed by RCM vendors, into systems to support RCM. The Hospital's central business office will aim to maximize cash recoveries. As per Deming, mistakes in the RCM pipeline result in rework and lost cash flow and revenue of between 4 - 12%. The staff must be trained and fully engaged in the design and operation of the pipeline. The front end processes are best placed to capture all the information needed to make the cycle successful. The activities include:
- Scheduling and Appointments - where visits and procedures are booked and demographic and insurance information is collected. If this information is incorrect it is likely the claims will not forward to third party payers. When resources and their states are accurately known an optimal set of plans can be constructed to efficiently and effectively flow patients through the system. But that is difficult to guarantee because of a number of interrelated problems:
- Scale - as the number of resources increases the ability of a central scheduling system to represent all of them accurately and reliably becomes impossible.
- Ubiquity - a CAS strategy for ensuring availability is to have an over-abundance of equivalent resource that can be used for schedule allocation. But often these resource levels are set by local decision makers who all respond at about the same time to imposed funding changes. The effect is to suddenly and unpredictably undermine the guarantee of over-abundance. Sometimes the assumption of equivalence also fails as in the desire of a patient to see only a specific surgeon.
- Changes can ripple through the plans requiring coordination meetings and notifications or guaranteed receipt of status updates.
- Verification checks for:
- Referral - Is there PCP authorization? Is the PCP referred service covered by the patient's plan,
- Authorization - obtain Insurance authorization if required, and
- Pre-certification - is there 'need' for inpatient care or other care before admission by the MCO. Otherwise could introduce problems including not obtaining/verifying the insurance name, number and eligibility, not securing pre-certification and pre-authorization with time limits, not copying the insurance card, not checking for secondary coverage, not detecting expired referral or authorization,
- Pre-registration - provide advice about their financial obligations and what documents to bring to the procedure. If there is a copay or an outstanding payment to be paid these should be processed,
- Registration - some patients are scheduled outside of the main admitting process (by OP clinic or E.D.) and this must be detected and the scheduling verification and pre-registration process be performed,
- Time of service payments - co pays and self pays,
- Coding - identify diagnosis (ICD 9 -> ICD-10 codes) and treatment (CPT) activities and charges for the episode. More than 80% of hospital cases are coded in error.
- Demographics and billing data entry - enter charges and adjust capitated charges,
- Patient statements - submit primary and secondary claims (following HIPAA formats) with or without involvement of a clearinghouse, produce patient statements including time of service, outstanding balance, charged amount with codes, insurance details, forms used (UB 92/04 and HCFA 1500). A paper based claims filing has a rejection rate of 30%. Duplicate claim payment rates of 1 - 2% of medical expenses are common. Duplicate claims detection is often not part of the process. Payer's goals are in conflict with Provider goals.
- Collections and payment posting - Post all payments and adjustments and deposit money into the bank,
- Denials and appeals - resubmission and appeal of claims, denial analysis and bad debts and write offs. To reduce denial rates and appeals the reimbursement contracts payer processes and actual denials must be analyzed and understood.
- Account follow up - Patient inquiries, resubmission of claims and issue refunds.
- Financial counseling;
operations to save costs and enhance collection. This
trend should be increased as 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.
, 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.
, value-based
purchasing Value-Based Purchasing is a Medicare program which predefines process and outcome performance measures and then rewards or punishes hospitals through payment adjustments based on their performance. Its purpose is to create a material link between reimbursement and clinical quality and patient satisfaction scores. CMMI is dedicating $500M to Partnership for Patients, targeting HAC readmissions. It is part of a broad push towards pay-for-performance. - Phase 1 2012 - 2014 focuses on quality.
- Phase 2 2014 - 2020 focuses on efficiency.
and ICD-10 is the 2009 iteration of the ICD. ICD is mainly focused on billing. ICD-10 allows for greater specificity which is assumed to translate into lower rejection rates, easier audit compliance, and better data mining. ICD is seen as less rich as a representation for clinical record keeping than SNOMED-CT which becomes a concern if the EHR standards force ICD-9 codes to be the required but insufficient representation of a medical procedure.
code conversions become the focus of IT and these programs
place additional requirements on RCM. ICD-10 has imposed
considerable extra processing in Canada where the conversion
occurred in 2002.
