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Economic situation
Summary
In this page we review the proximate economic situation.
Economic trends are discussed.
Introduction
Heath care markets are key aspects of the US economy.
Dramatic economic
shifts suggest major transformations of health care:
- New theories: Justify legislation
which may improve efficiency of the health care network or just
drive power to the major nodes;
- 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 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. acts are:
- Pushing power to the major nodes in the network. High
entry barriers to health
insurance exchanges have limited growth of co-ops.
- ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
funding
adjustments and state's: Georgia's; SCOTUS refusal of Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. expansion
threatening the hospital
safety net are hospitals which care for a financially challenged patient population. There are about 300 safety-net hospitals including: Grady memorial, Harris Health, Mcleod; in the US providing longer term care to the poor and indigent than regular for-profit and non-profit acute care hospitals. This arrangement allows the other hospitals to focus on the needs of their insured customers. Once acute treatment of a life-threatening illness, which will be funded by Emergency Medicaid, has completed, longer term treatment depends on the support of a safety net hospital. This dependency is being undermined by HRRP (Dec 2018). : Grady
Memorial (Aug
2016)
- Molina
Healthcare ousts Molina brothers (CEO/CFO) amid losses
from ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
individual
markets (May 2017).
- Penn's
Daniel
Polsky argues 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).
can improve value & price of premiums for policy holders if
reduce specialists but keep broad range 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. s (Oct
2016)
- Cloud technology:
- Pharmaceutical companies will: Provide the US with high level
control points in the global value chain and will gain legal and
pricing power. But at the same time tax havens and
political issues with high pricing are generating conflicts
between the companies and the politicians.
- Local and state 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.
- US municipal debt: Is transforming middle America into working
poor and undermining the funding of health care
infrastructure.
- Puerto Rico is only
the most high profile example (Jun
2016).
- It is being persued by 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.
(Oct 2015,
Nov
2015).
- Puerto Rico hurricane damage disrupts producers: AdvaMed,
Baxter,
J&J/Janssen, Mylan; medical supply
chain for 40 drugs: Humira, Xarelto,
methotrexate is a chemotherapy drug developed in 1947 and used to treat cancer: breast, leukemia, lung, lymphoma, osteosarcoma; suppress the immune system, and as a treatment for ectopic pregnancy. It is a W.H.O. essential medicine.
,
Tylenol, Prezista,
Baxter
small saline, including 13 sole-source; and AdvaMed
medical devices, produced by 10 companies, concerning F.D.A. Food and Drug Administration. 's Gottlieb
(Oct
2017)
- Puerto Rico collapse & exodus, impact housing, generate a
likely foreclosure crisis. Bottom-feeder: banks: Credit Suisse,
Goldman Sachs,
Perella Weinberg; 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.
, Private-equity:
Blackstone
affiliate Finance of America Reverse, TPG Capital
affiliate; snapped up the distressed mortgages. Many of
the mortgages are tax payer guaranteed (Dec
2017)
- UK's serial approach to solving the problems induced by BREXIT are enabling economic
collapse, a
scenario described by Dorner.
- Slumping UK is the United Kingdom of Great Britain and Northern Ireland. 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.
undermines
profits at government's outsourcing partners: Four Seasons,
Mears Group, Capita, Carillion; resulting in collapse of
Carillion and encouraging owners: 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.
Terra
Firma, 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. H/2
Capital Partners; to push the 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 the government
(Feb
2018)
- China is also
building a huge debt burden (Oct
2016). As currency leaves China, it acts to block
overseas transactions (Nov
2016).
- US student loan debt:
- US is the United States of America. financial
services companies own majority of European housing debt
after EU is European Union, the 1992 Maastricht Council of Ministers meeting agreed evolution of the ECSC & CAP cartels to include:
- A single market across the members' countries supporting the transformation of the ECSC. It maintained the CAP transfers assisting French farmers.
- A fixed currency 'snake' that allowed the ECSC to operate, binding the deutschmark to the other currencies of participating members: a mini Bretton Woods exchange rate mechanism; that became a single currency, the euro, managed by an independent ECB (based on the independent German Bundesbank); but tax gathering was allocated to the states whose leaders control the Council of Ministers and no effective mechanism was provided to reallocate revenues. This has left Germany with an advantage supported by the aggregate valuation of the euro and not having to flow tax revenues to the weaker economies of the south.
fiscal
crisis:
- US is the United States of America. 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.
moving into infrastructure investments
- Blackstone
leverage Saudi sovereign 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. fund to
finance US is the United States of America.
infrastructure with a $20 billion cornerstone investment (May
2017)
- World Bank was setup as part of the Bretton Woods agreements, as the International Bank for Reconstruction and Development, to repair and reconstruct Europe after the Second World War and as the World Bank continues to provide reconstruction and development resources for projects in developing economies. It includes:
- International Finance Corporation
president Kim aims to transform the organization, to gain
leverage from Wall Street
and support from the US is the United States of America.
government. Coached by 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.
titans from: Apollo,
Carlyle (Jan
2018)
- Trade deals: can shape and control the dynamics of economic
flows.
- Financial
network:
- Healthcare
conferences (J.P.Morgan)
bridge policy and finance.
- 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.
leverage Mutual
fund investments in health care with big impacts.
Valeant
was a huge and profitable hedge fund strategy and then
collapsed undermining the credibility of these funds and angering is an emotion which protects a person who has been cheated by a supposed friend. When the exploitation of the altruism is discovered, Steven Pinker explains, the result is a drive for moralistic aggression to hurt the cheater. Anger is mostly experienced as a rapid wave that then quickly dissipates. When it is repressed, for example by a strong moral sense (superego), it can sustain, inducing long term stress. their
investors.
- Hedge fund opacity adds to lack of returns (May
2016) encouraging sovereign funds and other large
investors (CalPERS)
to seek lower cost transparent strategies: E.T.F. is exchange traded fund, which tracks stock and bond indexes, adhering to a set of financial rules. These methods can be used to track any financial market segment. They are transparent, and low cost to operate, and invest in. ETFs are priced during normal trading hours. But their performance is impacted when they are forced by changing conditions to sell assets at a loss. Selling of an ETF by one investor to another does not redeem the ETF's underlying investments, limiting the capital gains tax distribution (Jul 2018).
s.
Outflows reach highest level since 2009 (Oct
2016). Pressure has major funds closing out: Perry (Sep
2016); and investment banks under pressure: Deutsche (Sep
2016, Dec
2016).
- High quality bond investments perform badly as
the Fed rate increases. Companies, locked in low
interest rates by issuing high quality bonds, leaving investors
with long term bonds that perform badly as interest rates
increase. E.T.F. is exchange traded fund, which tracks stock and bond indexes, adhering to a set of financial rules. These methods can be used to track any financial market segment. They are transparent, and low cost to operate, and invest in. ETFs are priced during normal trading hours. But their performance is impacted when they are forced by changing conditions to sell assets at a loss. Selling of an ETF by one investor to another does not redeem the ETF's underlying investments, limiting the capital gains tax distribution (Jul 2018).
s
of quality bonds will also suffer as these must sell bonds that
downgrade & no longer meet the E.T.F. specification, just
when the assets price has fallen. Active management is
less constrained & can hold the asset until it
appreciates. Corporations, like: CVS (Dec
2017), Bayer, General Mills;
that took on debt to acquire other companies, will see their
bond ratings fall, reflecting additional 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 if their
strategy is correct they will slowly improve their ratings,
offering investors: Dodge & Cox Income; a buying opportunity
(Jul
2018)
- Stock markets
- Only the top 200 public corporations make a profit - with the
top 5 making vast amounts; private companies allow no visibility
into what they are doing - although they reveal details 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.
investors; Company's asset values are far larger than
previously; lots of profit reflects non GAAP is generally accepted accounting principles. These are a framework of standards and procedures for compiling internationally equivalent financial statements. intellectual
property valuations; there are fewer publicly traded
corporations than previously (Aug
2018)
- Largest driver of tech stock bubble is tech stock repurchases,
leveraging tax reductions and capital repatriation. The
large technology companies are now on the sidelines because they
are reporting earnings, and can't trade, causing loss of
pressure in the bubble. ETF is exchange traded fund, which tracks stock and bond indexes, adhering to a set of financial rules. These methods can be used to track any financial market segment. They are transparent, and low cost to operate, and invest in. ETFs are priced during normal trading hours. But their performance is impacted when they are forced by changing conditions to sell assets at a loss. Selling of an ETF by one investor to another does not redeem the ETF's underlying investments, limiting the capital gains tax distribution (Jul 2018).
purchases are
second in volume but much smaller (Oct
2018)
- Healthcare is often used as a counter cyclical investment by
portfolio managers: Wellington Management (Vanguard Health Care
fund's manager) during downturns, because people still get sick
and injured during recessions. The ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
helped increase bed
and drug use; healthcare service spend increased 35% from 2010
to 2017, driving up the market value of commercial hospital
groups: HCA
- which has been expanding bed capacity; but that success helped
ensure performance of the health care sector has been relatively
poor recently. The ACA
unconstitutionality ruling, & health insurance
political shifts may also limit a counter cyclical investment
strategy (Jan
2019)
- With legislative help private equity
companies are replacing regulation constrained banks
with networks of their acquired operating companies to
finance, develop infrastructure and operate it. This
includes state and local government infrastructure: EMS is emergency medical services providing ambulance and critical care transport.
;
- VC Robert
Swanson and Herbert Boyer
bootstrap biotech with Genentech's 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.
- Old line companies add venture funds
and build start-up bubble (Apr
2016)
- Venture
funds financing increases, including jet.com (Wal-Mart), but Mutual funds
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.
hold back because VC funds are seen keeping weak start-ups alive
(Dec
2016).
- KPCB
built separate early and late venture funds, but with increased
competition to fund startups: Softbank; it has
decided to split them into two companies (Sep
2018)
- Politically, and financially, well connected, Thrive Capital
funds health insurance startup Oscar, which still
struggles.
- Google Ventures:
funds
DNA Nexus, One Medical, Rani
Therapeutics, Magic Leap, Foundation
medicine, SynapDx,
funds
23andMe, Flatiron Health,
Calico,
- New York City developed a game changers plan to build up
Silicon Alley, after Lehman Brother's
collapse in 2008, aimed at enabling applied science to induce
new technologies for its key industries: finance: J. P. Morgan
Chase, Goldman
Sachs, Citigroup;
fashion, design, advertising, law, consulting: KPMG; and media;
to be developed in the city - including new courses at Columbia,
NY
University City University, & Cornell Tech graduate
school. But NYC's Silicon Alley was fed by smart people's
interest in coming to NCY to live: museums, theater, opera,
dance, jazz, art galleries, bars, restaurants; and work:
entrepreneurs, technologists, corporate execs; with these
industries. Google
initially entered NYC to gain access to its advertising industry
cluster, a move that was tightened by its purchase of
DoubleClick. Google engineers wishing to live in NYC
initiated an additional technology node which pulled in
researchers from local companies including Bell Labs. As these clusters
grow VC is venture capital, venture companies invest in startups with intangable assets
funding
enables genetic operations to occur
enabling new startup formation (Feb
2019)
- Risk management focused asset managers: Blackrock; are
capturing more investment dollars than Goldman and J.P. Morgan
Chase, with E.T.F. is exchange traded fund, which tracks stock and bond indexes, adhering to a set of financial rules. These methods can be used to track any financial market segment. They are transparent, and low cost to operate, and invest in. ETFs are priced during normal trading hours. But their performance is impacted when they are forced by changing conditions to sell assets at a loss. Selling of an ETF by one investor to another does not redeem the ETF's underlying investments, limiting the capital gains tax distribution (Jul 2018).
s
(Sep
2016).
- E.T.F. is exchange traded fund, which tracks stock and bond indexes, adhering to a set of financial rules. These methods can be used to track any financial market segment. They are transparent, and low cost to operate, and invest in. ETFs are priced during normal trading hours. But their performance is impacted when they are forced by changing conditions to sell assets at a loss. Selling of an ETF by one investor to another does not redeem the ETF's underlying investments, limiting the capital gains tax distribution (Jul 2018).
's have
captured 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).
flows: Fundx, ETF Managers Group; ETF management strategies have
split the market up into thinner and thinner segments, allowing
investors more choice and 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. . Banks: Bank of America
Merrill Lynch;
use this thematic investing to drive portfolio
recommendations. Many portfolio advisors: RegentAtlantic,
LIPR advisors; do not like the trend (Jan
2019)
- Housing debt undermines patients' finances:
- Older adults have increasing amounts of mortgage debt (Nov
2016)
- I.M.F. is the International Monetary Fund developed as part of the Bretton Woods agreements to provide liquidity to national gold denominated reserve banks at times of stress in the global financial network - a shortage of a particular currency which was inhibiting trade; in support of a broader Bretton Woods framework designed so as to ensure that currencies did not become misaligned with one another, and were a fair representation of what things were worth. The IMF removed the need for nations to depend on private loans from commercial banks, such as Britain's dependence on J. P. Morgan during the 1920s and 30s. The agreement required each Bretton Woods signatory to provide a capital investment or 'quota' into the fund which would subsequently correspond to the amount that the country could borrow from the fund in times of financial stress. The top four countries and their quotas were set by IMF architect, Harry Dexter White, to match FDR's priorities:
- US - $2.9 billion, an amount the FDR administration could transfer from Exchange Stabilization Fund without any need to ask for Congress for funds.
- UK - $1.45 billion
- USSR - slightly less than UK quota
- China - less than USSR.
activity
- May
2016 I.M.F. is the International Monetary Fund developed as part of the Bretton Woods agreements to provide liquidity to national gold denominated reserve banks at times of stress in the global financial network - a shortage of a particular currency which was inhibiting trade; in support of a broader Bretton Woods framework designed so as to ensure that currencies did not become misaligned with one another, and were a fair representation of what things were worth. The IMF removed the need for nations to depend on private loans from commercial banks, such as Britain's dependence on J. P. Morgan during the 1920s and 30s. The agreement required each Bretton Woods signatory to provide a capital investment or 'quota' into the fund which would subsequently correspond to the amount that the country could borrow from the fund in times of financial stress. The top four countries and their quotas were set by IMF architect, Harry Dexter White, to match FDR's priorities:
- US - $2.9 billion, an amount the FDR administration could transfer from Exchange Stabilization Fund without any need to ask for Congress for funds.
- UK - $1.45 billion
- USSR - slightly less than UK quota
- China - less than USSR.
critical of Brazilian policy decisions
- Jun
2016 I.M.F. backed off from demanding debt restructuring
for Greece during 2015 negotiations
- Oct
2016 I.M.F. is the International Monetary Fund developed as part of the Bretton Woods agreements to provide liquidity to national gold denominated reserve banks at times of stress in the global financial network - a shortage of a particular currency which was inhibiting trade; in support of a broader Bretton Woods framework designed so as to ensure that currencies did not become misaligned with one another, and were a fair representation of what things were worth. The IMF removed the need for nations to depend on private loans from commercial banks, such as Britain's dependence on J. P. Morgan during the 1920s and 30s. The agreement required each Bretton Woods signatory to provide a capital investment or 'quota' into the fund which would subsequently correspond to the amount that the country could borrow from the fund in times of financial stress. The top four countries and their quotas were set by IMF architect, Harry Dexter White, to match FDR's priorities:
- US - $2.9 billion, an amount the FDR administration could transfer from Exchange Stabilization Fund without any need to ask for Congress for funds.
- UK - $1.45 billion
- USSR - slightly less than UK quota
- China - less than USSR.
internal monitor critical of I.M.F. actions during E.U. is European Union, the 1992 Maastricht Council of Ministers meeting agreed evolution of the ECSC & CAP cartels to include: - A single market across the members' countries supporting the transformation of the ECSC. It maintained the CAP transfers assisting French farmers.
- A fixed currency 'snake' that allowed the ECSC to operate, binding the deutschmark to the other currencies of participating members: a mini Bretton Woods exchange rate mechanism; that became a single currency, the euro, managed by an independent ECB (based on the independent German Bundesbank); but tax gathering was allocated to the states whose leaders control the Council of Ministers and no effective mechanism was provided to reallocate revenues. This has left Germany with an advantage supported by the aggregate valuation of the euro and not having to flow tax revenues to the weaker economies of the south.
debt
crisis.
- Oct
2016 Legarde worried at lack of commitment to trade deals.
- 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.
pressure is
altering health care markets:
- Insurers leverage legal, financial and physical network effects:
- UnitedHealth
purchases standalone
surgery center Surgical
Care Affiliates for Optum's OptumCare (Jan
2017)
- UnitedHealth
purchases DaVita's
physician group for Optum
for $4.9 Billion. US is the United States of America.
needs a Value Delivery
System (VDS is value delivery system. ) for
chronic disease: asthma is inflammation of the airways resulting in their narrowing, swelling and generating additional mucus which inhibits breathing. Its prevalence doubled in the US between 1980 and 2000. Asthma is the most common chronic disease in childhood, the most common reason for being away from school and the most common reason for hospitalization. 10 to 13% of children's asthma cases are due to obesity. Among obese children 23 to 27% of asthma cases are due to obesity. Diagnosis: Propeller Health; Treatments include: Xolair;
,
and diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
.
Northwestern's
Garthwaite
asks: is Kaiser's
business model under threat? (Dec
2017)
- CWRU
& former QualChoice
CEO Silvers's
model of health care insurance market
impact - a cascade of problems 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.
individual
markets lose 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.
spread and more insurers follow UHC or
increase premiums (Jan
2017)
- CVS Health, continues
its UHG
like diversified health services strategy:
merging with Aetna;
responding to Amazon's
potential disruption of pharmacy
market (Oct
2017)
- CVS Health purchases Aetna for $69 Billion - developing
community-based sites of care; a big deal argues Leerink
Partners' Gupte (Dec
2017)
- Assessments of the merger vary (Dec
2017)
- CVS +
Aetna merger is
allowed by regulators with the requirement that some Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
plans are
sold to WellCare
Health Plans. No discrete large PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. is left: UHG (OptumRx),
Cigna +
Express Scripts,
Anthem
building a PBM; limiting drug cost management for smaller
insurers and PBMs. PBMs have been criticised for secret deals
that have helped keep drug prices high. Health plan
control of where prescription drugs are purchased will limit Amazon's disruption of pharmacies,
and likely limit consumers opportunities to bargain. State
regulators will start to look at the operations of
PBMs. Large insurers are also entering health care
provision of low cost care for chronic conditions and chain care
in the community (Oct
2018)
- ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
and competitive
pressures encourage payer include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
-delivery
integration across the health care spectrum: UnitedHealth,
Anthem
CVS: IngenioRX PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. , Aetna: Inova, Banner
Health; Cleveland
clinic: Oscar;
(Nov
2017)
- Rx
Savings Solutions helps employers reduce employee drug
costs as 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.
: OptumRX,
Express Scripts;
agreements allow generics' prices to rise: crestor;
while BlinkHealth,
which is in litigation with its PBM MedImpact &
has lost access to Publix, Walgreens & CVS, and GoodRx supplied
coupons help 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.
generic prescription drug users find low cost offers as
Insurance: UHG,
Cigna, Humana; agreements, co-payment 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); &
deductible requirements & clawbacks refers to a contractual requirement between a payer and provider or retailer (pharmacy), where the cost of the goods supplied to a subscriber is lower than the reimbursement contracted with the payer, and the payer requires the difference to be refunded. with
pharmacists: Walgreens,
CVS; and HDHP is a high-deductible health plan which has lower premiums and a higher deductable than traditional health insurance plan such as a HMO plan or PPO plan. bite into 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.
regulated
transactions value. PCMA
argues these situations are outliers (Dec
2017)
- Major hospital
systems is the owner of a set of hospitals and other owned infrastructure and employer of direct staff. : Dignity + Catholic
Health Initiatives, Ascension,
Advocate
+ Aurora;
plan mergers; Tenet
& Community
Health sell off poor performing hospitals & shift
further to outpatient services. All are hoping to capture
patient base before new entrents: UnitedHealth,
CVS Health, Amazon; can.
And scale may help with margin & HCIT is health care information technology. The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets. Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.;
costs.
UnitedHealth's Optum
purchases the Advisory
Board. Republican tax law suggests reduced funding
of: ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
, Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
& Medicaid is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; will all
be further impacting revenue to hospitals (Dec
2017)
- 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)
- 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)
- Startups: Capsule,
DispatchHealth,
Dose Healthcare,
Heal, I.V. Doc, MedZed, Pager; with funding
from: IRA Capital,
Questa Capital,
Alta Partners,
Angels: Paul Jacobs, Lionel Ritchie; aim to be the Uber of
healthcare, treating nonemergency problems: prescriptions, strep
throat, sprained ankle; but hurdles are high: state based
regulations, insurance costs, health care network is powerful
and hard to integrate with; although health insurers are
offering on demand: Anthem,
Health Net, Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. , Aetna, CareFirst,
United
Healthcare, Cigna,
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.
; cover
Heal visits in many PPO
plans preferred provider organization health plan allows direct access to any health specialist although there is typically a network of contracted specialists as opposed to a HMO health plan. for chronic hypertension is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers.
and diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. ; 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. are significant
and powerful tech companies are also interested: Amazon through PillPack, Apple, Alphabet (Feb
2019)
- RWJ
funded RAND study, of 1,598 hospital treatment's insurance
claims, shows Parkwiew
Health, in Indiana, charges private
insurers 4 * its Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
prices. States paying the most are: Indiana, Wyoming,
Maine, Wisconsin, Montana, Colorado, Texas, Georgia, Ohio,
Washington; on average hospitals charge 2.4 * Medicare prices to
private health insurance patients. Outpatient care was 3 *
Medicare pricing; angering employers. Employers
say they must exert discipline on health care costs: will gather
data on prices and quality to decide on the best strategy: single-payer is a healthcare architecture in which there is a single financing organization. Significant aspects of single-payer include: - Strengths of single-payer:
- Removes the extensive replication of payer organizations and their different interfaces to the other healthcare entities and subscribers.
