Analysis frame

Analysis Frame

Summary

In this page we introduce the analysis covered in the frame.  The idea of the structure is to allow the linking of detailed observations, described in the PEST is: Politics, Economics, Sociology-Culture, Technology; signals and actions, complex adaptive effects on the business environment. 
is: Politics, Economics, Sociology-Culture, Technology; signals and actions, complex adaptive effects on the business environment. 
and current business situation, about the operation of the health care network into increasingly high level and abstract assessments of the situation.  This allows the reader to follow either thematic top down trends or to use the proximity of various detailed observations to look for alternative causal associations. 

The analysis associates trends in the environment including: Emergent forces focused by the state and federal governments, new technologies, regulation, the impact of the 2008 financial crisis, an aging population; with the evolution of the US health care market. 

Key influences within the health care network are highlighted. 

Both power and Longview analysis are discussed. 

Amplifiers are reviewed. 


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:

This leads to all health care providers having to solve a strategic dilemma.  Do they:
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 policies of FDR is President Franklin Delano Roosevelt.  He is notable for his contributions to the US CAS:
  • New Deal strategies including:
    • SSA
    • FFDCA 
    • IRC
  • 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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • 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.  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, Joint damage from over-exercise;
  • Research, monitoring and control of disease agents, processes and vectors by agencies including the CDC. 
  • Monitoring of the public's health by institutes including the NIH.  
  • Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.  
  • Development, deployment and maintenance of vaccination strategies. 
  • 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.  .  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:
  1. Financial Stability creates the FSOC and OFR. 
  2. Orderly Liquidation Authority
    • Section 619 is the Volcker Rule: prohibitions on proprietary trading and certain relationships. 
  3. Transfer of Powers to the Comptroller, the FDIC, and the Fed
  4. Regulation of Advisers to Hedge Funds and Others - which updated the powers of the Investment Company Act. 
  5. Insurance
  6. Improvements to Regulation
  7. Wall Street Transparency and Accountability
  8. Payment, Clearing and Settlement Supervision
  9. Investor Protections and Improvements to the Regulation of Securities
  10. Bureau of Consumer Financial Protection
  11. Federal Reserve System Provisions
  12. Improving Access to Mainstream Financial Institutions
  13. Pay It Back Act
  14. Mortgage Reform and Anti-Predatory Lending Act
  15. Miscellaneous Provisions
  16. 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 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). 

This system has unleashed powerful emergent forces including: Concentrating wealth in private equity 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.  Recent successes include: HPV vaccine.  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).  
    • Where clinics have been driven into local neighborhoods health improves (Apr 2016).  
    • Retail clinics (Mar 2016): CVS Minute Clinics focus on vaccination.  
  • Key vaccines include: BCG, C. difficile (May 2015), Cholera (El Tor), Dengvaxia (Mexico Dec 2015), Gvax, Malaria vaccine, Provenge;
  • 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);  
    • Coding : CVX, MVX;
  • 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; and issues: such as Chronic diseases, Epidemics is the rapid spread of infectious disease: AIDS (Oct 2016), Cholera (2010), Clostridium difficile (May 2015), Ebola, Influenza, Polio, SARS, Tuberculosis, Typhoid, 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), Powerful recessions (ECB Apr 2016), Expanding national debt driven by 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 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 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 effective, profitable but costly treatment 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 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 SCOTUS 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 patent-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. 
  • 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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • 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.  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.   incentives: ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Kaiser like business models (Dec 2015, Sep 2016) focused on wellness, and rewarding doctors for preventing problems.  Advocate health illustrates the idea.  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 programs 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, 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. 
s and health care networks. 

The Obama White House innovation strategy references a 2009 ITIF benchmark of international competitiveness. 

The USA is adapting to the loss of trillions of dollars in the 2008 financial crisis.  Among other impacts this undercut the wealth 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.  For more than twenty years healthcare has 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 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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
is designed to change that through two conflicting mechanisms:
  1. Expand health coverage to millions of Americans without insurance. 
  2. 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 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). 

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 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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
proceed:
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 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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
proceed:

The reduced wealth 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.  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.   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. 

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 a 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).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes 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.  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.  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 low FFS leverage of the PCP compared to specialists. 
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:

Waiting behind these diseases are the neuro-degenerative diseases as discussed by Stanley Prusiner which currently 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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • 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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • Premiums
    • Part A premium
    • Part B insurance premium
    • Part C & D premiums are set by the commercial insurer. 
(Apr 2016)




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, Joint damage from over-exercise;
  • Research, monitoring and control of disease agents, processes and vectors by agencies including the CDC. 
  • Monitoring of the public's health by institutes including the NIH.  
  • Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.  
  • Development, deployment and maintenance of vaccination strategies. 
  • 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. The logic of hot spots is reviewed by Atul Gawande. 
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.  The first 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 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 to 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 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.  Pain is the main reason people visit the ED in the US.   (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 amygdala increases in volume and is hyperactive.  As a result it remains in a heightened state, resulting in fear of recall and further stress.  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.   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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • 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:
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 health care architecture in which there is a single financing organization.  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 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 health care architecture in which there is a single financing organization.  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 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 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 (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 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 SCOTUS 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 patent-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. 
  • 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
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 are locked in to a yearly contracted revenue and payment streamIntermountain 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:
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:


Digital networks connecting patients to the health care network and each other.  Smart phones and appliances offering integration with cloud based applications allowing:

  • Collaboration,
  • Control,
  • Crowd sourcing, 
  • Modeling,
  • Sensing, 
  • Signalling;

Inhibition of digital data flow by:

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:

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 its drug prices and created MAC and RAC.  IT was sponsored by Senator Bill Tauzin and implemented by Tom Scully. 
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:
Limited support for integrating the trends into better practice - vision of EHR refers to electronic health records which are a synonym of EMR.  EHRs 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-patent setting. 
  • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  
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. 
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. 



PEST is: Politics, Economics, Sociology-Culture, Technology; signals and actions, complex adaptive effects on the business environment. 
ranking
High impact:
High impact and uncertainty:
Low impact and uncertainty:
High uncertainty:





To be ranked by Importance & Uncertainty, Political, Economic, Socio-Cultural and Technology factors in 2013 are:




A SWOT is used to derive the execution clusters. 


2013 SWOT Analysis
  1. 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
  • 1: <weakness>
  • 2: <weakness>
  • 3: <weakness>
  • 4: <weakness>
  • 5: <weakness>
  • 6: <weakness>
  • 7: <weakness>
  • 8: <weakness>
  • 9: <weakness>
  • 10: <weakness>
  • 11: <weakness>
  • 12: <weakness>
  • 13: <weakness>
  • 14: <weakness>
  • 15: <weakness>
  • 16: <weakness>
  • 17: <weakness>
  • 18: <weakness>
  • 19: <weakness>
  • 20: <weakness>
  • 21: <weakness>
  • 22: <weakness>
Opportunities: 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). 







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 colo-rectal 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.  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;  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: 
Price not a constraint: 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.  
:
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>.