- 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.
- Commercial insurers protected by ERISA is the Employee Retirement Income Security Act of 1974 signed by President Ford. It regulated both pension and health benefit plans once an employer had established one. It setup the PBGC to support voluntary private defined benefit pension plans. Where self-funded health plans under ERISA are exempt from a state's insurance regulation there will be no solvency or consumer protection in place to support providers that do business with ERISA plans. States may consequently require provider networks that do business with employer self-insured ERISA plans be licensed as an insurance company (an HMO, medical insurance plan, preferred provider arrangement or general casualty insurer). ERISA section 404(a)(1)(B) defines the prudent person rule associating prudence with portfolio theory allowing pension funds to invest in stocks (index funds). The labor department's interpretation of an ERISA employer has been modified to support President Trump's executive order to enable more use of AHPs (Jan 2018).
and with
only yearly contracts with their customers are motivated to
maximize their short term financial benefit, rather than the
long term wellbeing indicates the state of an organism is within homeostatic balance. It is described by Angus Deaton as all the things that are good for a person: - Material wellbeing includes income and wealth and its measures: GDP, personal income and consumption. It can be traded for goods and services which recapture time. Material wellbeing depends on investments in:
- Infrastructure
- Physical
- Property rights, contracts and dispute resolution
- People and their education
- Capturing of basic knowledge via science.
- Engineering to turn science into goods and services and then continuously improve them.
- Physical and psychological wellbeing are represented by health and happiness; and education and the ability to participate in civil society through democracy and the rule of law. University of Wisconsin's Ryff focuses on Aristotle's flourishing. Life expectancy as a measure of population health, highly weights reductions in child mortality.
of the insured patient. By encouraging the use of low
cost treatments with side effects rather than more expensive
treatments without these same issues additional conditions
can be induced in the patient population which complicate
the treatment and increase overall cost.
- Large commercial insurers responded to 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.
with plans to
merge (Jun
2015) but the Attorney General moved to block the
mergers on anti-trust grounds (Jul
2016).
- CMS is the centers for Medicare and Medicaid services. with its
long term relationships with providers and their patients is
using its position and power to:
- Drive sensors (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!
)
into the provider
networks is the owned health system and its extended network of partners. and shift uncertainty onto the providers
through 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.
.
- Increase state insurance plan competition by supporting the
startup costs of non-profit co-op insurers. Nov
2015 over half of these co-ops have failed.
- Judges agree with hospitals that 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.
locked in
errors in 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
levels, reducing 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.
for hospitals: Saint
Francis Medical Center, joined by 276 others; due to
associated models for the average
cost per discharge assessment (Jul
2018)
- Employers continue
to fund health care but their workers pay a bigger
share (Sep
2016)
- CalPERS
sets caps
on prices of commodity operations and provides 2013
list of hospitals which have agreed to the cap.
- CalPERS
drives prices for elective surgery down in California (Aug
2016).
- Patients
- Patients select hospitals based on 'patient experience'
assessments provided by their trusted social networks (Aug
2016).
- Bad debt from non-payment is expected to crest at 11% of
revenue in 2013 and then reducing due to 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.
.
- Dec 2013 The enrollment of young adults for health
insurance appears to be lagging behind the expectations of
federal officials and insurers. Obama administration
delays in implementaton of the ACA provisions sent a mixed
message to consumers about the significance of the Dec 22
2013 signup deadline. CMS is the centers for Medicare and Medicaid services. said the agency
was adding staff, training and outreach to encourage
consumers to beat the deadline. Officials said there
had been a surge in use of the ACA web site. The
enrollment period continues through to March 31. The
administration is encouraging insurers to accept payments
that are submitted by Jan 10th 2014.
- Benefits of breast-feeding is a mammalian adaptation which delivers breast milk to the infant and supports the mother's body in its transformation after birth. It is known to reduce the risk of: breast cancer: BRCA1, triple negative tumors; ovarian cancer, type 2 diabetes, rheumatoid arthritis; and may reduce the risk of cardiovascular disease.
could reach more mothers & children with expanded
maternity leave (Dec
2015).
- New cases of 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
,
in better educated, starts to trend down (Dec
2015).