- One payment organization, removing the need to allow subscribers the yearly choice to change payer, encouraging payers to help subscribers remain healthy
- Single-payer instantiates a political monopoly on health insurance.
- Problematic implementation of single-payer in the US
- Undermines the alignment of the healthcare network, threatening profits, power structures and financial rewards. This limits the possibility of single-payer in the US: Lobbying juggernaut: Politicians, Providers, Doctors, Insurers; leveraging dislike of tax increases, The 9 out of 10 Americans who are employed or retired are satisfied with their situation, Current insurance costs are hidden from the insured: in lowered pay packages, spread over all tax payers reducing government revenues; Current private insurers would be forced to reduce costs;
- Alters one sixth of the US economy: Commercial health insurance replaced, investors impacted by transformation of business models; a huge change of high uncertainty, something evolution works to avoid by including mechanisms to force small incremental changes.
- A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations. Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016).
,
focus on best value hospitals; Insurers are not incented
to keep prices down when working for self-insured companies -
where insurers are spending the companies money and make more
revenue when the company spends more. Anthem
claims narrow
networks - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans. This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans. By limiting the number of providers/doctors offered in the plans the few that are included should get more business. Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers). In large cities narrow networks are even more common. Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills. There are problems induced by narrow network constraints: - Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts. Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running. If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016).
of hospitals is its direction to drive down
prices. One-third of all healthcare spending goes to
hospital care. Hospitals are buying physician practices is physician practice management. This consolidation of PCP practices was partly a response to Wall Street's capitalization of HMOs and hospitals in early 1990s. As Wall Street switched to financing PPMs, enabling Medpartners's purchase of Mullikin Inc., hospitals responded by buying up the PPMs. Most PPMs struggled to control costs in the capitated care framework of the 1990s. Some of these PPMs shifted to become PBMs. and
spending on new facilities. Hospitals (AHA is the American_hospital association. ) argue they lose
money on Medicare and Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. , so the
comparison is biased (May
2019)
- Operators respond building network effects too
- NYT/UC
Berkeley study finds prices rise after hospital mergers,
since these: reduce competition, raise price of admission,
undermine quality; with major groups: Baylor
Scott, CHI
Franciscan Health, Dignity, Hartford,
Memorial
Hermann, Phoebe
Putney Health System, Sutter Health,
West
Virginia University Medicine, Yale
New Haven Health; integrating other hospitals and
especially physician groups (Nov
2018)
- Employers, still keen to benefit as
insurers, are shifting burden of cost to employees (Sep
2016)
- The broad reach of these policies and the premium cost
shifting -- an $18,000 yearly payment is having political
impacts on working families. Three academics propose
policy changes to empower these workers with more choice (Nov
2016).
- CalPERS
drives prices for elective surgery down in California (Aug
2016).
- 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).
- Senator Sherrod Brown, develops select committee to focus on
multiemployer pension liabilities: UPS,
Kroger, NCCMP;
and support PBGC is the pension benefit guarantee corporation. It is an independent agency of the US government created by ERISA.
backstop, lobbied for by USCC is the United States Chamber of Commerce
(Feb
2018)
- 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.
costly
but shown to provide long term benefits to recipients (Sep
2016).
- Actuaries, including CalPERS,
yearly government employer valuations of pension liabilities are
systemically low (Sep
2016)
- KQED's Forum on California politics and 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.
: CalPERS
losses from Great Recession & limited capital growth, City
revenues depleted by pension cost impacts inhibit funding of infrastructure maintenance, No revenue
for 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).
health care, Voters still rejecting tax increases; (Jul
2017)
- CalPERS
is pursuing Layalton, a small city that has failed to fully fund
their pension liabilities. And it is also considering
cutting pension payments if such cities fail to make good on
their commitments (Oct
2016).
- CalPERS puts pressure on other pension funds and state
finances as it lowers projected return on investment (Dec
2016).
- CVS Health, continues
its UHG
like diversified health services strategy:
merging with Aetna;
responding to Amazon's
potential disruption of pharmacy
market (Oct
2017)
- CVS Health purchases Aetna for $69 Billion - developing
community-based sites of care; a big deal argues Leerink
Partners' Gupte (Dec
2017)
- Assessments of the merger vary (Dec
2017)
- CVS +
Aetna merger is
allowed by regulators with the requirement that some Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
plans are
sold to WellCare
Health Plans. No discrete large PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. is left: UHG (OptumRx),
Cigna +
Express Scripts,
Anthem
building a PBM; limiting drug cost management for smaller
insurers and PBMs. PBMs have been criticised for secret deals
that have helped keep drug prices high. Health plan
control of where prescription drugs are purchased will limit Amazon's disruption of pharmacies,
and likely limit consumers opportunities to bargain. State
regulators will start to look at the operations of
PBMs. Large insurers are also entering health care
provision of low cost care for chronic conditions and chain care
in the community (Oct
2018)
- Screening related overtreatment
- Food and
beverage industry have significant influence 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.
:
soda (Sep
2015), sugar (Sep
2016);
- Mars pays off Berkshire
Hathaway for loans to acquire Wrigley (Oct
2016);
- Boston University SOM's
Matthew
Pase finds sugary drinks tied to rapid brain aging and 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.
markers (Apr
2017)
- Donations and product streams create conflicts of interest
for:
- Academics:
- Mylan coordinates
and funds academics
and lobbyists to remove EpiPen user's copayment 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);
(Sep
2016)
- Drug prices cause conflicts of interest for most patient
advocacy groups (Sep
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)
- Internal 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.
investigation concludes MACH study was tainted, with NIAAA is the national institute on alcohol abuse and alcoholism, a part of the NIH.
staff and Beth
Israel Deaconess/Harvard School
of public health's Mukamal breaking many rules in seeking
industry funding, and hiding problems from Dr.
Collins and his staff. So Collins cancelled MACH (Jun
2018)
- James Cresswell, West
Virginia University's James
Simpkins, colony collapse research and Syngenta's academic
influence (Jan
2017)
- Non-profit groups:
- Sep
2015, Oct
2016 Soda companies' sponsorships produce 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.
conflicts of interest for non-profits
Economic change provides
the potential to destabilize the US health care network.
Americans are increasing their use of prescription drugs (Nov
2015)
Federal
Reserve of 1913 was a response to a series of banking panics with the goal of responding effectively to stresses. It setup: - At least 8 and not more than 12 private regional Federal Reserve banks. Twelve were setup
- Federal Reserve Board with seven members to govern the system. The President appointed the seven, which must be confirmed by Congress. In 1935 the Board was renamed and restructured.
- Federal Advisory Committee with twelve members
- Single US currency - the Federal Reserve Note.
report argues: 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. robust
allowing for interest rate increases, Wage growth sluggish due
to poor productivity is the efficiency with which an agent's selected strategy converts the inputs to an action into the resulting outputs. It is a complex capability of agents. It will depend on the agent having: time, motivation, focus, appropriate skills; the coherence of the participating collaborators, and a beneficial environment including the contribution of: standardization of inputs and outputs, infrastructure and evolutionary amplifiers. ,
Decline in work force participation among less educated
Americans because of technology, Women providing child-care
rather than entering the work force, Oil increasingly produced
domestically reducing export of dollars, Trade war not mentioned
as a significant risk (Jul
2018)
The financial
network is betting on:
- Supply for genomics combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes.
- Crispr is clustered replicating interspersed silent palindromic repeats; a technique for exact targeting, cutting and editing of DNA based on leveraging bacterial enzymatic defenses against viruses generalized to any DNA sequence in a prokaryotic or eukaryotic cell. It was identified during studies of a bacterial adaptive immune system. In that system bacterial proteins grab parts of a virus that has infected them and record it within the palindromic structures that mark an array of inserted viral DNA used as a log persisted over generations. If a new infection occurs the viral DNA is compared with the sequences and if a match exists the CAS proteins break up the viral DNA initiating its destruction. This bacterial system was then updated and repurposed by the researchers to support targeted genetic engineering. As explained by Dr. Doudna, the CRISPR proteins and the 20 nucleotide RNA template migrate into the nucleus where they rapidly target DNA which complements the RNA template and the Cas9 enzyme performs the edits. Being a bacterial system CRISPR Cas9 does not target eukaryotic heterochromatic DNA well. It is not fully understood how they find the target sequence so quickly. It has been shown that Cas9 will bind to sites with a 5-8 base match but then it releases rapidly without cutting. To cut, Cas9 has to reconfigure, which does not occur in the mismatch situations.
genetic engineering
- Synthego raises
$41 million from Founders
Fund, Menlo
Ventures, 8VC, Jennifer
Doudna (Jan
2017)
- Novartis &
University of Cambridge researchers find P53 is a tumor suppressor which improves the specificity of transcription's DNA binding and promotes the transcriptional activity of E2F. P53's activity is controlled by phosphorylation by cyclin Cdk complexes allowing indirect control of the cell cycle. Among the many genes controlled by p53 are cyclin genes, genes for an inhibitor of cyclin-dependent kinases (Cdk), and the bax gene, which promotes apoptosis. p53 can thus promote cell proliferation. It can drive cells into apoptosis. But it can also stop cell proliferation by arresting the cell cycle. Normally there is a dynamic balance between proliferation of cells and their death. In cancer proliferation may become unregulated due to oncogenic mutations or over expression of key regulatory signalling G proteins such as Ras. Mutations of the p53 suppressor gene are the most frequent suppressor gene mutations in human cancers. Elephants like humans, have a relatively low buildup of cancer with age. Elephant's cells have twenty copies of p53 gene pairs which ensure cells with damaged DNA go into apoptosis blocking cancer onset. P53 has been shown to be involved in irregular brain cell activity in epilepsy and ASD.
blocks Crispr is clustered replicating interspersed silent palindromic repeats; a technique for exact targeting, cutting and editing of DNA based on leveraging bacterial enzymatic defenses against viruses generalized to any DNA sequence in a prokaryotic or eukaryotic cell. It was identified during studies of a bacterial adaptive immune system. In that system bacterial proteins grab parts of a virus that has infected them and record it within the palindromic structures that mark an array of inserted viral DNA used as a log persisted over generations. If a new infection occurs the viral DNA is compared with the sequences and if a match exists the CAS proteins break up the viral DNA initiating its destruction. This bacterial system was then updated and repurposed by the researchers to support targeted genetic engineering. As explained by Dr. Doudna, the CRISPR proteins and the 20 nucleotide RNA template migrate into the nucleus where they rapidly target DNA which complements the RNA template and the Cas9 enzyme performs the edits. Being a bacterial system CRISPR Cas9 does not target eukaryotic heterochromatic DNA well. It is not fully understood how they find the target sequence so quickly. It has been shown that Cas9 will bind to sites with a 5-8 base match but then it releases rapidly without cutting. To cut, Cas9 has to reconfigure, which does not occur in the mismatch situations. action,
detecting DNA (DNA), a polymer composed of a chain of deoxy ribose sugars with purine or pyrimidine side chains. DNA naturally forms into helical pairs with the side chains stacked in the center of the helix. It is a natural form of schematic string. The purines and pyrimidines couple so that AT and GC pairs make up the stackable items. A code of triplets of base pairs (enabling 64 separate items to be named) has evolved which now redundantly represents each of the 20 amino-acids that are deployed into proteins, along with triplets representing the termination sequence. Chemical modifications and histone binding (chromatin) allow cells to represent state directly on the DNA schema. To cope with inconsistencies in the cell wide state second messenger and evolved amplification strategies are used. changes
and blocking DNA synthesis and invoking apoptosis, programmed cell death is a signal initiated DNA controlled process which results in eukaryotic cells self-destructing. .
Gene editing companies: Crispr
therapeutics, Intellia
Therapeutics, Editas Medicine;
take a beating (Jun
2018)
Can society
afford to pay for the treatments? US pricing is
supported by the 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.
's
legislative constraints 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
actions. Pricing pressure has already impacted Europe
due to budget problems and austerity measures. The US is
expected to follow the trend. Pressure (Jul
2015) from government, insurers and managed care contracts together its subscribing patients with particular groups of doctors and hospitals who agree to provide contracted care for a particular price which the managed care organization reimburses. It was based on the group practice organizations: Kaiser, Mayo Clinic; operations. The initial HMOs, supported by the HMO act and PPOs has subsequently been joined by other forms of managed care. Original capitation based implementations were problematic with only Kaiser succeeding. Managed care is now enhanced by inclusion of upside measures as in alternative quality contracts.
companies will undermine big price increases.
- 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 use the formularies are lists of drugs that a health plan will cover. The health plans control where and if the drug is listed in the plan. A less expensive drug can be assigned a lower copayment to encourage patients to use it. To counter this attack on their profits drug companies responded with coupons to help patients pay copayments removing the incentive to select the lower-priced drugs. Health plans reacted to the copayment cards by dropping some drugs from the formulary altogether. That encourages drug companies to bid for their drug to be the only one listed resulting in some downward price pressure.
to control biologic are drugs made in living cells. Typically they are proteins developed using genetic engineering to develop the cellular host, and to customize animal source, DNA to produce human target proteins. Such biologics partially solve the problem of previous protein sources, extracted from animals or human sources, of contamination and immune responses. The strategy is very effective for blood transported proteins such as antibodies (MABs), hormones and blood factors. But intra-cellular proteins still demand delivery and accurate cell targeting. This creates analogous problems to those of gene therapy.
prices: 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.
price constrained (June
2014).
- Pressure on high cost anti-inflammatory medications: Humira, Enbrel; (Sep
2016).
- Biologic insulin regulates the metabolism of carbohydrates, fats and protein by signalling the absorption of glucose by fat, liver and skeletal muscle cells. It is a peptide hormone generated in the islets of Langerhans beta cells of the pancreas. Peter Medawar explains it was an early drug therapy success. As manufacturers have shifted from products developed by extraction to biologics: Humulin, Lantus, Levemir; safety has improved. But the US list price has risen steeply (Feb 2016, Jan 2017)
prices supported by patent extensions, data exclusivity, 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. rebates (Feb
2016)
- Manufacturers: Eli
Lilly, Novo
Nordisk, Sanofi;
accused in lawsuit of price fixing scheme with 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 for Insulin regulates the metabolism of carbohydrates, fats and protein by signalling the absorption of glucose by fat, liver and skeletal muscle cells. It is a peptide hormone generated in the islets of Langerhans beta cells of the pancreas. Peter Medawar explains it was an early drug therapy success. As manufacturers have shifted from products developed by extraction to biologics: Humulin, Lantus, Levemir; safety has improved. But the US list price has risen steeply (Feb 2016, Jan 2017) (Jan
2017).
- Bellevue
Hospital's Dr. Ofri struggles with prescriptions, as high
priced biologic are drugs made in living cells. Typically they are proteins developed using genetic engineering to develop the cellular host, and to customize animal source, DNA to produce human target proteins. Such biologics partially solve the problem of previous protein sources, extracted from animals or human sources, of contamination and immune responses. The strategy is very effective for blood transported proteins such as antibodies (MABs), hormones and blood factors. But intra-cellular proteins still demand delivery and accurate cell targeting. This creates analogous problems to those of gene therapy.
insulin regulates the metabolism of carbohydrates, fats and protein by signalling the absorption of glucose by fat, liver and skeletal muscle cells. It is a peptide hormone generated in the islets of Langerhans beta cells of the pancreas. Peter Medawar explains it was an early drug therapy success. As manufacturers have shifted from products developed by extraction to biologics: Humulin, Lantus, Levemir; safety has improved. But the US list price has risen steeply (Feb 2016, Jan 2017) causes
issues across the VDS is value delivery system. ,
with insurers changing formularies are lists of drugs that a health plan will cover. The health plans control where and if the drug is listed in the plan. A less expensive drug can be assigned a lower copayment to encourage patients to use it. To counter this attack on their profits drug companies responded with coupons to help patients pay copayments removing the incentive to select the lower-priced drugs. Health plans reacted to the copayment cards by dropping some drugs from the formulary altogether. That encourages drug companies to bid for their drug to be the only one listed resulting in some downward price pressure. all
the time to slow costly fulfillment (Jan
2019)
- Eli Lilly, under
pressure from Congress, move to protect high priced Humalog
100 insulin regulates the metabolism of carbohydrates, fats and protein by signalling the absorption of glucose by fat, liver and skeletal muscle cells. It is a peptide hormone generated in the islets of Langerhans beta cells of the pancreas. Peter Medawar explains it was an early drug therapy success. As manufacturers have shifted from products developed by extraction to biologics: Humulin, Lantus, Levemir; safety has improved. But the US list price has risen steeply (Feb 2016, Jan 2017)
,
leveraged by insurers and 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,
by releasing a lower priced generic: Imclone
Insulin Lispro; an 'authorized generic' strategy
previously used by Mylan
& Gilead,
at a price that is still historically expensive (Mar
2019)
- After criticism for pushing up drug prices 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.
Express Scripts
sets up InsideRx
program to offer discounts to some low income groups. Patients
for Affordable Drugs is not impressed while Pembroke
Consulting is more positive (May
2017)
- Pharmaceutical companies: Merck with Januvia
& Januvet, Novartis
with Entresto,
Amgen with Repatha
contracting with Harvard
Pilgrim & treating patients at Lahey;
propose outcomes-based
contracts require suppliers to return money to the health system if the drugs fail to work as expected. Typically drug makers pay rebates to insurers based on the number of drugs sold. The manufacturers gain easier access to insurers' members for their products. It appears unlikely that outcomes-based contracts reduce prescription drug prices (Jul 2017).
- with promotion by PhRMA,
but little evidence that they lower prices asserts MS-KCC
& 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: Express Scripts,
Prime
Therapeutics (Jul
2017)
- Insurers: Cigna (Express Scripts),
Harvard
Pilgrim, Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births.
;
worried at the high price and lifelong commitment of Amgen's Repatha
& Regeneron/Sanofi's Praluent, PCSK9 is proprotein convertase subtilisin/kexin type 9 an enzyme activator. It is encoded as zymogen and autocatalysed in the ER. It plays a major role in cholesterol homeostasis. It binds EGF-A domain of LDLR inducing LDLR degradation. Academic researchers Dr. Helen Hobbs and Jonathan Cohen, studying large populations found reduced LDLR results in reduced metabolism of LDL which can lead to hypercholesterolemia. Drugs that can inhibit PCSK9 can lower cholesterol much more than first generation cholesterol inhibitors. inhibitors, are
limiting their use by prior-authorization is a constraint imposed by some insurance companies prior to their agreeing to cover some prescribed medications or medical procedures. The constraint may be due to: age, medical necessity, availability of a generic alternative, or to check drug interactions. After a healthcare provider orders a service for a patient, the provider's staff will contact the patient's insurer to determine if they require prior authorization. This should result in an exception process which may involve the provider's staff manual faxing a prior authorization form to the insurer. If the service is rejected, the healthcare provider may file an appeal based on the provider's medical review process. It may take 30 days for the insurer to approve the request.
constraints, even to the one million heterozygous F.H. is Familial Hypercholesterolemia, which causes heart attacks at a young age with symptoms of very high cholesterol levels. A mutation in chromosome 19 inhibits removal of low density lipoprotein. sufferers in the US is the United States of America. where the F.D.A. Food and Drug Administration. has allowed
their use, causing problems for the patients and their
providers: Cleveland
Clinic; (Oct
2018)
- Employers work to shift power relations:
- 41 major employers including founders: American Express,
Verizon, Macy's; form the Health
Transformation Alliance, to reform the private sector
health care system, starting with 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.
relationships: CVS,
OptumRX;
& high cost & volume pricedures, with IBM providing data
analysis (Aug
2017)
- Amazon's purchase
of wholesale licences to sell drugs, and medical devices may disrupt health care markets. Express Scripts
Tim
Wentworth offers to help (Oct
2017)
- Rx
Savings Solutions helps employers reduce employee drug
costs as 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.
: OptumRX,
Express Scripts;
agreements allow generics' prices to rise: crestor;
while BlinkHealth,
which is in litigation with its PBM MedImpact &
has lost access to Publix, Walgreens & CVS, and GoodRx supplied
coupons help 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.
generic prescription drug users find low cost offers as
Insurance: UHG,
Cigna, Humana; agreements, co-payment 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); &
deductible requirements & clawbacks refers to a contractual requirement between a payer and provider or retailer (pharmacy), where the cost of the goods supplied to a subscriber is lower than the reimbursement contracted with the payer, and the payer requires the difference to be refunded. with
pharmacists: Walgreens,
CVS; and HDHP is a high-deductible health plan which has lower premiums and a higher deductable than traditional health insurance plan such as a HMO plan or PPO plan. bite into 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.
regulated
transactions value. PCMA
argues these situations are outliers (Dec
2017)
- Drug prices and price growth helps increase spend on health
care by 2025 (Jul
2016).
- President Trump's drug pricing plan: Increase competition in
drug markets, Allow Medicare 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.
private drug plans to negotiate discounts for 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.
beneficiaries, provide incentives for drug manufacturers to
reduce list prices, Cut consumers' out-of-pocket costs;
abandoning campaign promises to allow: Medicare to negoatiate on
prices, Drugs imported from lower cost markets; Instead Trump
asks trade representative to force price increases on foreign
markets (May
2018)
- Project Rx, a
generic drug company is formed by a group of over 300 hospitals:
Intermountain,
Ascension,
Trinity
Health, VA - Department of Veterans Affairs. Includes the Veterans Health Administration.
; with
advice from: Duke
SOM's Schulman,
Bob Kerrey, Harvard's
Donald
Berwick, Amgen
execs; to compete with parasitic is a long term relationship between the parasite and its host where the resources of the host are utilized by the parasite without reciprocity. Often parasites include schematic adaptations allowing the parasite to use the hosts modeling and control systems to divert resources to them or improve their chance of reproduction: Toxoplasma gondii.
pharmaceutical strategies: Turing,
Valeant;
manipulating the generic drug market (Jan
2018)
- While Forteo
has no competition Eli
Lilly has been dramatically increasing its price.
But that has just starved supply as insurance
plans refuse to pay for the osteoporosis is a set of diseases where the bones are being broken down faster than they are being renewed. The effect is for bones to lose strength and become brittle. The more bone mass developed the less likely osteoporosis becomes. The risk increases with age and more often impacts women. Certain hormone levels have an impact: Increased glucocorticoids and reduced sex hormone levels increase bone loss, over active: Thyroid, Parathyroid and Adrenal glands. Some medical treatments can accelerate bone loss (prostate cancer treatments). Osteoporosis treatments include:
- Amgen's Evenity (romosozumab) a sclerostin inhibitor (Apr 2019)
- Eli-Lilly's Forteo (teriparatide) a parathyroid hormone analog which encourages bone growth but is very expensive. And it is only allowed to be taken for two years since it was associated with bone cancer in rats.
- Biphosphonates reduce the rate of bone loss but have frightening side effects in a small number of patients (Jun 2016).
treatment. When competitor drugs are approved it is not
clear they will compete on price (Aug
2016).
- Overseas low tax domiciles and owners catalyze
big price increases: Valeant.
- Specialty
pharmacy 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.
relationships are allowing pharmaceutical
companies to catalyze big price increases: Horizon (Oct
2015), Turing
(Oct
2015), Valeant
with Philidor;
- University
of Pennsylvania's Ezekiel
Emanuel argues pricing of PCSK9 is proprotein convertase subtilisin/kexin type 9 an enzyme activator. It is encoded as zymogen and autocatalysed in the ER. It plays a major role in cholesterol homeostasis. It binds EGF-A domain of LDLR inducing LDLR degradation. Academic researchers Dr. Helen Hobbs and Jonathan Cohen, studying large populations found reduced LDLR results in reduced metabolism of LDL which can lead to hypercholesterolemia. Drugs that can inhibit PCSK9 can lower cholesterol much more than first generation cholesterol inhibitors.
inhibitors
alone may require everyone to pay more than $100 dollars! one
analysis suggests (Nov
2015).
- Main line drug manufacturers keep up the stream of
exceptionally high cost drugs (Dec
2015, 2).
- AstraZenica
fails to protect Crestor
with its ODA is either
- The orphan drug act of 1983 which aims to facilitate development of drugs for rare diseases. The F.D.A. ensures that qualifying manufacturers obtain reduced costs of some parts of the testing process, and has tax incentives, enhanced patent protection, clinical research subsidies and support of a GSE to do research and development. or
- Official development assistance, funds donated by rich country governments to poor countries. ODA is measured by the OECD's DAC.
patent
label argument (Jul
2016).
- 21st
Century Cures Act is a $6.3 billion bill to increase funding for research into cancer, Alzheimer's disease and other disease, support mental health networks and adjust regulations for drugs and medical devices. The act does not constrain drug prices. It is funded with money taken from a preventative health care fund. It aims to:
- Expand the funding of the NIH.
- Allocates an additional $4.8 billion over 10 years. Much of the expanded funding is focused on Alzheimer's and cancer. This funding will still have to be appropriated by Congress.
- Empowers the NIH:
- Provides them with authority to finance high-risk, high-reward research using special procurement procedures instead of grants and contracts,
- Requires the director to establish "Eureka prizes" for biomedical research and treatment improvements.
- Advances the Precision Medicine Initiative,
- Support the moonshot to cure cancer.
- Align the federal drug regulatory structure with the processes of the biotechnology industry. Critics argue it lowers drug and device approval standards, and raises the influence of surrogate endpoints.
- The F.D.A. is allocated half a billion dollars to help staff the expedited processes.
- It provides an expedited pathway for breakthrough medical technologies (offering options for life-threatening conditions with few treatment options).
- F.D.A. must consider the least burdensome means to show device safety.
- Streamline the mental health network. It strengthens the enforcement of the mental health parity law.
- Creates the Presidentially appointed position of assistant secretary for mental health and substance use.
- Directs federal agencies to step up enforcement of laws that require equal insurance coverage for mental and physical illnesses.
- Stem the problem of opioid drug abuse with a $1 billion investment that will allow expanded access of treatment programs.
targets $6.3 billion for 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). & 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.
research, expanding 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.
budget, mental health deployment and F.D.A. Food and Drug Administration. regulation of
medical devices & drugs (Nov
2016)
- F.D.A. Food and Drug Administration. approves Biogen's high
priced Spinraza
for SMA is spinal muscular atrophy, a recessive condition that typically results in paralysis and death by age two due to loss-of-function mutations in the SMN1 gene which codes for the SMN protein required by motor neurons. One in 40 individuals is a carrier of the SMA allele. 400 babies are born with SMA in the US each year. Treatments include: Spinraza (nusinersen).
(Dec
2016)
- Rare disease drugs are a focus for patients, 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.
and manufacturers.
- J&J's
Sylvant MAB as a terminator in medication names indicates the drug is a monoclonal antibody biologic. , Pfizer's Rapamune
used in treatment of Mayo Clinic
diagnosed Castleman
disease is a rare condition with symptoms of: Enlarged lymph nodes, hyperactivation of the immune system, excessive releases of cytokines, proliferation of lymphocytes and organ disfuction. It can affect subcomponents of the body or be multicentric when it is severe and deadly. Its cause is not defined: some argue it is viral, others an inherited genetic disorder or a cancer. It has been treated with: steroids, chemotherapy, J&J's targeted neoplastic disease therapy Sylvant (siltuximab) & Pfizer's Rapamune (sirolimus). . CDCN
at University
of Pennsylvania formed by Dr. Fajgenbaum to improve
research coordination; Everylife
advocates to F.D.A. Food and Drug Administration. (Feb
2017)
- Novartis's biologic are drugs made in living cells. Typically they are proteins developed using genetic engineering to develop the cellular host, and to customize animal source, DNA to produce human target proteins. Such biologics partially solve the problem of previous protein sources, extracted from animals or human sources, of contamination and immune responses. The strategy is very effective for blood transported proteins such as antibodies (MABs), hormones and blood factors. But intra-cellular proteins still demand delivery and accurate cell targeting. This creates analogous problems to those of gene therapy.
CAR is chimeric antigen receptor. Killer T lymphocytes are genetically engineered to produce a novel protein, composed of pieces from different parts of the immune system such as: antibody components to construct a new receptor binding site on the T cell that targeted an antigen exposed on the cell surface of cancer cells, and two receptor associated signals that switch the T-cell into kill mode and sustain it in that mode. Small clinical trials of CAR-T cells have shown substantial remissions among patients with various blood cancers (Aug 2016, Jul 2017, Oct 2017, Nov 2017). But there are severe side effects. -T Tisagenlecleucel
treatment for CD19 expressing unresponsive B-cell acute
lymphoblastic leukemia is a group of cancers of blood forming tissues: bone marrow, lymphatic network; where abnormal white blood cells are generated. One type of leukemia is induced when TAD boundaries near the TAL1 gene fail allowing promotors from across the TAD border to distort the operation of the TAL transcription factor. Mutation clusters common in leukemia have been identified in CHIP. ,
developed at University
of Pennsylvania & deployed at Children's
hospital of Philidelphia & Duke University,
based on research part funded by the Leukemia
& Lymphoma Society recommended for approval by F.D.A. Food and Drug Administration. panel (Jul
2017)
- Identifying gene issues and mechanisms, from 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).
mutation data, allows rapid association of
current medicines with rare diseases (Sep
2018)
- Generic EpiPen
from Teva
gets F.D.A. Food and Drug Administration. approval
(Aug
2018)
- Personalized
medicine is a medical strategy where decisions, practices, and products are tailored to the individual patient. Research is looking at the impact of providing potentially deleterious genomic testing information to people: The REVEAL study found no increased anxiety induced by hearing that one's genome implied increased risk of developing late onset Alzheimer's disease. The take-up of personalized medicine benefits from the focus on genomics, enabled by next generation sequencing of DNA, and detailed by the NIH director Francis Collins and includes:
- NCCN intensive cell therapies
- Direct to consumer genomic testing
- Direct to consumer diagnostics
- Pharmacogenomics tailored drug treatments reducing the risk and cost of adverse drug reactions.
& immunotherapy is indirect treatment of disease by altering the immune system. Targeted diseases include: cancers -- immuno-oncology, organ transplants.
clinical trials are constrained by: Limited patient base argue:
Yale CC,
MS-KCC,
Genentech;
Companies with me-too products requesting trials -- a situation
companies with F.D.A. Food and Drug Administration.
approval: Merck; are
happy to see. Targeted therapies: GSK, Pfizer, Loxo Oncology;
have even less potential patients which is a concern at Fred
Hutchinson (Aug
2017)
- F.D.A. Food and Drug Administration. commissioner
Gottlieb
champions easier
drug approval. But the approach exposes
methodological issues: 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. ,
reduced pressure to innovate 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.
,
limited impact on value based drug pricing strategy, reduced
feedback from smaller trials, targeted 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.
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). therapies 2%
success rate. Faster approval does not affect the
patient's price experience (Jun
2018)
- Branded drug prices are often raised sharply in response to
the planned entry of generic competition. Mylan's EpiPen pricing
matches this simple model (Aug
2016).
- 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)
- Twenty state attorneys general accuse Teva, Mylan of price fixing
(Dec
2016)
- Senate committee reports on stopping price spikes on
prescription drugs (Dec
2016)
- Biologic insulin regulates the metabolism of carbohydrates, fats and protein by signalling the absorption of glucose by fat, liver and skeletal muscle cells. It is a peptide hormone generated in the islets of Langerhans beta cells of the pancreas. Peter Medawar explains it was an early drug therapy success. As manufacturers have shifted from products developed by extraction to biologics: Humulin, Lantus, Levemir; safety has improved. But the US list price has risen steeply (Feb 2016, Jan 2017)
prices supported by patent extensions, data exclusivity, 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. rebates (Feb
2016)
- Manufacturers: Eli
Lilly, Novo
Nordisk, Sanofi;
accused in lawsuit of price fixing scheme with 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 for Insulin regulates the metabolism of carbohydrates, fats and protein by signalling the absorption of glucose by fat, liver and skeletal muscle cells. It is a peptide hormone generated in the islets of Langerhans beta cells of the pancreas. Peter Medawar explains it was an early drug therapy success. As manufacturers have shifted from products developed by extraction to biologics: Humulin, Lantus, Levemir; safety has improved. But the US list price has risen steeply (Feb 2016, Jan 2017) (Jan
2017).
- Eli Lilly, under
pressure from Congress, move to protect high priced Humalog
100 insulin regulates the metabolism of carbohydrates, fats and protein by signalling the absorption of glucose by fat, liver and skeletal muscle cells. It is a peptide hormone generated in the islets of Langerhans beta cells of the pancreas. Peter Medawar explains it was an early drug therapy success. As manufacturers have shifted from products developed by extraction to biologics: Humulin, Lantus, Levemir; safety has improved. But the US list price has risen steeply (Feb 2016, Jan 2017)
,
leveraged by insurers and 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,
by releasing a lower priced generic: Imclone
Insulin Lispro; an 'authorized generic' strategy
previously used by Mylan
& Gilead,
at a price that is still historically expensive (Mar
2019)
- UnitedHealth
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.
it will
pass on OptumRx
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. drug rebates to
consumers (Mar
2018)
- Brand drug sale rebates
to Insurers: UHC;
& 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: CVS;
are protecting market share for brand name market leading drugs
as generic competition appears. Shire uses the
technique with Adderall
XR. J&J
with Remicade.
Teva
uses it to cover Copaxone.
(Aug
2017)
- Trump administration: HHS is the U.S. Department of Health and Human Services.
secretary
Azar; considers reducing 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.
drug plan
out-of-pocket costs: Pharmaceutical rebates kept by 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 & Insurers:
Humana; would be
driven to patients; reducing political pressure on drug
companies, pleasing Medicare drug end users, increasing
insurance premiums and escalating federal Medicare costs.
PhRMA:
Amgen; defended the
proposal. PBMs: PCMA,
CVS; 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.
Insurers: AHIP;
disappointed (Feb
2018)
- CVS +
Aetna merger is
allowed by regulators with the requirement that some Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
plans are
sold to WellCare
Health Plans. No discrete large PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. is left: UHG (OptumRx),
Cigna +
Express Scripts,
Anthem
building a PBM; limiting drug cost management for smaller
insurers and PBMs. PBMs have been criticised for secret deals
that have helped keep drug prices high. Health plan
control of where prescription drugs are purchased will limit Amazon's disruption of pharmacies,
and likely limit consumers opportunities to bargain. State
regulators will start to look at the operations of
PBMs. Large insurers are also entering health care
provision of low cost care for chronic conditions and chain care
in the community (Oct
2018)
- President Trump signs two laws designed to block: gaging of
best price advice by pharmacists to customers (Collins act of 2018 blocks gag contracts that limit pharmacy staff advising purchasers of the cheapest option to obtain their prescription drugs. The act was sponsored by Senator Susan Collins of Maine and signed into law by President Trump.
),
Outpatient Medicare drug coverage gaging (Stabenow act of 2018 bans gag clauses from outpatient Medicare drug coverage: both Medicare Advantage and traditional FFS plans. It was sponsored by Senator Stabenow and signed into law by President Trump. );
and in an op. ed. he attacked Democrats, signalling, 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. 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
will be bad for retirees. The Senate resisted Democrat's
attempts to block Trump's short term, low cost, skimpy coverage,
insurance plans (Oct
2018)
- HHS is the U.S. Department of Health and Human Services. secretary
Azar, moves to require health insurers and 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 to pass on rebates to
consumers, by making them illegal kickbacks through eliminating
the legal protection provided by CMS is the centers for Medicare and Medicaid services. . The HHS OIG is the HHS Office of Inspector General. enabled the new
interpretation. The government would still provide rebate
protection as long as discounts were applied to the list price
of prescription drugs. Insurers (America's
Health Insurance Plans) were disappointed. Drug
manufacturers (PhRMA),
and oncologists (Community
Oncology Alliance) were pleased with the proposals - as
Democrats noted (Feb
2019)
- Lobbyists: PhRMA,
AAM,
NCPA is the national community pharmacists associations, a lobby for pharmacists.
; move to
constrain drug price concerns (Sep
2015) in Congress by: Fundraising for friendly
Congressmen: John Skimkus; Excluding Turing
from PhRMA, Shifting blame to 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 whose lobbyists,
the PCMA,
are active in courting the Trump administration, Killing CMS is the centers for Medicare and Medicaid services. Slavitt's
Innovation
center is the CMS Innovation Center. It was created by the ACA to test new models of health care delivery and payment including the Pioneer ACO and the Advance Payment ACO. It also offers technical support to providers to improve the coordination of care and share lessons learned and best practices. In 2016 Andy Slavitt proposed testing a new Medicare part B drug pricing rule, which was furiously resisted by PhRMA and blocked by Representative Skimkus collection of 242 Representative's signatures. 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.
Part B
drug pricing There is a monthy premium for Part B. It may be paid directly from Social Security. Higher earners may have to pay IRMAA. Medicare payments to doctors and hospitals for Part B drugs have been based on the average sale price of the drug plus 6%. MedPac advised Congress that this may encourage prescribers to select the highest priced alternative to maximize the 6% payment. Increasingly prescribed high priced biologics increase the impact of the nudge. rule test (May
2017)
- President Trump promises to significantly reduce drug prices:
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.
direct
negotiation on prices, consumer access to Canadian drug
inventories; which are popular with American voters.
Pharmaceutical companies: Amgen,
AstraZeneca, Celgene,
Eli Lilly, Genentech, Gilead, J&J, Merck, Novartis, Pfizer; spend $171.5
million, their trade associations: Biotechnology
Industry Organization, PhRMA
$10 million in first quarter; & lobbyists: BGR Government
Affairs, More than other industries; Administration: Azar,
Gottlieb;
and Congressional supporters: Kyl, Paxon, Whitfield, Andres,
Long, and staff to Dingell and Harkin; prepare to resist after
loss on Medicare
discounts (May
2018)
- Implications of Abbvie's
top selling drug Humira 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.
global
pricing, lobbying & patent strategy and treatment benefits
reviewed (Jan
2018)
- Low cost generics, especially injectables, suffer from supply
shortages (May
2016).
- Kaleo to
re-release Auvi-Q
in 2017 (Oct
2016).
- States respond to high drug prices (Jul
2016).
- California, Colorado and D.C.'s Aid-in-Dying is physician assisted termination of life by application of lethal medications. It was legalized in Oregon by the Death with Dignity act and other states have followed that blue print (Jan 2017).
laws significantly expand the opportunity for physician assisted
death. Vitas
opts out of prescribing. AMA is the American Medical Association. to study
options. Valeant
takes advantage (Jan
2016)
Global competition between brand-name and generic
pharmaceutical manufacturers becomes more complex:
- Teva
moves to join PhRMA:
Eli Lilly is
fighting Teva in court, Pfizer
has Greenstone,
Novartis has Sandoz, Amgen is building
competition for Abbvie's
Humira,
(Jul
2016)
- 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.
are already appearing in Europe putting pricing pressure on
Biotech offerings. They are expected to gain entry to
the US in a few years, but patents may slow the entry
- Patent strategy used by Amgen
& Abbvie to
limit biosimilar 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.
access to 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. formularies are lists of drugs that a health plan will cover. The health plans control where and if the drug is listed in the plan. A less expensive drug can be assigned a lower copayment to encourage patients to use it. To counter this attack on their profits drug companies responded with coupons to help patients pay copayments removing the incentive to select the lower-priced drugs. Health plans reacted to the copayment cards by dropping some drugs from the formulary altogether. That encourages drug companies to bid for their drug to be the only one listed resulting in some downward price pressure. (Jul
2016)
- Implications of Abbvie's
top selling drug Humira 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.
global
pricing, lobbying & patent strategy and treatment benefits
reviewed (Jan
2018)
Evolved amplifiers of trade
flows:
- The US is the United States of America. network trade
deals with Asia: T.P.P. 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.
(Oct
2015) & Europe: T.T.I.P. is transatlantic trade and investment partnership, a proposed trade agreement between the US and EU. (Oct
2016, 2):
Without the catalysis of these deals global growth & trade
slows.
- The dollar remains the global currency, leveraging high
interest rates, and freely available US is the United States of America. debt, to suck foreign
capital to the US: China's heavy handed actions: disappearing
people, captive belt and roads financing, constraining capital
flows from leaving the country; EU is European Union, the 1992 Maastricht Council of Ministers meeting agreed evolution of the ECSC & CAP cartels to include:
- A single market across the members' countries supporting the transformation of the ECSC. It maintained the CAP transfers assisting French farmers.
- A fixed currency 'snake' that allowed the ECSC to operate, binding the deutschmark to the other currencies of participating members: a mini Bretton Woods exchange rate mechanism; that became a single currency, the euro, managed by an independent ECB (based on the independent German Bundesbank); but tax gathering was allocated to the states whose leaders control the Council of Ministers and no effective mechanism was provided to reallocate revenues. This has left Germany with an advantage supported by the aggregate valuation of the euro and not having to flow tax revenues to the weaker economies of the south.
has: no German debt
for sale, no central political authority, Eurozone is the group of countries within the EU that use the euro currency. Economic decisions regarding the euro are centralized through the Eurogroup.
undermining South and East; UK is the United Kingdom of Great Britain and Northern Ireland. : Brexit; allowing the US to leverage
dollar debt to control the financial
system to: Slow China, Collapse
Venezuela & Iran, Pressure EU on sanctions; showing the
power of the Volcker
plan detailed Paul Volcker's strategies for sustaining the US centric post Second World War economic network, once the US became a deficit generator & Bretton Woods could not be sustained. Volcker's goal was to enable the US to use other country's surpluses to support the network's operation under US control, in place of the disappearing US dollar surplus. The strategies included: - Push American interest rates up much higher than those of other linked economies, attracting global free capital to the US dollar.
- Ensure that Wall Street offered a more lucrative market for investors than London, Frankfurt, Tokyo, or Paris.
- Support US business that was impacted by this costly high interest rate environment by supporting the reduction of wage costs. Once Volcker became chairman of the Federal Reserve in 1979, he executed the strategies.
, and allowing the Trump administration maximum power
- even as they build $22 trillion in national debt is a pool of payment promises developed to finance costly discrete and transient activities, Johnson & Kwak explain. Repayments of the capital and interest are made regularly through mechanisms such as a sinking fund. Charles Montague first setup such an indirect arrangement that allowed thirteen and a half million pounds in British war debt (using a million-pound loan serviced by 99 years of new excise duties sold to the public as annuities) to persist in 1693 and supported it with a sinking fund in 1696. This strategy was viewed as scandalous by conservatives at the time. The conservatives argued the debt should be liquidated but Montague's strategy allowed Britain to develop and sustain, until the 20th century, a triple-A fiscal reputation and allowed it to use financial leverage as a weapon of war. Montague's strategy was enabled by the revenues Britain's merchants were obtaining from its developing global trade. CAS theory looks at the pool as a collection of commitments to provide energy to the owners' of the promises.
(Feb
2019)
- The EU is European Union, the 1992 Maastricht Council of Ministers meeting agreed evolution of the ECSC & CAP cartels to include:
- A single market across the members' countries supporting the transformation of the ECSC. It maintained the CAP transfers assisting French farmers.