- 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.
expanded to treat pre-diabetes is a condition where the subject's blood sugar levels are higher than normal but they are not yet suffering from irreversible type 2 diabetes. In 2016 the CDC estimates 86 million adults, including at least 22 million people 65 or older, are pre-diabetic increasing their risk of heart disease, stroke and diabetes. Doctors test for pre-diabetes with a blood test: FPG, OGTT, A1C; with fasting required in the first two. Pre-diabetes is treatable but only about 10 percent with the condition are aware they have it. Left untreated, up to one-third of people with pre-diabetes will develop diabetes within five years. The YMCA developed a pre-diabetes treatment program. People can use a test devised by the CDC to assess their risk of pre-diabetes.
(Mar
2016).
- New technology and new entrants
- The transformation of the health care financial sub-network
from banks
to 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.
is undermining the quality of health care:
- Emergency services can't be trusted or depended on (Jun
2016).
- 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.
is buying up high profit dermatology is the branch of medicine dealing with skin, hair, nails and their diseases. Dermatology includes cosmetic and medical branches including pathology. Mohs surgery focuses on skin cancer. Tele medicine is allowing non-dermatologists to send details of a patient to an off-site dermatologist.
practices: Advanced
Dermatology and Cosmetic Surgery, Schweiger
Dermatology, United
Skin Specialists. A peer reviewed paper describing
the purchase of high throughput, and high billing, practices,
that generate significant profit, was removed from the AAD is the American academy of Dermatology. website after
powerful dermatologists linked to private equity complained (Oct
2018)
- Regulation and the courts:
- CMS is the centers for Medicare and Medicaid services. has finalized
2012 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.
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').
Program rules for 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. The final
version of these rules is less burdensome on providers.
The finalized rules weight 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.
more highly than any other measure for quality-scoring
purposes.
- CMS is the centers for Medicare and Medicaid services. has finalized
2006 PAHPA is pandemic and all hazards preparedness act of 2006, which resulted in the creation of the office of the ASPR. / 2013 PAHPRA is the 2013 reauthorization act for PAHPA. disaster
preparedness rules for ASPR is assistant secretary for preparedness and response . The final
version of these rules is less burdensome on
providers.
- Judges agree with hospitals that 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.
locked in
errors in 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
levels, reducing 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.
for hospitals: Saint
Francis Medical Center, joined by 276 others; due to
associated models for the average
cost per discharge assessment (Jul
2018)
- Malpractice liability risk
obscures medical errors and their restriction and
removal from the healthcare system. Reform of
malpractice policy can save money and enhance process
visibility.
- Supreme Court gives FTC - 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.
the power to block hospital mergers Feb 2013. But judge
disallows block on Illinois's NorthShore
& Advocate
(Jun
2016).
- Republican 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. Saposky observes the disconnect between power hierarchies and wisdom in apes. John Adair developed a modern leadership methodology based on the three-circles model.
keen to reduce and restructure 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.
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. .
They see opportunity to do so in long term US is the United States of America. debt negotiations. Hospitals
are the target of some of these planned cuts, as well as 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 Fiscal cliff
legislated cuts. Non-profit and 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);
will be impacted by reductions in GME is graduate medical education funding.
- Court strikes down Obama administration rule on allowable
health insurance policies (Jul
2016).
- Judicial bias
- Harvard
law school's
Alma Cohen & Crystal Yang's study found black Americans get
longer sentences from Republican appointed judges (May
2018)
- State health strategies
- Democratic implementing Medicaid under 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.
.
- In New York where the hospitals are funded by the state
but struggling hospitals serve the city, politically
significant developments include:
- Republican not implementing Medicaid under ACA, but some
pressure from Governors to change position.
- CMS is the centers for Medicare and Medicaid services. administrator
Verma enforces 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.
legislation, blocking Idaho's plan to allow the sale of
stripped-down health insurance (Mar
2018).
- Senate introduces CSI act of 2013 to strengthen toxic
chemical regulation (TSC is the Toxic Substances Control Act of 1976 which governs the regulation of chemicals used in consumer products and manufacturing processes. It was updated in 2016 and signed into law by President Obama. But it still mainly reflects the needs of the chemical industry (Jul 2016). ).