- A fixed currency 'snake' that allowed the ECSC to operate, binding the deutschmark to the other currencies of participating members: a mini Bretton Woods exchange rate mechanism; that became a single currency, the euro, managed by an independent ECB (based on the independent German Bundesbank); but tax gathering was allocated to the states whose leaders control the Council of Ministers and no effective mechanism was provided to reallocate revenues. This has left Germany with an advantage supported by the aggregate valuation of the euro and not having to flow tax revenues to the weaker economies of the south.
network trade
deal with Canada: CETA is the comprehensive economic and trade agreement between the EU and Canada signed in October 2016. The EU argue there will be half a billion euros in taxes saved yearly by EU exporters. It was framed by TIEA. It does not alter EU non-tariff barriers such as: GMO and growth hormone constraints, Environmental protection. The EU argues it: helps generate growth and jobs, ends customs duties, lets EU businesses bid for Canadian public contracts, Increases regulatory cooperation, Protects EU innovations, Streamlines trade in services and promotes and protects investments. It includes: - Trade in goods
- Tariff elimination on trade in goods
- Rules of Origin
- Technical barriers to trade made more transparent and conformity assessed by protocol.
- SPS rules
- Customs and trade facilitation
- Services and investment facilitation
- Government procurement
- EU law on designations of high quality agricultural products will hold
- Trade and sustainable development (trade and labor)
- Non-tariff barriers on cars (UN-ECE), pharma practices, culture and media, competition, state owned enterprises
- Intellectual property rights
- Copyright provisions
- Investor-state dispute settlement procedure
- Visa restriction removal by Canada on Czech, Romania and Bulgaria.
(Oct
2016, 2);
- Juncker's chief of staff, Selmajr, mysteriously promoted to EU is European Union, the 1992 Maastricht Council of Ministers meeting agreed evolution of the ECSC & CAP cartels to include:
- A single market across the members' countries supporting the transformation of the ECSC. It maintained the CAP transfers assisting French farmers.
- A fixed currency 'snake' that allowed the ECSC to operate, binding the deutschmark to the other currencies of participating members: a mini Bretton Woods exchange rate mechanism; that became a single currency, the euro, managed by an independent ECB (based on the independent German Bundesbank); but tax gathering was allocated to the states whose leaders control the Council of Ministers and no effective mechanism was provided to reallocate revenues. This has left Germany with an advantage supported by the aggregate valuation of the euro and not having to flow tax revenues to the weaker economies of the south.
commission is the policy initiating & executive arm: implementing already agreed policies; of the EU. Policy proposals are legislated by the Council of Ministers. The European Commission is led by the president who is supported by commissioners, and staffed by a large bureaucracy. The president is appointed for five years nominated by the Council of Ministers and approved by the European Parliament. The commissioners are appointed by the Council of Ministers for a five year term, with consultation from the president & ratified by a vote of the European Parliament. France, Germany, Italy, Spain and, until Brexit, the UK appoint two commissioners each, while the other members appoint one each. 's
secretary general (Mar
2018)
- China punishes Glaxo Chinese market
development for corrupt
practices (Nov
2016)
Boom and bust has been the typical scenario in health
care/biotech.
- Part of a broader trend with low rates (Nov
2016)
Patent evergreening describes how drug companies try to extend patent protection by introducing a new version of a drug with minor variations without much clinical benefit but that extends the patent. The new drug is heavily advertised so that it replaces most of the still patented, but old, drug on the market.
and pay-for-delay is a practice used to extend the high profits of a soon to be off-patent protected drug. The companies pay generic manufacturers to delay release of their generic competitor to sustain high pricing.
are under threat (Nov
2015).
Payment and financial innovation have been slow to keep
up. But the 2015
health evolution summit sees a shift.
Contents
- Health care economics
- 2013 Aug Behavioral
Hazard is Sendhil Mullainathan, Katherine Baicker and Josh Schwartzstein's name for patients underuse of highly effective drugs so they can avoid constraining copayments.
- 2013 Sep
More doctors accepting 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.
- 2013 Dec
Growth in U.S. is the United States of America. Health
Care Spending Slows, but 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.
likely to push it up again (Jul 2015, Aug 2015,
Mar 2016, 2, May 2016,
Jul 2016).
Geisinger
Health Plan actuary
agrees costs are going up (Jun 2016)
- 2018 Dec
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
- 2018 Jun
Chicago's
Austan Goolsbee & Stanford's
Peter Klenow, Northwestern's
Robert Gordon and MIT is Massachusetts Institute of Technology. 's Brynjolfsson, note that price
declines, new digital products, and online channels are
distorting the CPI is consumer price index. It reflects the prices of a market basket of consumer goods. Weights are used to reflect models of the share each item in the basket. Gordon notes it suffers from miss-representing standard of living changes due to outlet substitution bias. And it ignored automobiles until 1935 and under-represented their quality impact prior to 1940. Digital channels & products have added to the bias issues (Jun 2018)
models and likely are keeping US is the United States of America. inflation low
- 2018 Jul
Austin
Frakt highlights findings that patients follow doctors
recommendations about where to get treatment, even for highly
elective items: MRI is magnetic resonance imaging where the nucleus of any atom with a net spin will produce a response to the signal. The variety of molecules that can be detected has generated a variety of specialized medical applications.
;
where tools provide details of cost and quality but patients
travel past low cost providers to get to recommended ones
- 2018 Nov
Austin
Frakt explains the network
that generates high spending on drugs in the US is the United States of America. : History shows just
two bumps relative to rest of world: 1997 - 2007, 2013 - 2018;
More drugs developed (1970
- 80s genomics combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes.
based disease treatment explosion) and approved (increased fees
from manufactures to F.D.A. Food and Drug Administration.
increased approvals rate, but by 2007 F.D.A. approval rate was
very low, and now approval standards have lowered) in these
periods: TV promotion in 1990s with reduced regulatory
constraints on advertising, New payment mechanisms: CHIP is:
- The Children's Health Insurance Program started in 1997 as part of the BBA as SCHIP. It provides health insurance coverage for children in families with income below 200 percent of the poverty line. The coverage is focused on care specialized for children including: developmental delays, chronic conditions including asthma and obesity. CHIP's funding must be iteratively re-authorized by Congress. CHIP is financed federally, but states must enroll eligible children. In many states one agency administers CHIP and Medicaid. CHIP is leveraged by families that have employer based insurance with costly premiums, so the families only cover the adults.
- Clonal Hematopoiesis of Indeterminate Potential, where stem cells develop a somatic mutation cluster pair often found in leukemia, which is expressed in white blood cells they produce. The mutation clusters give these stem cells a competitive advantage and they accumulate over time. The white blood cells form inflammatory plaques. CHIP increases with age, increasing the risk of dying, of clot fragment induced heart attacks and stroke, over the subsequent 10 years by 54%
/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.
expansions, 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.
universal
prescription drug benefit in 2006 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.
; supported flows/use; No
constraints on brand name drug prices in US - while UK and
Germany apply price/value constraints on prescribing, which
other countries, except the US, use as models for their
prescription constraints, between 2000 and 2014 30% of the rise
in drug spending attributed to price increases & use of
higher priced drugs. In 2007 patents on cancer therapies
started to expire shifting US to generic flows. In 2013 MAB as a terminator in medication names indicates the drug is a monoclonal antibody biologic. s and other precision
medicines 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). , which are likely to provide focused value,
started to be approved, which suggests US drug spending will
escalate again in the future
- 2019 Feb
Even with 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.
protections,
pre-existing conditions is ACA quality affordable care for all Americans. It mandates community rating & essential health benefits. It includes: - Subtitle A: Immediate improvements in health care for all Americans.
- Subtitle B: Immediate actions to preserve and expand coverage.
- Subtitle C: Quality health insurance coverage for all Americans. Which reforms the health insurance markets and prohibits preexisting condition exclusions and forms of health status discrimination.
- Subtitle D: Available coverage choices for all Americans.
- Subtitle E: Affordable coverage choices for all Americans.
- Subtitle F: Shared responsibility for health care which mandates individuals and employers to pay for insurance.
- The employer mandate requires employers with more than 50 full-time workers to offer most of their employees insurance or face penalties.
information is often used by
insurers to avoid high drug payments, via high out-of-pocket
insurance plan costs - set to drive these patients away from the
plans: HIV is human immunodeficiency virus, an RNA retrovirus which causes AIDS. It infects T-lymphocytes helper cells slowly destroying the host's immune system. The main pandemic form of HIV is HIV-1 M which has been traced back to a spillover to Cameroon/Congolese forest Chimpanzees of SIVs that weakly infected proximate humans and then was amplified by social conditions in expanding towns: Ouesso, Brazzaville, Leopoldville; down river from these forests during the 1900 - 1920s. Additional amplification occurred through public health programs: Trypanosomiasis, STDs; which cross-infected subpopulations of Leopoldville/Kinshasa around the same time. UNESCO organized Haitian support for the DRC in the 1960s vectored HIV-1 M back to Haiti where the blood plasma trade provided an evolved amplifier for HIV-1 M infected plasma to flow into the US healthcare supply chain through Miami. Some HIV's enter the lymphocytes by leveraging the T cells CCR5 protein. The HIV X4 variant leverages CXCR4. , 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. ;
sufferers
- 2017 Jul
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).
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. .
Krugman explains why 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.
architects didn't use it (Jul 2017)
- 2017 Nov ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
and competitive
pressures encourage payer include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
-delivery
integration across the health care spectrum
- 2018 Feb University
of Pennsylvania's Ezekiel
Emanuel argues traditional
hospital business model is under pressure
- 2019 Feb
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 and health insurance (fear powerful
new competitor taking profits) industries to respond, whith
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
- 2014 Jan,
Sep Patients'
costs skyrocket as specialists incomes soar (infrastructure
amplifier)
- 2018 Oct 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. A peer reviewed paper describing 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
- 2019 Mar
Investing 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.
involves: indirectly
investing in illiquid assets that are not traded on a public
market: debt, real estate,
specialized financing, stressed loans in Europe; all with
different 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. ,
high fees, locking in for 4 to 14 years with the same manager,
mandatory extensions, capital calls is a legally enforceable transfer of investor committed funds, to an investment or insurance firm, so that the firm can use the fund's capital to purchase an asset. ,
drawdowns of investment fund commitments over years, returns
only occurring when a funds purchased asset is sold, and minimal
regulations; with 7000 private investment companies: Apollo
Global; Cambridge Associates Anrea Auerbach offers
comments: The skill of the manager is important to the bottom
line, spreading investments across different: fund raising years
- to hedge against all assets being purchased at market peaks,
& strategies; coping with capital calls when 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. is
collapsing, large investors usually allocate 15% to 40% of their
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). to Private
Equity
- 2015 Oct Dementia is a classification of memory impairment, constrained feelings and enfeebled or extinct intellect. The most common form for people under 60 is FTD. Dementia has multiple causes including: vascular disease (inducing VCI) including strokes, head trauma, syphilis and mercury poisoning for treating syphilis, alcoholism, B12 deficiency (Sep 2016), privation, Androgen deprivation therapy (Oct 2016), stress, Parkinson's disease, Alzheimer's disease, and prion infections such as CJD and kuru. The condition is typically chronic and treatment long term (Laguna Honda ward) and is predicted by Stanley Prusiner to become a major burden on the health system. It may be possible to constrain the development some forms of dementia by: physical activity, hypertension management, and ongoing cognitive training. Dementia appears to develop faster in women than men. is hugely
expensive for everybody
- 2018 Jan
Nursing homes: Allenbrooke,
Bruis
Healthcare, Fairfield
Nursing & Rehabilitation; purchased by 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.
,
private investors and public companies, are structured into LLCs
with ownership and owned supply networks to extract profits and
limit owner liabilities & taxes, but impacting quality and
safety; a finding disputed by the American
Health Care Association
- 2016 Aug
After CMS is the centers for Medicare and Medicaid services. allows
for-profits into PACE is either:
- Protecting Affordable Coverage for Employees Act of 2015, which amends ACA title 1 to alter the definition of a small business, or
- Program of All-Inclusive Care for the Elderly, a Medicare program which pays for facilities and services to keep older and disabled Americans in their own homes instead of their having to enter nursing homes. It was intended to consequently save Medicare and Medicaid money. All states are required to pay less than the cost of a nursing home stay. It leverages the success of Britain's Day Hospitals. PACE started as On Lok, which provided capitation funded day care, to San Francisco's Asian & Italian immigrant families trying to avoid use of nursing homes. This payment model should encourage providers to keep their patients healthy. The services include dentistry, which constrains a problematic cascade of issues and rehabilitation which protects against falls. Medicare sanctioned the model in 1990. Its implementation was restricted to non-profit organizations but in 2016 CMS allowed for-profit organizations to participate (Aug 2016).
the program is highlighted at the J.P.Morgan
Healthcare
Conference and gains the interest of 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. .
- 2017 Aug
Long-term care issue: Poor pay, little allocated 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.
budget at
the federal or state level, immigrant female staff, demeaning cultural is how we do and think about things, transmitted by non-genetic means as defined by Frans de Waal. CAS theory views cultures as operating via memetic schemata evolved by memetic operators to support a cultural superorganism. Evolutionary psychology asserts that human culture reflects adaptations generated while hunting and gathering. Dehaene views culture as essentially human, shaped by exaptations and reading, transmitted with support of the neuronal workspace and stabilized by neuronal recycling. Damasio notes prokaryotes and social insects have developed cultural social behaviors. Sapolsky argues that parents must show children how to transform their genetically derived capabilities into a culturally effective toolset. He is interested in the broad differences across cultures of: Life expectancy, GDP, Death in childbirth, Violence, Chronic bullying, Gender equality, Happiness, Response to cheating, Individualist or collectivist, Enforcing honor, Approach to hierarchy; illustrating how different a person's life will be depending on the culture where they are raised. Culture: - Is deployed during pregnancy & childhood, with parental mediation. Nutrients, immune messages and hormones all affect the prenatal brain. Hormones: Testosterone with anti-Mullerian hormone masculinizes the brain by entering target cells and after conversion to estrogen binding to intracellular estrogen receptors; have organizational effects producing lifelong changes. Parenting style typically produces adults who adopt the same approach. And mothering style can alter gene regulation in the fetus in ways that transfer epigenetically to future generations! PMS symptoms vary by culture.
- Is also significantly transmitted to children by their peers during play. So parents try to control their children's peer group.
- Is transmitted to children by their neighborhoods, tribes, nations etc.
- Influences the parenting style that is considered appropriate.
- Can transform dominance into honor. There are ecological correlates of adopting honor cultures. Parents in honor cultures are typically authoritarian.
- Is strongly adapted across a meta-ethnic frontier according to Turchin.
- Across Europe was shaped by the Carolingian empire.
- Can provide varying levels of support for innovation. Damasio suggests culture is influenced by feelings:
- As motives for intellectual creation: prompting
detection and diagnosis of homeostatic
deficiencies, identifying
desirable states worthy of creative effort.
- As monitors of the success and failure of cultural
instruments and practices
- As participants in the negotiation of adjustments
required by the cultural process over time
- Produces consciousness according to Dennet.
view of
the role; are ensuring a huge shortage of home aides who will be
needed to support the growing elderly population. MIT is Massachusetts Institute of Technology. Sloan's Osterman
hope reducing system errors will justify investment in the
role.
- 2018 Oct
Fewer people are going to SNF is skilled nursing facility.
s.
Many facilities, even with 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.
5 star ratings 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
are closing. At 70% occupancy, revenue from assisted living is an alternative to parents joining their children's nuclear family or entering a SNF, or Greenhouse Nursinghome. Atul Gawande's Being Mortal describes the situation. Federal Medicaid does not directly cover assisted living. State Medicaid adds coverage through a federal waiver. Congressional legislation covering assisted living is limited. Assisted living providers are represented by the National Center for Assisted Living.
and independent residents, did not compensate for SNF losses,
because of costly regulatory requirements: 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.
hospital readmission have become a source of increased revenue for hospitals. But with government interested in reducing the US health care cost curve ACA's HRRP (pay-for-performance), BPCI and CTI and Interact discharge initiative have all increased the focus on unnecessary readmissions. Now the end-to-end process is under scrutiny with hospitals reengineering discharge (RED) and PAC providers using RAI and TCN.
penalties have driven many patients to be admitted to hospital
as observation
stays observation stays are inpatient like stays in hospital, except Medicare does not count the stay towards the qualification for SNF reimbursements and the copay for the observation may be considerable. The volume of outpatient observation stays has been rising. , where Medicare won't cover rehabilitation after
discharge, More outpatient surgery is being performed, 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 seek lower cost alternatives, Patients
seek other options when they can: assisted living, home
care. The 2005 DRA is the deficit reduction act of 2005. It includes a critical imperative to CMS to develop a Medicare payment reform demonstration, using standardized patient information to examine consistency of payment incentives for various Medicare populations, treated in various settings. As the 2006 budget reconciliation bill (S 1932) it included provisions expected to reduce Medicaid spending by $10 billion over 10 years. Among the rules are: - Tighter restrictions on asset transfers. Aims to reduce seniors transferring substantial amounts of their money and other assetts to relatives to be eligible for Medicaid funded long term care services. Those with $500,000 or more in home equity would be automatically disqualified from applying for Medicaid.
- Greater flexibility to impose premiums and cost-sharing and to change benefit design for certain Medicaid beneficiaries.
- Gives all states long-term care partnership programs
- Authorizes states to include home and community-based services as an optional Medicaid benefit.
allowed 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.
to fund assisted living and home care alternatives to SNF
care. Most SNF businesses are at 82% occupancy.
These businesses will cut staffing to protect margins. It
is expected that as the baby boomers reach 80 the demand for SNF
will rise again
- 2018 Aug
Study by Stanford's
Liran Einav, MIT is Massachusetts Institute of Technology. 's
Amy Finkelstein & University
of Chicago's Neale Mahoney, reports LTCH is a long-term care hospital. The formal designation began as a congressional strategy to protect the 40 chronic disease hospitals from the impact of the original PPS being deployed to constrain costs in acute care hospitals in the 1980s. A historic example San Francisco's Laguna Honda Hospital is discussed in Victoria Sweet's God's Hotel. LTCH PPS reimburses at far higher rates than the PPSs for other PAC providers. Most of the more than 400 LTCHs are now operated by large for-profit health care networks: Select Medical. LTCH's trade group is the NALTH.
market has
expanded in response to high 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.
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.
funds
relative to other 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.
,
but with no indication of improvements for patients over SNF is skilled nursing facility. s. Researchers
conclude $5 billion could be saved yearly by using SNF
reimbursement rates, agreeing with 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. 's prior
recommendations, but at odds with NALTH
and Select
Medical
- 2018 Mar
MIT is Massachusetts Institute of Technology. 's economist 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.
Finkelstein & Northwestern
economist Notowidigdo's research finds income significantly
impacted, averaging to a $11,000 a year reduction, for people
who have had hospital treatment. Health insurance protects
against the treatment costs but US is the United States of America. is missing disability
insurance. This aligns with Hunter College's
Himmelstein & Senator/Harvard's
Elizabeth Warren's key paper on medical problems associations
with bankruptcy is a legal status for an entity that cannot repay its creditor's loans. It holds creditor lawsuits in abeyance while the restructuring process proceeds to allow the entity to continue operations. It also has legal tools for forcing holdout creditors to accept repayments that are lower than the bond sale initially promised. .
- 2018 Aug Bankruptcy is a legal status for an entity that cannot repay its creditor's loans. It holds creditor lawsuits in abeyance while the restructuring process proceeds to allow the entity to continue operations. It also has legal tools for forcing holdout creditors to accept repayments that are lower than the bond sale initially promised.
faces
3 times as many retired people as in 1991, driven by 3 decade
structural shift of financial risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. from government
and employers to individuals, through: increased wait for social security 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.
, shift
to 401(k) pension plans, increased out-of-pocket spending on
health care (Boston College), falling incomes; with many
finding: Gaps in Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
coverage exposing them to costs they can't manage, Support for
children or parents
- 2015 Nov
Prostate
cancer is cancer of the prostate gland. Genomics detected several common DNA variants associated with increased risk of prostate cancer. Dr. Francis Collins explains that a cluster of these risk variants lies in a stretch of 1 million DNA base pairs on chromosome 8. The cluster contains seven or more risk variants, each of which can raise the risk of prostate cancer by 10 to 30%. The high risk variants occur more frequently in African-American men than European or Asians. African-Americans die from prostate cancer at more than twice the rate of Europeans. Research in mice may explain a link between obesity and prostate cancer (Jan 2018). The average diagnosis is at age 66. Worldwide in 2012 there were 1.1 million cases from which 307,000 died. A common life-saving (Feb 2017) treatment is androgen deprivation therapy, but it has worrying side effects. Various classically defined types of cancer can occur. The most common is adenocarcinoma associated with the epithelial gland cells that generate seminal fluid. Epithelial cell differentiation potency makes these significant cancer agents. Other very rare types of cancer that can start in the prostate are:
- Sarcomas
- Small cell carcinomas
- Neuroendocrine tumors
- Transitional cell carcinomas
testing USPSTF is United States preventative services task force. It is an independent expert panel focused on prevention and evidence-based medicine appointed by HHS.
recommendation questioned by new study. Androgen
deprivation therapy lowers the levels of male sex hormones. These hormones stimulate the growth of prostrate cancer cells. But the treatment: Bicalutamide, Lupron; is associated with increased rates of: Depression (Apr 2016), Dementia (Oct 2016) including Alzheimer's disease (Dec 2015). associated with increased depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult; (Apr 2016), and dementia is a classification of memory impairment, constrained feelings and enfeebled or extinct intellect. The most common form for people under 60 is FTD. Dementia has multiple causes including: vascular disease (inducing VCI) including strokes, head trauma, syphilis and mercury poisoning for treating syphilis, alcoholism, B12 deficiency (Sep 2016), privation, Androgen deprivation therapy (Oct 2016), stress, Parkinson's disease, Alzheimer's disease, and prion infections such as CJD and kuru. The condition is typically chronic and treatment long term (Laguna Honda ward) and is predicted by Stanley Prusiner to become a major burden on the health system. It may be possible to constrain the development some forms of dementia by: physical activity, hypertension management, and ongoing cognitive training. Dementia appears to develop faster in women than men. including
Alzheimer's
disease 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.
(Oct
2016).
- 2018 May ACS
shifts to starting colon cancer is a major hereditary cancer also called colorectal cancer. It:
- Follows a slow, many yearlong, progression from a benign polyp to a localized cancer to an invasive one. Two bacteria: Bacteroides fragilis, Escherichia coli variant; from the gut microbiome have been implicated in the early stages of tumor induction (Feb 2018). It
- Is often associated with Ras mutations and the high risk allele TCF7L2. 30 to 50% of colon cancers have KRAS mutations. Intensive medical surveillance and removal of polyps can be lifesaving for those at high risk. Types of colon cancer include the single gene mutation hereditary: FAP, HNPCC;
- Is linked to obesity.
screening at 45, as people are increasingly getting: rectal cancer is also called colon cancer. It:
- Follows a slow, many yearlong, progression from a benign
polyp to a localized cancer to an invasive one. Two
bacteria: Bacteroides fragilis, Escherichia coli variant;
from the gut microbiome have
been implicated in the early stages of tumor induction (Feb
2018). It
- Is often associated with Ras
mutations and the high risk allele TCF7L2.
30 to 50% of colon cancers have KRAS
mutations. Intensive medical surveillance and
removal of polyps can be lifesaving for those at high
risk. Types of colon cancer include the single gene
mutation hereditary: FAP, HNPCC;
- Is linked to obesity.
- person born in 1990 is four times more likely as a person born
in 1950, colon cancer - 2 times as likely; at a comparable
age. This new recommendation currently conflicts with the
2016 USPSTF is United States preventative services task force. It is an independent expert panel focused on prevention and evidence-based medicine appointed by HHS.
guidelines
- 2017 Oct
Pfizer strategy
review keeps innovative health & Essential health but
considers spinnoff or sale of consumer
health unit
- 2016 Aug
Pfizer buys Medivation for
prostate cancer drug Xtandi.
- 2019 Jan
Bristol-Myers,
under CEO Giovanni Caforio, acquires Celgene,
a company: near the top of Trump F.D.A. Food and Drug Administration. 's shame
list, which cancelled its REVOLVE Crohn's disease is an IBD which results in abdominal pain, diarrhea, weight loss, anemia, skin rashes, arthritis, colon cancer. There are genetic risk factors: PD-1 failure, and mutations of LRRK2, SLC11A1. Treatments include: Natalizumab, Remicade;
drug trial, which makes Thalomid (2/3 of its revenues, but on a
patent cliff while resisting providing samples to generic drug
makers) & Revlimid,
which has acquired Impact Biomedicines & Juno
Therapeutics; for $74 billion. BMS's Opdivo sales have
lagged Merck's Keytruda
- 2019 Mar
Large pharmaceutical companies: BMS, Eli Lilly, Roche; rich with cash
from tax repatriation, are using it to purchase biotech
companies: Celgene,
Loxo Oncology,
Spark
Therapeutics; to obtain blockbuster drugs
- 2016 Nov
Consolidation is expected while rates are low.
- 2015 Nov 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.
- 2016 Apr
NSAID is a nonsteroidal anti-inflammatory drug, such as ibuprofen. They inhibit the production of prostaglandins. They are often used to treat pain and inflammation. Since prostaglandins are involved in collagen production NSAIDs can undermine healing. They are also associated with increased risk of heart attacks (May 2017).
s and
tendinitis
- 2015 Nov
Review of Ending Medical Reversal
- 2016 Aug
Review of safety net
hospital are hospitals which care for a financially challenged patient population. There are about 300 safety-net hospitals including: Grady memorial, Harris Health, Mcleod; in the US providing longer term care to the poor and indigent than regular for-profit and non-profit acute care hospitals. This arrangement allows the other hospitals to focus on the needs of their insured customers. Once acute treatment of a life-threatening illness, which will be funded by Emergency Medicaid, has completed, longer term treatment depends on the support of a safety net hospital. This dependency is being undermined by HRRP (Dec 2018).
funding
- 2014 Mar
New Jersey developers repurposing closed hospitals as for-profit
medical
malls & 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).
(Jul 2014)s
- 2016 Aug
Hospitals adding hotel facilities
- 2017 Nov
Brown
University accepts CV Properties vision & partners
with public schools: University of Rhode Island, Rhode Island
College; deploying a nursing school, to create innovation hub
- 2016 May Mt.
Sinai Beth Israel to be replaced by smaller buildings
- 2018 Dec
New York hospitals: Mount
Sinai West, New
York Presbyterian's Allen Hospital & Lower Manhattan
Hospital, Bellevue;
reduced natural birthing services & infrastructure, while
regulations still require midwifes at birthing centers to be
supervised by a doctor. These limitations &
constraints reduce the opportunity for natural births in New
York by: reducing facilities & encouraging profitable 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. interventions:
C-section (is reimbursed for $10,000 more than a vaginal birth),
episiotomies is an incision made in the perineum and posterior vaginal wall to assist with childbirth.
& sleep facilitates salient memory formation and removal of non-salient memories. The five different stages of the nightly sleep cycles support different aspects of memory formation. The sleep stages follow Pre-sleep and include: Stage one characterized by light sleep and lasting 10 minutes, Stage two where theta waves and sleep spindles occur, Stage three and Stage four together represent deep slow-wave sleep (SWS) with delta waves, Stage five is REM sleep; sleep cycles last between 90-110 minutes each and as the night progresses SWS times reduce and REM times increase. Sleep includes the operation of synapse synthesis and maintenance through DNA based activity including membrane trafficking, synaptic vesicle recycling, myelin structural protein formation and cholesterol and protein synthesis. Sleep also controls inflammation (Jan 2019) Sleep deprivation undermines the thalamus & nucleus accumbens management of pain.
injections. Mount Sinai West plans to replace its birthing
center with 13 NICU is neonatal ICU also called an intensive care nursery.
beds & 15 private postpartum beds ($900 a night per
bed). New York Presbyterian is building the Alexandra
Cohen Hospital for Women and Newborns with 75 postpartum rooms
& 60 NICU beds and a proximate OR is operating room. as a state-of-the-art
maternity facility to compete for a hotel like experience.
In NYC: African Americans die in childbirth 12 times more often
than whites, Home births are viewed as risky, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. , and insurance
is out of network for midwifes who do home birthing. Doula is a birth coach, a non-medical person who supports the mother and her family during childbirth and recovery. s and Midwifery
practices have closed in response to high malpractice insurance
and low 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.
.
NYCHHC's
Metropolitan bucks the trend in partnership with Village
Maternity & private postpartum rooms at no extra
charge. New York has four remaining birthing centers: New
York Presbyterian, Brooklyn, Buffalo, New York in Brooklyn; New
Jersey is a more accommodating state. Texas has 70
birthing centers. California has 44
- 2017 Oct
Arkansas,
Rural Baxter
Regional Medical Center, hovers at break even: dependent
on ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. expansion,
is center of regional economy is a human SuperOrganism complex adaptive system (CAS) which operates and controls trade flows within a rich niche. Economics models economies. Robert Gordon has described the evolution of the American economy. Like other CAS, economic flows are maintained far from equilibrium by: demand, financial flows and constraints, supply infrastructure constraints, political and military constraints; ensuring wealth, legislative control, legal contracts and power have significant leverage through evolved amplifiers. ;
Arkansas
State University-Mountain Home 2 year college focuses on
supplying the hospital with workers
- 2018 Jul 85
rural hospitals (5% of them) have closed since 2010. 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
- 2018 Sep
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.
- 2019 Mar
Time of day, month during the year, and type of hospital, affect
the risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty.
of
complications from giving birth. 12,000 of two million
births included: severe perineal laceration, ruptured uterus,
unplanned hysterectomy, admission to ICU is intensive care unit. It is now being realized that the procedures and environment of the ICU is highly stressful for the patients. In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD. Intubation and catheterization are also traumatic. Sometimes seperated into MICU and SICU. eICU skill centralization may bring down costs. , unplanned
follow-on operation; with night shift risk 21% higher, weekends
9% higher, holidays 29% higher. Teaching hospitals is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017); , at
the start of new residencies, are 28% higher - with risk droping
to normal by June. All these factors increase the costs of
a hospital birth
- 2016 Jun Boston
Children's Hospital upgrade
- 2016 Nov
Cloud and Agile adopted outside of technology area.
- 2017 Jun
Exclusive concierge
practices: Encina,
MD Squared, Private
Medical; focused increasingly on the super rich
- 2018 Apr
Concierge
practices stretch to cover 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.
services: Priority
Private Care; and hospitals also support concierge
offerings: Mount
Sinai Hospital, Hospital
for Special Surgery, Weill
Cornell; while Texas allows free standing ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). s: Coppell ER;
- 2014 Jul
The Long Wait to See a Doctor
- 2017 Sep
Medical schools disintermediated
by for-profit systems: Adtalem Global's: Dominica sited Ross,
St. Martin sited American; Dominica's All Saints, Granada's St.
Georges; but hurricanes: Wilma Maria; intervene
- 2016 May
Prostate is a male only gland positioned between the bladder and rectum. It generates part of the seminal fluid. It enlarges during puberty to the size of a walnut stimulated by androgens and the remains stable or grows slowly with age. The prostate includes several types of cells including the gland cells that make the prostate fluid. The Urethra passes through the middle of the prostate.
tests:
still being performed on older men, as recommendations say don't
test at all (May
2016)
- 2019 Jan
Hospitals required to display chargemaster is a hospital specific mapping of chargeable ICD procedure codes to the description and list price set by the hospital.
and DRG is a diagnosis-related group. It transformed the health care operating model, when 467 DRGs with standard payments were introduced by Medicare in the 1980s, enabling for-profit business strategies to seek ways to cut expenses and hence increase profits. The DRG is a classification, designed by Yale's Robert Fetter and John Thompson, intended to define the products that a hospital provides. It assumes patients within a grouping are clinically similar. Grouping is based on ICDs adjusted for age, sex, discharge status and comorbidities. For Medicare hospital inpatient claims the DRG is used to select the fee that will be reimbursed. charges for
common procedures by CMS is the centers for Medicare and Medicaid services. .
Listings: Highland
Hospital, Kaiser, Santa
Clara Valley Medical Center, Seton,
Stanford,
UCSF MC;
provide little insight into patient bills
- 2019 May
RAND study, of 1,598 hospital treatment's insurance claims,
shows Parkwiew
Health, in Indiana, charges private
insurers 4 * its Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
prices. States paying the most are: Indiana, Wyoming,
Maine, Wisconsin, Montana, Colorado, Texas, Georgia, Ohio,
Washington; On average hospitals charge 2.4 * Medicare
prices to private health insurance patients. Outpatient
care was 3 * Medicare pricing; angering employers. Employers
say they must exert discipline on health care costs: will gather
data on prices and quality to decide on the best strategy: single-payer is a healthcare architecture in which there is a single financing organization. Significant aspects of single-payer include: - Strengths of single-payer:
- Removes the extensive replication of payer organizations and their different interfaces to the other healthcare entities and subscribers.
- One payment organization, removing the need to allow subscribers the yearly choice to change payer, encouraging payers to help subscribers remain healthy
- Single-payer instantiates a political monopoly on health insurance.
- Problematic implementation of single-payer in the US
- Undermines the alignment of the healthcare network, threatening profits, power structures and financial rewards. This limits the possibility of single-payer in the US: Lobbying juggernaut: Politicians, Providers, Doctors, Insurers; leveraging dislike of tax increases, The 9 out of 10 Americans who are employed or retired are satisfied with their situation, Current insurance costs are hidden from the insured: in lowered pay packages, spread over all tax payers reducing government revenues; Current private insurers would be forced to reduce costs;
- Alters one sixth of the US economy: Commercial health insurance replaced, investors impacted by transformation of business models; a huge change of high uncertainty, something evolution works to avoid by including mechanisms to force small incremental changes.
- A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations. Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016).
;
Insurers are not incented to keep prices down when working for
self-insured companies - where insurers are spending the
companies money and make more revenue when the company spends
more. Anthem
claims narrow
networks - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans. This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans. By limiting the number of providers/doctors offered in the plans the few that are included should get more business. Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers). In large cities narrow networks are even more common. Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills. There are problems induced by narrow network constraints: - Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts. Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running. If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016).
of hospitals is its direction to drive down
prices. One-third of all healthcare spending goes to
hospital care. Hospitals are buying physician practices is physician practice management. This consolidation of PCP practices was partly a response to Wall Street's capitalization of HMOs and hospitals in early 1990s. As Wall Street switched to financing PPMs, enabling Medpartners's purchase of Mullikin Inc., hospitals responded by buying up the PPMs. Most PPMs struggled to control costs in the capitated care framework of the 1990s. Some of these PPMs shifted to become PBMs. and
spending on new buildings. Hospitals argue they lose money
on Medicare and Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. ,
so the comparison is biased
- 2016 Nov
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).
pricing issues
- 2017 Jul
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).
pricing and surprise
billing is where a contracted service is used by a patient and the bill contains huge out-of-network charges from doctors who were consulting to the health care provider. The opportunity to catalyze profits for: hospitals, physician staffing companies; while coping with rural E.D. staff shortages is encouraging this situation. Examples include: E.D. billing (Nov 2016, Jul 2017) issues associated with outsourced servicing
provided by Envision's
EmCare finds Yale's Zack
Cooper.
- 2018 Sep
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).
pricing is a
hospital controlled monopoly is a power relation within: - A state in which a group has enough power to enforce its will on other citizens. If this is a central authority with a cohesive military, it can overpower other warlords and stabilize the society.
- An economy in which one business has enough share in a market segment to control margins to its advantage. An economic monopoly can be broadly beneficial: AT&T monopoly, US patent monopoly rights;
enabled by state laws requiring insurance to pay, even when
there is no insurance contract. Half of all hospital
admissions are through the ED. Billed charges is a hospital's undiscounted chargemaster bill for a procedure. In the ED it will include a high facility fee, and each seperate procedure, which may be due to strategic billing, can be upcoded (1 - 5) depending on its complexity. It is found that hospitals are increasingly upcoding to level 4 or 5 (serious auto accident) for provision of basic care. While in-network insurance constrains the actual charges a hospital can make, the use of ED contract staff, not bound by the patients insurance contract with the hospital, can result in surprise billing.
have risen exceptionally. Maryland has capped billed
charges at 125% of contracted rates
- 2014 Jul
Race Is On to Profit From Rise of 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.
- 2016 Mar
(2, Apr 2016)
RAND concludes minute clinics are not slowing ED use
- 2015 Oct
Regional hospitals hit by ACA are closing
- 2015 Apr
Health Care Trade-off: Fewer Choices, Lower Bills
- 2013 Dec
Frail elderly hot
spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community. patient numbers have grown significantly. They
get better primary care at home: VA - Department of Veterans Affairs. Includes the Veterans Health Administration.
home-based primary
care, Sutter's
AIM is Sutter Health's Advanced Illness Management, a home-based primary care program for treating its frail elderly hot spot patients. By keeping patients out of the hospital whenever possible, it saves Medicare > $2000 per patient per month. (Brad Stuart's ACIStrategies
Advanced Care Innovation consultancy) Hospice of
the Valley's David Butler, Georgetown
university/MedStar
Washington
hospital center's George Taler; see cross functional teams
treating aging hot
spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community. patients at home as better value and removing the
frail from hospital/ICU is intensive care unit. It is now being realized that the procedures and environment of the ICU is highly stressful for the patients. In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD. Intubation and catheterization are also traumatic. Sometimes seperated into MICU and SICU. eICU skill centralization may bring down costs.
dangers. But there were problems: American's think of
hospitals and health care as improving health,
Multi-disciplinary team based treatment focused on the patient's
goals is radical, Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
funding focus historically on hospital based care; all
constrained the strategy. It may be enabled by ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
: readmission
penalties have become a source of increased revenue for hospitals. But with government interested in reducing the US health care cost curve ACA's HRRP (pay-for-performance), BPCI and CTI and Interact discharge initiative have all increased the focus on unnecessary readmissions. Now the end-to-end process is under scrutiny with hospitals reengineering discharge (RED) and PAC providers using RAI and TCN. bundled
payment is where the purchaser disburses a single predefined payment to cover certain combinations of hospital, physician, post-acute, or other services performed during an episode of care relating to a particular condition (unlike capitation). This bundling is assumed (Sep 2018) to allow the value delivery system to optimize around low cost high quality long term health care. With one bundled payment physicians & hospitals must coordinate care and reduce the unit costs to remain profitable. And to avoid taking on risk of expensive complications physicians & hospitals are incented to standardize and focus on quality. This optimization is dependent on quantifying the value of the outcome of the episode of care. Previously FFS payments induced excessive treatment activity. Bundled payment is included in CMS ACE demonstrations and BPCI initiatives. There are significant impacts on IT. - It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.
- Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments.
- Care delivery must be re-architected to reduce costs and improve quality.
- Monitoring sensors can be used to feed reports to ensure re-architected operations conform.
ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. - CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
s, CMMI is the center for Medicare and Medicaid Innovation. It is a test bed for new ways of financing and delivering care. It allowed Congress to institutionalize innovation sending a signal to providers that they would be participating in CMS driven programs that could become mainstream. It funds evaluations of innovative health care models. Under the ACA if the HHS secretary finds any of its projects would reduce Medicare spending without harming the quality of care the projects may be expanded nationwide. The CBO estimates the CMMI will save $34 billion between 2016 and 2026. CMMI projects include: - Medicare will make a bundled payment for hip and knee replacement surgery (CJR) and 90 days of follow-up care forcing hospitals to work closely with doctors, nursing homes and home health agencies.
- New ways to pay for prescription drugs, medical devices, cancer care (OCM).
- HHS secretary has invoked his 3021 authority to institute DPP.
encouraging
insurance companies to seek home based hospice has the key goal of helping people with a fatal illness to have the fullest possible life right now. There are major hospice chains focused on providing palliative care. care; with
Medicare funding linked to cost savings
- 2017 Sep
Weill
Cornell healthcare policy researcher & New
York-Presbyterian physician Dhruv Khullar notes: Anthem's
CareMore,
Geisinger;
aim to support potential hot spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community. patients
in their homes with full support team deployed into the
neighborhoods
- 2016 Feb
Intermountain
Healthcare cost-of-living strategy
- 2017 Sep
Natural disasters: hurricanes; demand special facilities at
hospitals: Texas
Medical Center adds flood doors & raises generators
- 2015 Jul
California
exchange keeps insurance rate rises to 4% on
average.
- 2015 Sep 2015
health insurance deductibles increasing faster than wages
- 2017 Aug
41 major employers including founders: American Express,
Verizon, Macy's; form the Health
Transformation Alliance to reform the private sector
health care system, with IBM
providing data analysis
- 2015 Oct
2015 Poor dropping ACA health insurance
- 2015 Oct
2015 employer mandate insurance has 2% take-up
- 2015 Jul
ACA tax on Cadillac plans builds concerns among employees
- 2015 Jul
Federal
marketplace sees competition between insurers keeping
premiums down.
- 2016 Apr
Health care companies merge but subsequently Abbott Labs
acquisitions have problems (Aug 2016).
- 2017 Feb
Judges block Humana+Aetna & Cigna+Anthem
insurer mergers
- 2015 Aug
Health
Insurance co-ops on the ropes.
- 2015 Sep
What makes it hard to enter state health insurance markets
- 2017 May
President Trump pushes insurers: Aetna, Humana; from the individual
markets by refusing
to guarantee insurance plan subsidies and then shouts 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.
'death spiral'
- 2017 Aug
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.
remains vulnerable
to Trump attacks: threats to withhold risk adjustment aims to lessen the: Influence of risk selection on the premiums that health insurance plans charge, Incentive for plans to avoid sicker enrollees. ACA legislated risk adjustment also has three additional issues: New populations, Cost & rating factors, Balanced transfers within a state/market. CMS developed a methodology that includes a risk adjustment model and a risk transfer formula to ensure premiums reflect the insurance plans scope of coverage rather than health status. Companies with healthier client pools have to transfer money to insurers with sicker populations.
subsidies to drive insurers from the individual
markets, Actions to limit signups by officials
- 2018 Jul
Insurance
co-op New Mexico
Health Connections wins case invalidating federal
government's risk
adjustment aims to lessen the: Influence of risk selection on the premiums that health insurance plans charge, Incentive for plans to avoid sicker enrollees. ACA legislated risk adjustment also has three additional issues: New populations, Cost & rating factors, Balanced transfers within a state/market. CMS developed a methodology that includes a risk adjustment model and a risk transfer formula to ensure premiums reflect the insurance plans scope of coverage rather than health status. Companies with healthier client pools have to transfer money to insurers with sicker populations.
formula. Judge Browning sees no
explanation of federal model justifications - which appear to
erroneously force $0 revenue loss for the government. CMS is the centers for Medicare and Medicaid services. Administrator
Verma uses the result to justify halting adjustment
payments to insurers, blaming Obama model for the error
- 2018 Jul
Trump administration to resume paying risk adjustment aims to lessen the: Influence of risk selection on the premiums that health insurance plans charge, Incentive for plans to avoid sicker enrollees. ACA legislated risk adjustment also has three additional issues: New populations, Cost & rating factors, Balanced transfers within a state/market. CMS developed a methodology that includes a risk adjustment model and a risk transfer formula to ensure premiums reflect the insurance plans scope of coverage rather than health status. Companies with healthier client pools have to transfer money to insurers with sicker populations.
payments
- 2015 Nov
12 of 23 co-ops have closed
- 2015 Nov
UnitedHealth
exchange loss prompts threat to exit exchanges.