- F.D.A. Food and Drug Administration. does not
certify end-to-end.
- S.E.C. is the Securities and Exchange Commission. It was provided with power to regulate the securities industry by the Securities act and Securities Exchange act. moves against
corporate inversions allows a U.S. company to move its tax domicile overseas by purchasing a foreign company. In 2015 the U.S. Treasury department adjusted the inversion rules to require 40% of the combined company is owned by the shareholders of the purchased foreign entity. In Apr 2016 they clamped down on the option to serially acquire American companies. In section 7874 of the tax code, Congress defined statutory hurdles that must be cleared to gain tax benefits: Shareholders of foreign acquirers owning less than 20% of the combined entity the inversion fails, If less than 40% and the acquirer does substantial business in the foreign jurisdiction the inversion works but with some pain, If they own more than 40% there are few negative consequences. Companies purchased serially within three years would be disregarded by the new rules. Companies invert because of lower foreign tax rates and earnings stripping. Once foreign, the parent loans the US subsidiary money. The loan repayments offset the US income and the US tax bill is vastly reduced.
(Nov
2015). Treasury is the department of the treasury. It is a federal government executive department created by Act of Congress in 1789 to manage government revenue. The Secretary of the Treasury is a Cabinet officer. With monetary policy devolved to the Federal Reserve, treasury manages fiscal policy. To support funding of high cost investments: Disaster recovery, Wars, Famines; the treasury can issue debt instruments and manage the national debt.
& IRS is the Internal Revenue Service. add rules (Apr
2016).
- S.E.C. is the Securities and Exchange Commission. It was provided with power to regulate the securities industry by the Securities act and Securities Exchange act. continues to
nominally fine 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 for short changing investors (Aug
2016).
-
In September 2016 the S.E.C. is the Securities and Exchange Commission. It was provided with power to regulate the securities industry by the Securities act and Securities Exchange act.
charged Cooperman and Omega with
insider trading. Cooperman denied the charges.
- S.E.C. is the Securities and Exchange Commission. It was provided with power to regulate the securities industry by the Securities act and Securities Exchange act. prosecutes
major 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.
Och-Ziff (Sep
2016).
- GE
results mixed: Power generation still a problem, $121 billion
debt to finance - so plans to cut it by $50 billion selling
assets: rail locomotive, oil field equipment, health care; GE
capital aviation services not for sale, jet engines sold well,
WMC sub-prime mortgage issues settled with DOJ - U.S. Department of Justice. with $1.5 billion
penalty. GE
Capital, still being investigated by S.E.C. is the Securities and Exchange Commission. It was provided with power to regulate the securities industry by the Securities act and Securities Exchange act. , set aside $15
billion reserves for higher
costs to reinsuring long-term
care policies at GE Capital (Feb
2019)
- Dodd-Frank is the 2010 Dodd-Frank Wall Street Reform and Consumer Protection Act. Its titles include:
- Financial Stability creates the FSOC and OFR.
- Orderly Liquidation Authority
- Section 619 is the Volcker Rule: prohibitions on proprietary trading and certain relationships.
- Transfer of Powers to the Comptroller, the FDIC, and the Fed
- Regulation of Advisers to Hedge Funds and Others - which updated the powers of the Investment Company Act.
- Insurance
- Improvements to Regulation
- Wall Street Transparency and Accountability
- Payment, Clearing and Settlement Supervision
- Investor Protections and Improvements to the Regulation of Securities
- Bureau of Consumer Financial Protection
- Federal Reserve System Provisions
- Improving Access to Mainstream Financial Institutions
- Pay It Back Act
- Mortgage Reform and Anti-Predatory Lending Act
- Miscellaneous Provisions
- Section 1256 Contracts
process (FSOC is the Financial Stability Oversight Council. It was created by Title I of Dodd Frank, with Treasury Secretary as chair, to: - Facilitate communication among regulators
- Identify and monitor excessive risks to the U.S. financial system from the failure of large companies. It can promote market discipline by eliminating expectations that the Government will shield losses. It can also respond to emerging threats.
- It can set aside certain financial regulations published by the CFPB it those rules threaten financial stability.