- 2017 Jan
UnitedHealth
purchases standalone
surgery center Surgical
Care Affiliates for Optum's
OptumCare
- 2017 Dec
UnitedHealth purchases DaVita's
physician group for Optum's OptumCare for $4.9
Billion
- 2017 Dec
Major Hospital networks: Dignity + Catholic
Health Initiatives, Ascension,
Advocate
+ Aurora;
plan mergers; Tenet
& Community
Health sell off poor performing hospitals & shift
further to outpatient services. All are hoping to capture
patient base before new entrents: UnitedHealth,
CVS Health; can.
United Health's Optum
purchases the Advisory
Board. Republican tax law suggests reduced funding
of: ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
, Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
& Medicaid is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; will all
be further impacting revenue to hospitals
- 2018 Aug
Catholic hospital networks: Dignity, Mercy;
are consolidating with secular hospital networks, and 'silently'
constraining what procedures are allowed to be performed: No
abortion, euthenasia, assisted suicide, direct sterilization; on
their combined infrastructure - which treats one sixth of all
hospital patients, with the support of President Trump's HHS is the U.S. Department of Health and Human Services. OCR
Conscience
& Religious Freedom Division updated 'conscience is the mental agent that punishes behavior that deviates from internal and external norms, according to Ness and Lloyd. Sapolsky views conscience as an evolved process driven by reciprocal altruism and neo-group selection.
protections' rules and the US Conference of Catholic Bishops
- 2018 Mar
UnitedHealth
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.
it will
pass on 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. drug rebates to
consumers
- 2016 Aug
Aetna says it will
leave exchanges.
- 2017 Jun
Anthem
to leave Ohio exchange for 2018 - it is still to decide on its
other markets. Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments. Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures. The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment. Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy.
have
announced other market exits recently. Harvard
Pilgrim ramps premiums. Republicans say they will
provide billions of dollars to stabilize them but with deadlines
in June, maybe not soon enough
- 2017 Aug
New York State's NorthWell
is to close CareConnect
insurance which has been losing money after Rubio
attacks 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.
insurance risk
corridors are a federal program established in 2010 to protect health insurers against the uncertainties they faced in setting the level of insurance premiums when they did not know who would sign up for coverage under the ACA. HHS collects funds from plans with lower than expected claims and transfers them to plans with higher than expected claims. The ACA was designed to capture back excess insurance profits while supporting initial losses with the goal of making the corridors tax payer neutral. They phase out in 2016 (Dec 2015). & ACA risk adjustment are a federal program established in 2010 to protect health insurers against the uncertainties they faced in setting the level of insurance premiums when they did not know who would sign up for coverage under the ACA. HHS collects funds from plans with lower than expected claims and transfers them to plans with higher than expected claims. The ACA was designed to capture back excess insurance profits while supporting initial losses with the goal of making the corridors tax payer neutral. They phase out in 2016 (Dec 2015).
drained reserves
- 2017 Dec
Insurers: Aetna, Anthem,
Blue
Cross Blue Shield of Georgia, Cigna, Humana; have left 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.
individual
marketplaces for 2018 and Trump Administration HHS is the U.S. Department of Health and Human Services. has automatically
reenrolled their former subscribers in new, sometimes costly,
plans: Optima
Health, Harvard
Pilgrim, Community
Health Options; enrollment counselors: Community Health
Works; have a surge of interest
- 2017 Oct
Matching UHG's
OptumRx,
Anthem
sets up 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.
with CVS, replacing
integration with Express Scripts
- 2017 Oct
CVS Health, continues
its UHG
like diversified health services strategy:
merging with Aetna;
responding to Amazon's
potential disruption of pharmacy
market. CVS Health buy Aetna for $69 Billion (Dec 2017).
Views of the merger differ (Dec 2017)
- 2018 Oct
CVS +
Aetna merger is
allowed by regulators with the requirement that some Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
plans are
sold to WellCare
Health Plans. No discrete large PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. is left: UHG (OptumRx),
Cigna +
Express Scripts,
Anthem
building a PBM; limiting drug cost management for smaller
insurers and PBMs. PBMs have been criticised for secret deals
that have helped keep drug prices high. Health plan
control of where prescription drugs are purchased will limit Amazon's disruption of pharmacies,
and likely limit consumers opportunities to bargain. State
regulators will start to look at the operations of
PBMs. Large insurers are also entering health care
provision of low cost care for chronic conditions and chain care
in the community
- 2018 Mar Cigna acquires 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.
Express Scripts
for $52 billion
- 2019 Feb
Startups: Capsule,
DispatchHealth,
Dose Healthcare,
Heal, I.V. Doc, MedZed, Pager; with funding
from: IRA Capital,
Questa Capital,
Alta Partners,
Angels: Paul Jacobs, Lionel Ritchie; aim to be the Uber of
healthcare, treating nonemergency problems: prescriptions, strep
throat, sprained ankle; but hurdles are high: state based
regulations, insurance costs, health care network is powerful
and hard to integrate with; although health insurers are
offering on demand: Anthem,
Health Net, Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. , Aetna, CareFirst,
United
Healthcare, Cigna,
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.
; cover
Heal visits in many PPO
plans preferred provider organization health plan allows direct access to any health specialist although there is typically a network of contracted specialists as opposed to a HMO health plan. for chronic hypertension is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers.
and diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. ; 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. are significant
and powerful tech companies are also interested: Amazon through PillPack, Apple, Alphabet
- 2019 Apr
Lifestyle medicine sites: Hers,
Keeps, Kick Health, Roman and Hims,
Nurx; are allowing
people to self-diagnose and pick drugs. Doctors then act
as gate keepers to the fulfillment of the request. The
sites do off label prescription offers, which may get them in
trouble with States who usually require a relationship between
the doctor and patient before the doctor goes off label.
Sites argue they do not provide health care directly.
Investors are keen and advisors are helping the sites
- 2019 Mar
Lyft increases IPO common stock price to $72 - a $24 billion
market valuation from underwriters, led by J.P. Morgan
Chase & Credit Suisse,
- reflecting strong demand for its positive
return, W. Brian Arthur's conception of how high tech products have positive economic feedback as they deploy. Classical products such as foods have negative returns to scale since they take increasing amounts of land, and distribution infrastructure to support getting them to market. High tech products typically become easier to produce or gain from platform and network effects of being connected together overcoming the negative effects of scale.
networked business model and
delivering huge returns for founders Zimmer & Green and VC is venture capital, venture companies invest in startups with intangable assets s Rakuten and Andreessen
Horowitz, even as it loses $1 billion in 2018
- 2019 Mar
Texas, using templates from company lobbyists: Uber, Tusk Holdings,
Handy; moves to class electronically linked workers as
contractors, not employees. Company strategy is to create
enough state examples to encourage a later federal push to drive
up the power and share prices for Uber, GrubHub, Lyft,
Postmates, Thumbtack, YourMechanic, TaskRabbit
- 2017 Oct
Amazon's purchase of
wholesale licences to sell drugs, and medical devices may disrupt health care markets. Express Scripts's
Tim
Wentworth offers to help
- 2018 Jun Amazon enters online
drug sales in all fifty states with purchase of Venture funded:
Accel Partners,
Atlas Venture,
CRV,
Founder
Collective, Menlo Ventures,
Sherpa Capital,
Techstars; online pharmacy
PillPack for $ 1
billion, where they can use low price to drive orders from 25
million people without insurance or with 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.
. Immediate
filling of orders and reordering has kept purchases at physical
stores but that may change. Market values of retail
pharmacists: Walgreens,
Rite aid, CVS Health; tumbled
- 2018 Jul
Analysis suggests Amazon
may not succeed in disruption of
prescription drug distribution.
PillPack has
relationships with 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:
Express Scripts
(which must renew in July and is owned by Cigna), CVS strategy
and responds to Amazon's move into prescription drug sales
- 2018 Jan
Amazon, Berkshire
Hathaway, JPMorgan
Chase partnership aims to disrupt health care; leveraging
their combined consumer choice & health insurance knowledge
to enable technology to simplify care.
- Analysts doubt they will achieve their goals (Jan 2018) or
the impact will be limited or adverse for other Americans (Feb 2018)
- 2018 Apr
Amazon business model is
pulling in profits from cloud & advertising
businesses. Power allows price increase for Prime
- 2019 Feb Amazon retail sales
slow - to 17% growth while costing more to generate - 23%
increase in shipping costs to $9 billion, as competitors:
Target, Best Buy, WalMart;
learn to leverage physical infrastructure to fulfill customer
orders faster and cheaper, forcing Amazon to respond and spend
more, & Amazon's dependence on 3rd parties for online
shopping VDS hurt revenue, as Amazon has to share it, but
increased margin with lower direct costs. Prime membership
plateauing, India growth strategy constrained, but still huge
growth in AWS (45%), and Advertising based on awareness of
consumer choices
- 2018 Jun
Amazon risks monopoly is a power relation within:
- A state in which a group has enough power to enforce its will on other citizens. If this is a central authority with a cohesive military, it can overpower other warlords and stabilize the society.
- An economy in which one business has enough share in a market segment to control margins to its advantage. An economic monopoly can be broadly beneficial: AT&T monopoly, US patent monopoly rights;
/monopsony is a power relation within an economy where a single buyer of a product interacts with many sellers, to its advantage.
actions, attracting the interest of lawyers and economists, who
admit it does not appear to be harming consumers, with marketing
strategies including: private labeling and promotion emails,
word searches, customer review networks and experiments on its
platform. Limited data is provided to branded
suppliers. Analysts conclude Amazon favors its brands in
some channels or crowds out other brands
- 2018 Feb
Alibaba, TenCent, VoxelCloud;
supported by funding from VC is venture capital, venture companies invest in startups with intangable assets
s:
Sequoia, Matrix Partners;
use machine learning to enable Chinese health care cope with 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 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
- 2014 Jun
Health Insurers pressing down on drug prices. Oct 2014
seems to be working for 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
drugs. Jul 2015
Pressure increases from more angles. Express scripts
covers high priced cholesterol drugs (Oct 2015).
May push up dividends for all (Nov 2015).
Gilead
faces law suits on pricing and patents (Jan 2016).
Gilead discounts hit earnings (Apr 2016).
Expensive anti-inflammatory drugs are significant (Sep 2016).
- 2018 Oct
Insurers: Cigna (Express Scripts),
Harvard
Pilgrim, Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births.
;
worried at the high price and lifelong commitment of Amgen's Repatha
& Regeneron's
Praluent PCSK9 is proprotein convertase subtilisin/kexin type 9 an enzyme activator. It is encoded as zymogen and autocatalysed in the ER. It plays a major role in cholesterol homeostasis. It binds EGF-A domain of LDLR inducing LDLR degradation. Academic researchers Dr. Helen Hobbs and Jonathan Cohen, studying large populations found reduced LDLR results in reduced metabolism of LDL which can lead to hypercholesterolemia. Drugs that can inhibit PCSK9 can lower cholesterol much more than first generation cholesterol inhibitors. inhibitors are
limiting their use by prior-authorization is a constraint imposed by some insurance companies prior to their agreeing to cover some prescribed medications or medical procedures. The constraint may be due to: age, medical necessity, availability of a generic alternative, or to check drug interactions. After a healthcare provider orders a service for a patient, the provider's staff will contact the patient's insurer to determine if they require prior authorization. This should result in an exception process which may involve the provider's staff manual faxing a prior authorization form to the insurer. If the service is rejected, the healthcare provider may file an appeal based on the provider's medical review process. It may take 30 days for the insurer to approve the request.
constraints, even to the one million F.H. is Familial Hypercholesterolemia, which causes heart attacks at a young age with symptoms of very high cholesterol levels. A mutation in chromosome 19 inhibits removal of low density lipoprotein. sufferers in the US is the United States of America. where the F.D.A. Food and Drug Administration. has allowed
their use
- 2018 Oct
Amgen responds to poor
sales of PCSK9 is proprotein convertase subtilisin/kexin type 9 an enzyme activator. It is encoded as zymogen and autocatalysed in the ER. It plays a major role in cholesterol homeostasis. It binds EGF-A domain of LDLR inducing LDLR degradation. Academic researchers Dr. Helen Hobbs and Jonathan Cohen, studying large populations found reduced LDLR results in reduced metabolism of LDL which can lead to hypercholesterolemia. Drugs that can inhibit PCSK9 can lower cholesterol much more than first generation cholesterol inhibitors.
inhibitor Repatha:
$319 million world wide vs. $5.4 billion for Enbrel; due to
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. 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.
constraints and impact of high $14,000 list price 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.
copayment 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); , lowers
the list price to $5850 and removes current rebates. Merck already used the
strategy with poorly selling 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.
drug Zepatier
- 2017 Aug
Gilead to
acquire Kite
Pharma for $11.9 billion
- 2017 Jan
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.
: Prime Aid
Pharmacy; take Express
Scripts to court for its 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. blocking their
dispensing to subscribers. The pharmacies see it as
driving their business to Accredo.
- 2017 May
After criticism for pushing up drug prices Express Scripts
sets up InsideRx program to offer discounts to some low income
groups.
- 2017 Aug
Huge price drops impact generic suppliers: Teva;
and distributors:
Cardinal Health;
as pharmacies & 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:
Express Scripts
+ Walgreens;
cooperate to buy generics at lower prices. FDA Food and Drug Administration. commissioner
Gottlieb
says he will make it easier for generics to get to market.
Consumers don't see the savings
- 2017 Aug Brand
drug sale rebates to Insurers: UHC; &
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: CVS;
are protecting market share for brand name market leading drugs
as generic competition appears. Shire uses the
technique with Adderall
XR. J&J
with Remicade.
Teva
uses it to cover Copaxone.
- 2017 Dec
2 Teva
restructures, cutting 25% of jobs, as Copaxone
attacked by generics & Teva's generics suffer from power of
buying groups formed by pharmacy
chains, wholesalers
& 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
- 2016 Dec
Biogen releases high priced Spinraza for SMA.
- 2016 Aug
Inverted 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. generic
manufacturer Mylan
criticised for pricing of EpiPen.
Investigation links executive incentives (Sep 2016)
Mylan enlists funded academics and lobbyists to remove copayment 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);
issue (Sep 2016).
Patient advocates often have conflicts of interest regarding
drug pricing due to pharmaceutical funding (Sep 2016).
Kaleo to
relaunch Auvi-Q
(Oct 2016).
- 2019 Feb
Generics' low prices limit interest in manufacturing.
Consolidation to 3 powerful wholesalers:
Amerisource,
Cardinal, McKesson;
resulted in rock bottom prices for generics, and little stimulus
for generic manufacturers. So F.D.A. Food and Drug Administration. requirements to
correct manufacturing issues can result in stoppages: Mylan manufactures buspirone is an anti-anxiety medication, marketed as Buspar, which is not a GABA receptor agonist, minimizing potential for physical dependence and withdrawal. It is used to treat: GAD, major depressive disorder where it augments antidepressents.
, at
Morgantown, West Virginia, was told to clean the facility.
It has stopped production of the low profit anti-anxiety is manifested in the amygdala mediating inhibition of dopamine rewards. Anxiety disorders are now seen as a related cluster, including PTSD, panic attacks, and phobias. Major anxiety, is typically episodic, correlated with increased activity in the amygdala, results in elevated glucocorticoids and reduces hippocampal dendrite & spine density. Some estrogen receptor variants are associated with anxiety in women. Women are four times more likely to suffer from anxiety. Louann Brizendine concludes this helps prepare mothers, so they are ready to protect their children. Michael Pollan concludes anxiety is fear of the future. Sufferers of mild autism often develop anxiety disorders. Treatments for anxiety differ. 50 to 70% of people with generalized anxiety respond to drugs increasing serotonin concentrations, where there is relief from symptoms: worry, guilt; linked to depression, which are treated with SSRIs (Prozac). Cognitive anxiety (extreme for worries and anxious thoughts) is also helped by yoga. But many fear-related disorders respond better to psychotherapy: psychoanalysis, and intensive CBT. Tara Brach notes that genuine freedom from fear is enabled by taking refuge. drug
causing major shortages. Impax
already stopped producing buspirone
- 2017 May
Lobbyists: PhRMA,
AAM,
Pharmacists; move to constrain drug price concerns in Congress -
fundraising for friendly Congressmen: John Skimkus; by:
Excluding Turing
from PhRMA, Shifting blame to 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 whose lobbyists,
the PCMA,
are active in courting the Trump administration, Killing CMS is the centers for Medicare and Medicaid services. Slavitt's
Innovation
center is the CMS Innovation Center. It was created by the ACA to test new models of health care delivery and payment including the Pioneer ACO and the Advance Payment ACO. It also offers technical support to providers to improve the coordination of care and share lessons learned and best practices. In 2016 Andy Slavitt proposed testing a new Medicare part B drug pricing rule, which was furiously resisted by PhRMA and blocked by Representative Skimkus collection of 242 Representative's signatures. 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.
Part B
drug pricing There is a monthy premium for Part B. It may be paid directly from Social Security. Higher earners may have to pay IRMAA. Medicare payments to doctors and hospitals for Part B drugs have been based on the average sale price of the drug plus 6%. MedPac advised Congress that this may encourage prescribers to select the highest priced alternative to maximize the 6% payment. Increasingly prescribed high priced biologics increase the impact of the nudge. rule test
- 2016 Jul
Amgen and AbbVie use patents to
block 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.
- 2017 Sep
Using Shore
Chan Depumpo's novel legal strategy, Allergan sells and
leases back patents on Restasis
to Mohawk Tribe to avoid AIA is the Leahy-Smith America Invents Act of 2011 which aimed to modernize the patent system. A key provision of AIA was the creation of the Inter Partes Review process which third parties can use to contest the validity of a patent (for not being novel & non-obvious) within 9 months of its issuance to the Patent Trial and Appeal Board.
US patent review process brought by: Teva;
and other generic drug manufacturers
- 2015 Dec
Sanofi and Boehringer
swap assets
- 2016 Jan Eli Lilly, Novo Nordisk, Sanofi accused in law
suit of price fixing scheme with 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 for Insulin regulates the metabolism of carbohydrates, fats and protein by signalling the absorption of glucose by fat, liver and skeletal muscle cells. It is a peptide hormone generated in the islets of Langerhans beta cells of the pancreas. Peter Medawar explains it was an early drug therapy success. As manufacturers have shifted from products developed by extraction to biologics: Humulin, Lantus, Levemir; safety has improved. But the US list price has risen steeply (Feb 2016, Jan 2017) .
- 2019 Jan Bellevue
Hospital's Dr. Ofri struggles with prescriptions, as high
priced biologic are drugs made in living cells. Typically they are proteins developed using genetic engineering to develop the cellular host, and to customize animal source, DNA to produce human target proteins. Such biologics partially solve the problem of previous protein sources, extracted from animals or human sources, of contamination and immune responses. The strategy is very effective for blood transported proteins such as antibodies (MABs), hormones and blood factors. But intra-cellular proteins still demand delivery and accurate cell targeting. This creates analogous problems to those of gene therapy.
insulin regulates the metabolism of carbohydrates, fats and protein by signalling the absorption of glucose by fat, liver and skeletal muscle cells. It is a peptide hormone generated in the islets of Langerhans beta cells of the pancreas. Peter Medawar explains it was an early drug therapy success. As manufacturers have shifted from products developed by extraction to biologics: Humulin, Lantus, Levemir; safety has improved. But the US list price has risen steeply (Feb 2016, Jan 2017) causes
issues across the VDS is value delivery system. ,
with insurers changing formularies are lists of drugs that a health plan will cover. The health plans control where and if the drug is listed in the plan. A less expensive drug can be assigned a lower copayment to encourage patients to use it. To counter this attack on their profits drug companies responded with coupons to help patients pay copayments removing the incentive to select the lower-priced drugs. Health plans reacted to the copayment cards by dropping some drugs from the formulary altogether. That encourages drug companies to bid for their drug to be the only one listed resulting in some downward price pressure. all
the time to slow costly fulfillment
- 2019 Mar Eli Lilly, under
pressure from Congress, move to protect high priced Humalog
100 insulin regulates the metabolism of carbohydrates, fats and protein by signalling the absorption of glucose by fat, liver and skeletal muscle cells. It is a peptide hormone generated in the islets of Langerhans beta cells of the pancreas. Peter Medawar explains it was an early drug therapy success. As manufacturers have shifted from products developed by extraction to biologics: Humulin, Lantus, Levemir; safety has improved. But the US list price has risen steeply (Feb 2016, Jan 2017)
,
leveraged by insurers and 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,
by releasing a lower priced generic that is still historically
expensive
- 2017 May Hospira (Pfizer), Amphastar generic
injectable base sodiium bicarbonate is in shortage at hospitals:
Duke University
Medical
Center pharmacy.
- 2015 Oct
AAP
urges screening for childhood hunger
- 2018 Apr
Propel's smartphone
app FreshEBT assists with SNAP is the supplemental nutrition action program, food stamps program. It helps about 40 million low-income Americans in 2018. One in four children is on SNAP. The program is federally funded but administered by the states. Most states outsource the operation to private contractors: Conduent, FIS; , but is blocked
by Government contractor Conduent
- 2016 Oct
Fertility clinics promise much more than they can deliver
- 2015 Sep
Hospitals ask oncologists to solicit donations from grateful is an emotion that sets the strength of the desire to reciprocate a favor based on the costs and benefits of the earlier gift. When a favor helps a lot and is costly to the giver we are very grateful. 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.
patients.
- 2015 Oct
House Calls may be more cost effective than they initially
appear.
- 2015 Sep
Startup Turing
Pharmaceuticals increases price of Daraprim 20
fold. NYT's Gretchen Morgenson fills in business drivers (Oct 2015).
With amplifiers reversed Valeant
searches for a credible strategy (Mar 2016).
Horizon
shows how to sidestep insurers and retail pharmacists price
constraints (Oct
2015), Valeant hedge funds highlight amplifiers (Oct 2015,
Apr 2016,
Jun 2016).
Mainline drug makers add to the increasing cost of drugs (Dec 2015).
Arrest of Shkreli gives mainline makers cover (Dec 2015).
Valeant heart drug discount offer hollow (May 2016).
- 2018 Jan
Project Rx, a
generic drug company is formed by a group of over 300 hospitals:
Intermountain,
Ascension,
Trinity
Health; with advice from Duke SOM's
Schulman, to compete with parasitic pharmaceutical strategies
manipulating the generic drug market
- 2018 Jun
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.
Elliott
with asset
managers: Janus
Henderson, ClearBridge;
push out Jonathan Bush, founder and CEO at AthenaHealth.
- 2017 Dec
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.
Elliott
Management reported to take activist stake in Alexion
Pharmaceutical
- 2017 Sep
Glenview
Capital suffers from investments in hospitals: Tenet;
that have added debt from acquisitions but lost customers to
outpatient treatment and HDHP is a high-deductible health plan which has lower premiums and a higher deductable than traditional health insurance plan such as a HMO plan or PPO plan.
pressure
- 2016 Jul 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.
fight each other through Herbalife.
- 2016 May
Insurers flee 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.
as investment logic exposed. Perry Capital
closes flagship fund (Sep 2016).
Outflows reach highest level since 2009 crisis (Oct 2016).
- 2016 Mar
Valeant's Addyi
found to have little benefit
- 2016 Mar
Visium discloses Federal investigation
- 2017 Jul
Pharmaceutical companies: Merck
with Januvia & Januvet, Novartis with Entresto,
Amgen with Repatha
contracting with Harvard
Pilgrim; propose outcomes-based
contracts require suppliers to return money to the health system if the drugs fail to work as expected. Typically drug makers pay rebates to insurers based on the number of drugs sold. The manufacturers gain easier access to insurers' members for their products. It appears unlikely that outcomes-based contracts reduce prescription drug prices (Jul 2017).
- with promotion by PhRMA,
but little evidence that they lower prices asserts 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: Express Scripts,
Prime
Therapeutics;
- 2018 May
Novartis general
counsel, Felix Ehrat, retires, admitting the contract with
Michael Cohen was a mistake. Novartis F.D.A. Food and Drug Administration. approved 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).
drug Kymriah
costs $475,000. Additionally Novartis admitted it is being
investigated by the US government for: marketing practices with
Gilenya, generic industry price-fixing, contributions to
Novartis drug using patient's financial assistance by charitable
groups
- 2016 Mar
Package structure generates costly waste 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
- 2016 Jan
Hemophiliacs is the inability to form blood clots. There are multiple forms: A, B; with mutations of different clotting factor genes. Traditional treatment: Advate; is expensive for the hemophiliacs (Jan 2016). Gene therapy holds the promise of replacing the defective somatic genes in the liver of the sufferer (Aug 2018).
recruited as channel for their specialty
pharmaceuticals 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). .
- 2015 Nov
Even as prices rise the number of Americans using prescription
drugs increases
- 2016 Feb
Startups Blinkhealth
and GoodRx reveal
generic drug prices
- 2017 Dec
Rx Savings
Solutions helps employers reduce employee drug costs as 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.
agreements allow
generics' prices to rise: crestor;
while BlinkHealth,
which is in litigation with its PBM MedImpact &
has lost access to Publix, Walgreens & CVS, and GoodRx supplied
coupons help 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.
generic prescription drug users find low cost offers as
Insurance: UHG,
Cigna, Humana; agreements, co-payment 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); &
deductible requirements & clawbacks refers to a contractual requirement between a payer and provider or retailer (pharmacy), where the cost of the goods supplied to a subscriber is lower than the reimbursement contracted with the payer, and the payer requires the difference to be refunded. with
pharmacists: Walgreens,
CVS; and HDHP is a high-deductible health plan which has lower premiums and a higher deductable than traditional health insurance plan such as a HMO plan or PPO plan. bite into 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.
regulated
transactions value
- 2017 Aug
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
- 2018 Apr
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, CVS Health & Aetna, Wal-Mart & Humana, United Health
employs 30,000 physicians and owns one of the largest urgent care
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
- 2018 Aug
Apple's
[& Amazon's]
current business model reviewed by Harvard's
Mihir Desai, who notes that Tim Cook has: pushed inventory costs
onto suppliers, captures cash from customers fast; with little
stock required with a just in time operation. Cook has
built up predictable subscription models. But Apple has:
taken on debt, purchased shares in buy-backs and limited
investment in hard assets; which all suggest Apple will avoid
making large risky capital intensive investments that perturb
cash flow
- 2018 Jun
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
- 2016 May
Generic injectables are often in shortage for ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016).
- 2015 Jun
ASCO
and UHC release cancer drug evaluation frameworks.
- 2017 Jul
AstraZeneca's Mystic
fails trial endpoint putting company under pressure
- 2013 Health and education may not sustain local growth as
planned (Oct 2013)
- 2016 Apr
Ambulance
firm bankruptcy is a legal status for an entity that cannot repay its creditor's loans. It holds creditor lawsuits in abeyance while the restructuring process proceeds to allow the entity to continue operations. It also has legal tools for forcing holdout creditors to accept repayments that are lower than the bond sale initially promised.
raises infrastructure robustness questions. Driven by the forces
of 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. (Jun
2016).
- 2017 Jul
New York Private
Equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors. Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges. Private equity companies were initially corporate raiders.
company Royalty Pharma
purchases future drug sales royalty rights from Universities
once drugs: Humira,
Remicade;
are FDA Food and Drug Administration.
approved.
- 2019 Mar
J&J
& Bayer will pay
$775 million to settle 25,000 lawsuits about blood thinner Xarelto
causing fatal bleeding episodes the companies did not warn
patients about. Neither company admitted any liability and
they aim to sell Xarelto to the 45 million patients it is
prescribed to. Until recently there was no antidote to the
bleeding that Xarelto, Eliquis and
Pradaxa can cause in some people. Boehringer Ingelheim has
already paid $650 million for bleeding deaths and injuries
caused by Pradaxa. This year the F.D.A. Food and Drug Administration. approved
bleeding antidote Andexxa
- 2017 Dec
TV advertising by big pharma targets elderly for cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
and cardiovascular 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).
treatments: Lyrica,
Humira, Eliquis; as
viewers respond positively to warning lists
- 2018 Jan
Implications of Abbvie's
Humira 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.
global
pricing, lobbying & patent strategy and treatment benefits
reviewed
- 2016 Nov
EMS is emergency medical services providing ambulance and critical care transport.
used as
alternative to 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). use
for elderly
- 2014 Sep New
health care configuration emerges in California
- 2016 Aug
Surgery became cheaper in California
- 2016 Jun
Behavioral health mandated but poorly served.
- 2015 Aug
Puerto Rico loses more doctors as cuts in federal reimbursements
occur.
- 2015 Aug
Paul Krugman compares Puerto Rico situation to Greece
- 2015 Aug
Puerto Rico Fails to make payments on municipal bonds
- 2015 Oct
Puerto Rico and 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.
get cold reception from US Congress
- 2015 Nov
Creditors signal support for Puerto Rico debt overhaul
- 2015 Dec
Puerto Rico tax credits leveraged by pharmaceutical industry
from 1976 to 1990s
- 2015 Dec
Puerto Rico chooses to stop some debt repayments
- 2016 May Puerto Rico issues championed by
Treasury Secretary as other cities
and states in US look in similar risk.
- 2016 Jun
Bill sent to president to support Puerto Rico 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.
restructuring
- 2016 Oct
Puerto Rico federal oversight board meets
- 2017 May
Puerto Rico executes PROMESA is the Puerto Rico oversight, management, and economic stability act of 2016 which establishes:
- An oversight board, including three people picked by Democrats and four picked by Republicans
- A process for restructuring debt, similar to a bankruptcy which was protested vigorously by Puerto Rico bondholders as they failed to derail the legislation. The process includes:
- Expedited procedures for approving critical infrastructure projects; to combat the Puerto Rican debt crisis.
bankruptcy is a legal status for an entity that cannot repay its creditor's loans. It holds creditor lawsuits in abeyance while the restructuring process proceeds to allow the entity to continue operations. It also has legal tools for forcing holdout creditors to accept repayments that are lower than the bond sale initially promised. cramdown provision requires creditors to accept a bankruptcy court imposed restructuring of debt. on Fundamental
debt - Negroni
frustrated
- 2017 Oct
Puerto Rico hurricane damage disrupts medical supply chain for
40 drugs: Humira,
Xarelto,
methotrexate is a chemotherapy drug developed in 1947 and used to treat cancer: breast, leukemia, lung, lymphoma, osteosarcoma; suppress the immune system, and as a treatment for ectopic pregnancy. It is a W.H.O. essential medicine.
,
Tylenol, Prezista,
Baxter
small saline, including 13 sole-source; and AdvaMed
medical devices, produced by 10 companies, concerning F.D.A. Food and Drug Administration. 's Gottlieb
- 2017 Dec
Puerto Rico collapse & exodus, impact housing, generate a
likely foreclosure crisis. Bottom-feeder: banks: Credit Suisse,
Goldman Sachs,
Perella Weinberg; 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.
, Private-equity:
Blackstone
affiliate Finance of America Reverse, TPG Capital
affiliate; snapped up the distressed mortgages. Many of
the mortgages are tax payer guaranteed.
- 2015 Aug
Vaccine are a core strategy of public health and have significantly extended global wellbeing over 200 years. Smallpox & polio were virtually eradicated. Recent successes include: HPV vaccine: Gardasil. They induce active acquired immunity to a particular disease. But the development and deployment of vaccines is complex:
- The business model for vaccine development has been failing (Aug 2015):
- No Zika vaccine was available as the epidemic grew (Mar 2016). No vaccine for: CMV;
- Major foundations: Michael J. Fox, Gates, Wellcome; are working to improve the situation including sponsorship of the GAVI alliance. A geographic cluster is forming in Seattle including PATH (Apr 2016).
- Commercial developers include: Affiris, Cell Genesis, Chiron, CSL, Sanofi, Valeant;
- Vaccine deployment traditionally benefited from centrally managed vertical health programs. But political issues are now constraining success with less than 95-99% coverage required for herd immunity (Aug 2015, Sep 2015, Nov 2015, Nov 2016, Jul 2018).
- Where clinics have been driven into local neighborhoods health improves (Apr 2016).
- Retail clinics (Mar 2016): CVS Minute Clinics focus on vaccination.
- NNT is a useful metric for vaccine benefit. Influenza vaccine has an NNT of between 37 and 77, is cheap and causes little harm, so it is very beneficial.
- Key vaccines include: BCG, C. difficile (May 2015), Cholera (El Tor), Cervical Cancer (Gardasil HPV Jun 2018, Oct 2018), Dengvaxia (Mexico Dec 2015), Gvax, Influenza, Malaria vaccine, Provenge, Typbar-TCV (XDR typhoid Pakistan Apr 2018);
- Regulation involves: FDA (CBER), with CMS monitoring (star ratings, PACE (Aug 2016), Report cards (Sep 2015)) & CDC promoting vaccines: as a sepsis measure, To control C. difficile (May 2015);
- Research on vaccines includes:
- NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.
- NCI:
- Roswell Park clinical trial of immuno-oncology vaccine cimavax.
- Geisinger: effective process leverage in treatment.
- Stanford Edge immuno-oncology for cancer vaccines.
- P53-driven-cancer focused, gene therapy (Jun 2015).
funding
models - CEPI
(Jan 2017)
- 2018 Jun
Former president of Merck
Vaccines, Dr.
Adel Mahmoud dies. He promoted CEPI
and previously pushed for the development of cervical cancer is mostly caused by HPV infection. Cervical cancer surgery performs a radical hysterectomy, where the uterus, part of the vagina and other surrounding tissues are removed. In 2017 it was concluded that the rates of cervical cancer had been previously under estimated and far more black women were impacted (Jan 2017). Prophylactic vaccination of young girls is dramatically reducing occurence of this cancer.
(HPV is human papillomavirus which causes cancer of the cervix in women and is also associated with anal cancer.
) vaccine are a core strategy of public health and have significantly extended global wellbeing over 200 years. Smallpox & polio were virtually eradicated. Recent successes include: HPV vaccine: Gardasil. They induce active acquired immunity to a particular disease. But the development and deployment of vaccines is complex: - The business model for vaccine development has been failing (Aug 2015):
- No Zika vaccine was available as the epidemic grew (Mar 2016). No vaccine for: CMV;
- Major foundations: Michael J. Fox, Gates, Wellcome; are working to improve the situation including sponsorship of the GAVI alliance. A geographic cluster is forming in Seattle including PATH (Apr 2016).
- Commercial developers include: Affiris, Cell Genesis, Chiron, CSL, Sanofi, Valeant;
- Vaccine deployment traditionally benefited from centrally managed vertical health programs. But political issues are now constraining success with less than 95-99% coverage required for herd immunity (Aug 2015, Sep 2015, Nov 2015, Nov 2016, Jul 2018).
- Where clinics have been driven into local neighborhoods health improves (Apr 2016).
- Retail clinics (Mar 2016): CVS Minute Clinics focus on vaccination.
- NNT is a useful metric for vaccine benefit. Influenza vaccine has an NNT of between 37 and 77, is cheap and causes little harm, so it is very beneficial.
- Key vaccines include: BCG, C. difficile (May 2015), Cholera (El Tor), Cervical Cancer (Gardasil HPV Jun 2018, Oct 2018), Dengvaxia (Mexico Dec 2015), Gvax, Influenza, Malaria vaccine, Provenge, Typbar-TCV (XDR typhoid Pakistan Apr 2018);
- Regulation involves: FDA (CBER), with CMS monitoring (star ratings, PACE (Aug 2016), Report cards (Sep 2015)) & CDC promoting vaccines: as a sepsis measure, To control C. difficile (May 2015);
- Research on vaccines includes:
- NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.
- NCI:
- Roswell Park clinical trial of immuno-oncology vaccine cimavax.
- Geisinger: effective process leverage in treatment.
- Stanford Edge immuno-oncology for cancer vaccines.
- P53-driven-cancer focused, gene therapy (Jun 2015).
, Gardasil is Merck's HPV vaccine designed to prevent infections with HPV types 6, 11, 16 and 18. Gardasil will not protect people from a virus type they have already been exposed to, so it is recommended to vaccinate young people. It protects against cervical, vulvar and vaginal cancers caused by HPV types 16 & 18 and anal cancers caused by HPV types 6, 11, 16 & 18. It protects against genital warts caused by HPV 6 & 11. It protects against some cancers of the penis and parts of the throat (oropharyngeal cancers). Gardasil does not prevent cervical cancer in women aged 27 to 45. , and a rotavirus is an RNA virus that is the most common cause of diarrheal disease among infants. It is transmitted by fecal-oral route.
vaccine, both seen as having highly risky, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. business models,
ensuring huge trials and saving many lives
- 2018 Oct
F.D.A. Food and Drug Administration. extends HPV is human papillomavirus which causes cancer of the cervix in women and is also associated with anal cancer.
vaccination 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).
to men
& women 27 to 45
- 2015 Dec
dengue fever 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.
vaccine are a core strategy of public health and have significantly extended global wellbeing over 200 years. Smallpox & polio were virtually eradicated. Recent successes include: HPV vaccine: Gardasil. They induce active acquired immunity to a particular disease. But the development and deployment of vaccines is complex: - The business model for vaccine development has been failing (Aug 2015):
- No Zika vaccine was available as the epidemic grew (Mar 2016). No vaccine for: CMV;
- Major foundations: Michael J. Fox, Gates, Wellcome; are working to improve the situation including sponsorship of the GAVI alliance. A geographic cluster is forming in Seattle including PATH (Apr 2016).
- Commercial developers include: Affiris, Cell Genesis, Chiron, CSL, Sanofi, Valeant;
- Vaccine deployment traditionally benefited from centrally managed vertical health programs. But political issues are now constraining success with less than 95-99% coverage required for herd immunity (Aug 2015, Sep 2015, Nov 2015, Nov 2016, Jul 2018).
- Where clinics have been driven into local neighborhoods health improves (Apr 2016).
- Retail clinics (Mar 2016): CVS Minute Clinics focus on vaccination.
- NNT is a useful metric for vaccine benefit. Influenza vaccine has an NNT of between 37 and 77, is cheap and causes little harm, so it is very beneficial.
- Key vaccines include: BCG, C. difficile (May 2015), Cholera (El Tor), Cervical Cancer (Gardasil HPV Jun 2018, Oct 2018), Dengvaxia (Mexico Dec 2015), Gvax, Influenza, Malaria vaccine, Provenge, Typbar-TCV (XDR typhoid Pakistan Apr 2018);
- Regulation involves: FDA (CBER), with CMS monitoring (star ratings, PACE (Aug 2016), Report cards (Sep 2015)) & CDC promoting vaccines: as a sepsis measure, To control C. difficile (May 2015);
- Research on vaccines includes:
- NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.
- NCI:
- Roswell Park clinical trial of immuno-oncology vaccine cimavax.
- Geisinger: effective process leverage in treatment.
- Stanford Edge immuno-oncology for cancer vaccines.
- P53-driven-cancer focused, gene therapy (Jun 2015).
- 2015 Nov
leveraged debt ignored by investors leaves banks with debts
- 2015 Jul
The death toll of sugary drinks world wide
- 2015 Oct
Mexico's leaders now aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group. Pinker notes the evolved pressure of social rivalry associating power with leadership. Different evolved personality types reinforced during development provided hunter-gatherer bands with alternate adult capabilities for coping with the various challenges of the African savanna. As the situation changed different personalities would prove most helpful in leading the band. Big men, chiefs and leaders of early states leveraged their power over the flow of resources to capture and redistribute wealth to their supporters. As the environmental state changed and began threatening the polity's fitness, one leader would be abandoned, replaced by another who the group hoped might improve the situation for all. Sapolsky observes the disconnect that occurs between power hierarchies and wisdom in apes. In modern Anglo-American style corporations, which typically follow Malthus, and are disconnected from the superOrganism nest site, the goal of leadership has become detached from the needs of this broader polity, instead: seeking market and revenue growth, hiring and firing workers, and leveraging power to reduce these commitments further. Dorner notes that corporate executives show an appreciation of how to control a CAS. Robert Iger with personality types: Reformer, Achiever, Investigator; describes his time as Disney CEO, where he experienced a highly aligned environment, working to nurture the good and manage the bad. He notes something is always coming up. Leadership requires the ability to adapt to challenges while compartmentalizing. John Boyd: Achiever, Investigator, Challenger; could not align with the military hierarchy but developed an innovative systematic perspective which his supporters championed and politicians leveraged. John Adair developed a modern leadership methodology based on the three-circles model.
try to constrain soda tax
- 2016 Mar
British soda tax
- 2016 Apr
Philadelphia soda tax
- 2016 Sep
Documents show Harvard
academics and sugar industry distorted research to shift health
issues from sugar to saturated fat. Harvard releases study
showing issues with saturated fats (Nov 2016)
- 2015 Jul
America Starts to Push Away From the Plate but 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).
is still
rising in the U.S. (Nov 2015, Mar 2016)
- 2018 Aug Boston
Children's Ludwig & Harvard's
Rogoff note that US is the United States of America. 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).
is still
rising - doubling in adults from 1970 to 2018 and tripling in
children, and children aged 2 are now modeled to have a 60%
chance of being obese by 35 - especially if poor, non-white, in
the South or mid-west
- 2017 Sep
Global processed food network: Coca-Cola, General Mills,
Nestle, PepsiCo; delays W.H.O. is World Health Organization a United Nations organization. nutrition
guideline improvements & captures Brazil resulting in 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 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
;
among its poorest citizens
- 2018 Oct
CDC is the HHS's center for disease control and prevention based in Atlanta Georgia.
report from Nhanes is the National Health and Nutrition Examination Survey, a program that continuously monitors the health and nutritional status of Americans. that well
paid 29 to 39 year olds are particularly keen on fast-food is defined by Nhanes as any item obtained from a fast-food/pizza establishment. Gordon discusses the development of fast-food restaurants in the US. Michael Pollan compares the industrial processed food supply chain with organic and hunter gatherer equivalents. .
- 2018 Aug
PepsiCo under Indra
Nooyi, focused on building revenue in healthier products.
Activist investors: Trian's
Peltz; fought her, arguing the strategy was wrong, even as she
expanded revenue to $63 billion. Trian pushed to split the
company into a beverage giant & a snack king
- 2017 Nov
Columbia shows power and strategies of the beverage industry: Coke, Pepsi,
Postobon; focused through the ICBA
onto legislators and power elites to block a soda tax. WHO is World Health Organization a United Nations organization. , Bloomberg
Philanthropies and activists push back against induced 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 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
- 2017 Nov General Mills
market leading children's breakfast cereal, Honey Nut Cheerios,
is massively sweetened & contains no nuts
- 2015 Aug,
Sep Coca-Cola funds
effort to alter obesity battle. Coke and PepsiCo continue to
invest to turn nonprofit is a tax strategy selected by many hospitals in the US. These hospitals, which include: Cleveland Clinic, Johns Hopkins, Massachusetts General, Mayo Clinic; are exempt from federal and local taxes because they provide a level of community benefit. They are considered charitable institutions and benefit from tax-free contributions from donors and tax-free bonds for capital projects, explains Bellevue Hospital's Dr. Danielle Ofri. Prior to 1969, community benefit had to include charity medical care, but then the tax code was altered to allow many expenses to qualify as community benefits including: Accepting Medicaid insurance at a hospital estimated loss; and charitable care became optional. The ACA encouraged hospital networks to consolidate and with this additional pricing power, revenue at the top seven nonprofits has increased 15%, while charitable care decreased 35%.
health groups from anti-soda legislation (Oct 2016).