) for
constraining systemically
important is a Dodd-Frank financial reform act designation for the largest companies which would have a catastrophic impact on the global financial system and can not be allowed to fail. non-financial companies weakened by courts (Apr
2016).
- Financial regulations: Europe, US; are weak and getting weaker
takeover of Banco Popular by Banko Santander shows (Jun
2017)
- Northern District of Ohio Judge Dan Polster's opioid MDL is multidistrict litigation, where many legal cases are consolidated to improve efficiency & reduce costs.
has multiple types
of defendent: Pharmaceutical companies: Purdue Pharma,
J&J,
and others; Distributors: McKesson, Cardinal Health;
Pharmacy chains: Walgreens,
CVS Health; and includes
a DOJ - U.S. Department of Justice. statement of
interest (Mar
2018)
Amplifiers
Amplifiers significantly shape the
health care industry.
Evolved
amplifiers support high margins in US is the United States of America. health care. They
promote the selection of expensive treatments, price opacity, and
cost management constraints.
The screening, diagnosis and treatment of colorectal 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.
provide an illustrative case. Patients with little impact from
prices are encouraged to get screened. CMS is the centers for Medicare and Medicaid services. 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.
price
controls, and lobbying by medical guilds, supported by the risk
of litigation encourages the amplifying development of fat
margins for overelaborate procedures that benefit all the
participants financed from taxes and insurance fees.
The screening
decision has become important to Americans and shaped by
powerful actors:
- The ACG is the American College of Gastroenterology. promotes
colonoscopy as the 'preferred strategy'.
- It's a medical necessity:
- The colonoscopy procedure has been mandated by Congress,
after lobbying by gastroenterologists, as medically necessary,
so it cannot be refused by 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. or
other insurers.
Price not a constraint:
- It's typically not available prior to the operation.
With insurance or equivalent the price is often unrelated to the
amount directly paid by the patient.
- Comparative pricing is compiled by the international
federation of health plans. US was most costly in
all 21 categories often by a huge margin.
- Pricing is driven by:
- Hospital business plans maximizing revenue. Medicare
part B payment to hospitals and doctors may be adjusted to
constrain increasing prescription drug costs (Mar
2016).
- Agreements between hospitals and insurers. Insurers
may pass along price increases indirectly as rate hikes to
health plans. Healthcare
Blue Book tracks this.
- Lobbying,
- Focus of specialists in treatment turf battles.
- 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.
and
Medicaid pricing
mechanism.
Screening process
via colonoscopy enables high charges. In approving the
sedative Propofol is an intravenous sedative that takes effect quickly and wears off within minutes. When Propofol won the approval of the FDA in 1989 as an anesthesia drug, it carried a label advising that it "should be administered only by those who are trained in the administration of general anesthesia" because of concerns that too high a dose could depress breathing and blood pressure to a point of requiring resuscitation.
the FDA Food and Drug Administration. advised it should
only be administered by a trained anesthesiologist is a physician who has completed an accredited residency program in anesthesiology and is trained in anesthesia and perioperative medicine. .
With lobbying from the American
Society of Anesthesiologists the FDA has so far declined to
rescind the advisory for low doses required for sedation is the inducement of a relaxed state with a Valium-like drug (a benzodiazepine) or a low dose of Propofol. In most countries sedative mixes are administered in offices and hospitals by a wide range of doctor and nurses unlike general anesthesia which typically requires a specialist. Sedation in traumatic situations such as are typical in ICUs has been correlated with subsequent PTSD. . In
2007 Aetna tried to
disallow payments for anesthesiologists delivering Propofol for
colonoscopy sedation but backed off after heavy criticism from
anesthesiologists and endoscopy groups.
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.
:
- Billed at $4,000 - $20,000. It may be fully covered by
some health plans, while other plans use 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);
to
discourage 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.
.
- In other countries the basic colonoscopy costs $400 - $800
including biopsies and sedation.
Long term learning:
- Many patients forgo necessary treatments due to high
out-of-pocket expenses. This has the effect of undermining
preventative care strategies (which
may not help with cost constraints anyway), while
potentially inducing complex problems later in life that are
well suited to general hospital diagnosis and treatment.
Amplifiers that will allow <name
of health care provider>'s business to ramp faster than its
competition include <amplifier list>.
.
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