- 2017 Jul C.D.C. is the HHS's center for disease control and prevention based in Atlanta Georgia.
chief Fitzgerald
leveraged Coca-Cola
when she tackled child 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). with an
exercise focused strategy.
- 2015 Sep US
Adults select large portions
- 2016 Jun
Baby bottle size associated with fatter babies
- 2015 Aug
Perdue reduces its
use of 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).
in mainstream chicken product lines.
- 2015 Nov Real
Food Challenges the Food Industry
- 2018 Mar
Supermarket chains disrupt: Winn-Dixie/Bi-Lo, Tops (Morgan Stanley
debt loading), A & P
(2nd bankruptcy in 2015); go bankrupt is a legal status for an entity that cannot repay its creditor's loans. It holds creditor lawsuits in abeyance while the restructuring process proceeds to allow the entity to continue operations. It also has legal tools for forcing holdout creditors to accept repayments that are lower than the bond sale initially promised.
under
assault of discount
stores: Dollar
General; Wal-Mart,
& Amazon.
Fairway is
struggling but is getting investment from Blackstone.
Marsh
needed federal assistance. Unionized shop workers who had
pension benefits will loose them
- 2015 Jul
Chamber of Commerce is the United States Chamber of Commerce
and tobacco
- 2018 Apr JUUL Labs, backed
by venture
capital, provides easily hidden device for vaping.
JUUL disingenuously claims to be marketing only to smokers but
sells: online, at convenience stores, and was funded for
exponential growth. Schools are finding children addicted 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.
to
nicotine and 4 times more likely to start smoking
- 2018 Sep KPCB
built separate early and late venture funds, but with increased
competition to fund startups: Softbank; it has
decided to split them into two companies
- 2015 May
Digital record sharing issues
- 2015 Sep
VW diesel deception impacts public health
- 2019 Feb
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 SEC 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
- 2016 Oct
Mars cashes out Berkshire
Hathaway to take full control of Wrigley.
- 2017 May Warren
Buffett of Berkshire
Hathaway condemns House AHCA is American health care act. The House version (May 2017): removes the ACA's progressive taxes on the wealthy enabling the rest of the Republican's tax cut strategy a chance of passing in the Senate, Cancels the ACA: Medicaid expansion - stripping coverage from 23 million Americans (May 2017), Preexisting conditions constraints, Employee mandate; Provides grants to states to help offset lost ACA federal funding.
bill.
- 2018 May 3G founders
sponsored Bernardo Hees, who they encouraged to analyze and run
a railroad at 23, Burger king, H. J. Heinz; and to
join them at the closely held private equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors. Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges. Private equity companies were initially corporate raiders.
company
- 2015 Dec
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.
fees and returns
- 2018 Feb
Slumping UK is the United Kingdom of Great Britain and Northern Ireland. 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.
undermines
profits at government's outsourcing partners: Four Seasons,
Mears Group, Capita, Carillion; resulting in collapse of
Carillion and encouraging owners: 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.
Terra
Firma, 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. H/2
Capital Partners; to push the 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 the government
- 2018 May
SVCF
process and culture builds 3rd largest foundation, after Gates
and Open
Society, but focus generates toxic issues
- 2018 Feb
Dubai 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.
Abraaj
Group focused on the developing world, including $1
billion health care fund; is accused of misusing funds by
investors: World
Bank was setup as part of the Bretton Woods agreements, as the International Bank for Reconstruction and Development, to repair and reconstruct Europe after the Second World War and as the World Bank continues to provide reconstruction and development resources for projects in developing economies. It includes: - International Finance Corporation
, Gates
Foundation;
- 2018 Jan
World Bank
president Kim aims to transform the organization to gain
leverage from Wall Street
and support from the US government
- 2017 Jul
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.
KKR
increases investment in health and wellness is a health care oriented employer based strategy for reducing health care costs and encouraging wellbeing. Wellbeing has traditionally been a focus of public health. : WebMD, Nature's Bounty;
- 2018 Jun
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.
KKR
aims to acquire Envision
Healthcare for $10 billion including taking on $4.5
billion of its debt. Envision lost $228 million in the
last year on revenues of $7.8 billion
- 2015 Dec Mutual funds
with junk illiquid assets bar investors from selling out and fear is an emotion which prepares the body for time sensitive action: Blood is sent to the muscles from the gut and skin, Adrenalin is released stimulating: Fuel to be released from the liver, Blood is encouraged to clot, and Face is wide-eyed and fearful. The short-term high priority goal, experienced as a sense of urgency, is to flee, fight or deflect the danger. There are both 'innate' - really high priority learning - which are mediated by the central amygdala and learned fears which are mediated by the BLA which learns to fear a stimulus and then signals the central amygdala. Tara Brach notes we experience fear as a painfully constricted throat, chest and belly, and racing heart. The mind can build stories of the future which include fearful situations making us anxious about current ideas and actions that we associate with the potential future scenario. And it can associate traumatic events from early childhood with our being at fault. Consequent assumptions of our being unworthy can result in shame and fear of losing friendships. The mechanism for human fear was significantly evolved to protect us in the African savanna. This does not align perfectly with our needs in current environments: U.S. Grant was unusually un-afraid of the noise or risk of guns and trusted his horses' judgment, which mostly benefited his agency as a modern soldier.
spreads (Dec 2015, Jan 2016).
Large mutual funds hurting (Jan 2016).
Janus
Capital acquired by Henderson Group
(Oct 2016).
- 2016 Jan
Junk bonds continue to sour.
- 2017 Jan Rokos
fixed income 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.
future investments funded by Blackstone &
investment by Brevan
Howard
- 2016 Jan Blackstone income
down 70%
- 2017 May
Blackstone
leverage Saudi sovereign 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. fund to
finance US is the United States of America.
infrastructure with a $20 billion cornerstone investment
fund
- 2017 Aug
Blackstone's Invitation
Homes consolidates rental properties with Starwood
Waypoint Homes
- 2018 Oct
California renters, & AIDS
Healthcare Foundation, drive proposition 10, which repeals
Costa-Hawkins is the Costa-Hawkins Rental Housing Act of 1995, a California state law which constrains municipal rent control ordinances. Cities are prohibited from using rent control for single family dwellings, condominiums and newly constructed apartment units. And the law prohibited municipalities from applying rent controls to new tenants. Before the law passed, cities had responded to high rental increases driven by demand generated by high house prices, with rent controls.
and angers: 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. : Blackstone
(Invitation
Homes); builders, and construction unions. Lack of
affordable housing, increases: rents, evictions, homelessness,
commutes, overcrowding and debt. Stanford
economist, Rebecca Diamond, found rent control accelerates
gentrification and so prefers, state budget impacting, tax
credits
- 2018 Apr
Freddie Mac is the Federal home loan mortgage corporation (FHLMC), a GSE. , CoreVest
real estate loans possibly used by Casas Baratas
Aqui, in contract-for-deed is a type of long term real estate loan:
- That offers renters the opportunity to structure their
rental payments to subsequently own the dwelling.
- Where the contracts are often onerous, lacking basic
consumer protections, carry high interest rates and pull
the renters in with the opportunity to purchase.
- Often lead to eviction.
and rent-to-own is a type of long term real estate loan: - That offers renters the opportunity to structure their rental payments to subsequently own the dwelling.
- Where the contracts are often onerous, lacking basic consumer protections, carry high interest rates and pull the renters in with the opportunity to purchase.
- Often lead to eviction.
rental deals
- 2018 Jul 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.
claim to operate best in troubled markets where they can act flexibly. But results continue
to be poor as 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.
turns more uncertain 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. .
Quantitative
funds uses quantitative models of market performance to decide on investment assets to buy and sell. , Macro
strategy is a hedge fund strategy where bets are made on the direction of global economic trends. funds, and long-short is used primarily by hedge funds when they take a long position in stocks expected to increase in value and short positions in stocks that are expected to decrease in value.
funds have dragged down the whole group. Activist is where a hedge fund invests a large enough amount in a public company to obtain an influence in a firms decision making and leadership portfolio.
funds, Merger
arbitrage is a hedge fund strategy where for stock mergers of companies, the hedge fund will simultaneously purchase the target and short sell the acquirers stock, while for cash mergers the hedge fund purchases the target stock; to speculate on the successful completion of the deal, when the target's stock should reach the offer price, leveraging pricing inefficiencies awaiting the event. funds; have done better, but still don't match
the S&P 500 performance which leveraged reinvestment
dividends. Wealthy are putting money in hedge funds to
hedge the arrival of the bear market. Management fees of
2% of huge assets have made the fund managers risk averse
- 2018 Jul
Federal
Reserve of 1913 was a response to a series of banking panics with the goal of responding effectively to stresses. It setup:
- At least 8 and not more than 12 private regional Federal Reserve banks. Twelve were setup
- Federal Reserve Board with seven members to govern the system. The President appointed the seven, which must be confirmed by Congress. In 1935 the Board was renamed and restructured.
- Federal Advisory Committee with twelve members
- Single US currency - the Federal Reserve Note.
report argues: 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. robust
allowing for interest rate increases, Wage growth sluggish due
to poor productivity is the efficiency with which an agent's selected strategy converts the inputs to an action into the resulting outputs. It is a complex capability of agents. It will depend on the agent having: time, motivation, focus, appropriate skills; the coherence of the participating collaborators, and a beneficial environment including the contribution of: standardization of inputs and outputs, infrastructure and evolutionary amplifiers. ,
Decline in work force participation among less educated
Americans because of technology, Women providing child-care
rather than entering the work force, Oil increasingly produced
domestically reducing export of dollars, Trade war not mentioned
as a significant risk
- 2018 Jul
High quality bond investments perform badly as
the Fed rate increases. Companies, locked in low
interest rates by issuing high quality bonds, leaving investors
with long term bonds that perform badly as interest rates
increase. E.T.F. is exchange traded fund, which tracks stock and bond indexes, adhering to a set of financial rules. These methods can be used to track any financial market segment. They are transparent, and low cost to operate, and invest in. ETFs are priced during normal trading hours. But their performance is impacted when they are forced by changing conditions to sell assets at a loss. Selling of an ETF by one investor to another does not redeem the ETF's underlying investments, limiting the capital gains tax distribution (Jul 2018).
s
of quality bonds will also suffer as these must sell bonds that
downgrade & no longer meet the E.T.F. specification, just
when the assets price has fallen. Active management is
less constrained & can hold the asset until it
appreciates. Corporations, like CVS (Dec
2017), that took on debt to acquire other companies, will
see their bond ratings fall, reflecting additional 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 if their
strategy is correct they will slowly improve their ratings,
offering investors: Dodge & Cox Income; a buying opportunity
- 2018 Apr
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.
: EJF, Melody
Capital Partners; Banks: DZ Bank; provide
finance to loan arrangers: Law Cash, Banyan Finance,
Medstar Funding;
driving loans to perform surgeries: Earle Pescatore; that
increase the likely size of evolved
amplifier, coordinated by: Surgical Assistance; leveraging
marketing operations: Conferences,
business development, web and tele sales; to increase litigant
capture and payouts in personal injury suits, organized by
lawyers: Alpha Law,
McSweeney
Langevin; against device manufacturers: Boston
Scientific, J&J; for
pelvic mesh implants. The removal of the implants that
bond with living tissue is highly risky, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. .
- 2018 Jun
Personal injury mass-tort financing strategy expands at 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.
: EJF, Fir Tree
Partners (Deer Finance), Fortress,
Pravati, Virage;
and 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. : Blackstone
(DRB Capital), PIMCO;
with state and federal authorities and Congress studying what is
going on
- 2016 Sep BlackRock
strategies
- 2017 Jul
Forum on California politics and 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.
: CalPERS
losses, No revenue for 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).
health care
- 2017 Oct
Intelligence Squared U.S. Debate: Is the U.S. is the United States of America. Health care system
terminally broken? with Shannon
Brownlee, Ezekiel
Emanuel, Robert Pearl, David
Feinberg
- 2018 Apr
Constrained demand for Proton
Therapy irradiates diseased tissues, including cancers, with protons. The particles destroy the DNA of cells they interact with stopping their reproduction. The powerful control of the large charged particles allows acute focus and limited exit dosage. Cyclotrons, synchrotrons and linear accelerators are used to accelerate and control the protons. A significant drawback is the cost and size of the particle accelerator. The therapy is viewed as useful in treating children and for tumors that are proximate to sensitive organs such as eyes. Infrastructure competition driven over-deployment has resulted in business failures for the treatment centers (Apr 2018)
leaves Cancer Centers: Georgetown
University Hospital,
Indiana
University Health System, University
of Maryland MS Greenebaum
CCC, New York (Memorial
Sloan-Kettering, Mount
Sinai Health System, Montefiore Health),
Northwestern
Medical, Scripps,
Seattle cancer care alliance (Fred
Hutchinson, Seattle
Children's, University
of Washington); with costly underperforming or bankrupt is a legal status for an entity that cannot repay its creditor's loans. It holds creditor lawsuits in abeyance while the restructuring process proceeds to allow the entity to continue operations. It also has legal tools for forcing holdout creditors to accept repayments that are lower than the bond sale initially promised.
investments
- 2017 Nov
Princeton
health policy economist 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.
Uwe Reinhardt, who promoted: German health care, 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.
reforms: 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.
pay for
performance represents a number of programs: - Value-Based Purchasing Program which includes mandatory pay-for-performance where a percentage of hospital inpatient payments are withheld and then earned back based on achieving quality metrics. Withholds begin at 1% in 2013 and rise to 2% by 2017.
- HRRP which penalizes Hospitals with a readmission rate that is greater than expected. Penalties capped at 1% of total DRG in 2013, 2% in 2014 and 3% in 2015.
- CMS is also using a high HAC percentage as a penalty - 1% penalty deducted from DRG payment (HACRP) starting in 2015 to encourage reduction of HACs.
- MCMP EHR deployment in physician practices.
, individual mandate is ACA quality affordable care for all Americans. It mandates community rating & essential health benefits. It includes: - Subtitle A: Immediate improvements in health care for all Americans.
- Subtitle B: Immediate actions to preserve and expand coverage.
- Subtitle C: Quality health insurance coverage for all Americans. Which reforms the health insurance markets and prohibits preexisting condition exclusions and forms of health status discrimination.
- Subtitle D: Available coverage choices for all Americans.
- Subtitle E: Affordable coverage choices for all Americans.
- Subtitle F: Shared responsibility for health care which mandates individuals and employers to pay for insurance.
- The employer mandate requires employers with more than 50 full-time workers to offer most of their employees insurance or face penalties.
;
& designed Taiwan's health care framework, dies of sepsis is an infection triggered over-reaction by the immune system which causes general inflammation resulting in a cascade of problems: Blood clots, Leaky blood vessels; impeding blood flow to vital organs which can induce septic shock: Blood pressure drops, multiple organ failure, Heart damage and death. For every hour without antibiotics the probability of death increases 8%. Most cases start before people are hospitalized. People over 65, infants under 1 year, people with chronic diseases such as diabetes, or weakened immune systems and healthy people with incorrectly treated infections are most likely to contract sepsis. Most often the infections are of: lungs, urinary tract, skin, gut or intestines. Typically such infections were the result of a previous visit to a clinic or hospital. Symptoms of sepsis include: chills or fever, extreme pain or discomfort, clammy or sweaty skin, confusion or disorientation, shortness of breath and high heart rate. Dr. Diane Craig noted that sepsis had become the leading cause of death among hospitalized patients. Using patient matching on: age, symptoms, degree of illness; from the hospital system EHR, Craig identified the blood-lactate test as the key diagnostic that supported early, aggressive treatment of sepsis. She argued that whenever a patient had two symptoms of significant infection a lactate test be used along with EGDT treatment for patients with lactate counts as low as 2.5 millimoles/liter. This reduced sepsis mortality to 40% below the national average. But only half the hospitals in the US followed Craig's recommendations. Dr. Robert Pearl concludes this is because of the high risk of killing a patient with EGDT treatment, even though the protocol will reduce overall mortality by half. Doctors don't want to be responsible for killing patients so they opt not to order the lactate test. In 2017 sepsis is estimated to cost the US health care system more than $20 billion a year. The C.D.C. is concerned (Sep 2016) with antibiotic resistance generating more sepsis.
- 2016 Jul
lawmakers move to protect 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.
- 2016 Jul
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.
shift into unregulated banking and infrastructure investments
leverages cozy relations with federal and state politicians
- 2017 Oct Yale University
endowment
maintains diversification strategy avoids US equities
- 2017 Nov
Appleby leak
shows how investment advisers such as: Quintana
Capital Group; helped university endowments:
Indiana
University, Texas Christian University, Colgate, Dartmouth,
Duke, Johns
Hopkins, Stanford,
University
of Texas, University
of Southern California, University of Alabama, DePauw,
Northeastern, Pittsburgh,
Purdue, Reed College, Rutgers, Syracuse, Texas Tech and
Washington State; use offshore blocker
corporations are used to place a legal entity between the highly leveraged activities of hedge funds and private equity companies and their clients. The structure avoids a federal tax on returns derived from borrowed money, which was designed to prevent nonprofits from competing unfairly with for-profit businesses. It effectively blocks any taxable income from flowing to the clients who include US university endowments (Nov 2017). The blocker corporations are setup in a low tax domicile such as the Cayman Islands or British Virgin Islands. : H&F investors, TX Liquidity Capital;
limiting profit flows to the endowments from
their private
equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors. Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges. Private equity companies were initially corporate raiders.
funds: EnCap
Investments, Genstar Capital,
Hellman &
Friedman; that: limit taxes, obscure unpalatable
investments: Oil, gas, Ferrous Resources; successfully
- 2016 Aug 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. punish Apollo
Global for opaque charges regarding company monitoring
fees.
- 2016 Sep
Och-Ziff
pay $400 million for bribery of African officials
- 2016 Apr
Venture funds
must cope with soft startup market. New rounds reduce fear
of downturn (Sep
2016). VCs hope for more funding in 2017 after tight
year (Dec 2016).
- 2016 Jul
Thrive
raises fifth round of $700 million.
- 2017 Jan
Kushner global network connections reviewed
- 2017 Jan Synthego raises $41
million from Founders
Fund, Menlo
Ventures, Jennifer
Doudna
- 2016 Apr
BlackRock acts
like activist
- 2016 Sep
Deutsche Bank
business model worries investors 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.
apply short is a multi part transaction where: - A borrowed tradable asset (this part of the transaction is not performed in the naked version) is sold under the assumption that the asset is going to fall in price during the period when it has been borrowed.
- Once the asset falls in price it is then purchased.
- The asset is returned to the lender, with any additional risk premium.
- The short seller keeps any profit. If the asset gained value during the period of the short then the seller makes a loss.
pressure (Sep
2016). Market sensitive to leverage and connectivity
(Oct 2016).
But the final penalty is much less (Dec 2016).
- 2016 Nov
Wells Fargo
asks court to move class-action law suits responding to 2
million deposit and credit card accounts opened without
permission to arbitration.
- 2016 Feb
Credit Suisse
reports huge loss
- 2016 Sep IBM Watson platforms
buys financial advisor Promontory
Financial.
- 2016 Feb
Zenefits
exponential growth valuation causes scandal and replacement of
founder CEO Parker Conrad.
- 2018 Sep
Comcast
keeps health care costs to 1% growth (instead of 3% average of
large employers) with an innovative go it alone approach to
health benefits, helped by Venrock portfolio
companies and Comcast
ventures companies: Accolade health benefit navigators,
Grand Rounds for second opinions, Doctors on Demand for telehealth is the use of remote health care. It includes telepharmacy and clinical telehealth for stroke and psychiatry. It also includes sessions between primary care providers and patients and assisted caregiving such as medication reminders and DME usage monitors.
,
Brightside, which helps employees manage their finances, is a
startup which Comcast Ventures created; for its 225,000
employees - although many of its workers are contractors.
National business group on health vets the startups for its
members. Some large companies cover the costs of health
care for their employees, but most use insurers to do paperwork,
and contract with hospitals and doctors. It can be hard
for the partners to get data from the insurers. Fidelity
Investments is large enough to make insurers
cooperate. Companies and employees are unhappy with the
regular service
2007 Jun
Bear Stearns mortgage finance restructuring shows economic
catalyst
NYTimes
Two 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.
aimed at avoiding both a fire sale in mortgage-securities market,
and getting stuck with an exploding liability that could result in
steep losses for financiers. A melt down was avoided, but the
New York Times wonders if the talks had just delayed an inevitable
collapse over time.
The Bear Stearns
investment bank was aiming to find out what they could obtain as
payments from the market if the auctioned off mortgage securities
with a face value of $2 billion. The solicitations were
hastily withdrawn when investors reacted with little
enthusiasm. However, by the end of the day some of the less
risky securities had exchanged hands.
Bear Stearns was under pressure from other lenders who were worried
about the effect of the sale on the book valuations of mortgage
securities.
The week of escalating problems at the Bear Stearns's High Grade
Structured Credit Strategies Enhanced Leveraged Fund and a related
fund have jarred investors into confronting systemic risks in the
once booming market for bonds that are backed by mortgages to
homeowners with weak or subprime, credit. Last year, more than
$483 billion of such bonds were issued, up 5% from 2005.
The deal that JP
Morgan Chase reached with Bear Stearns asset Management
allowed it to sell $400 million collateral back to the hedge funds
for cash. It was not released what the price was.
Goldman Sachs and
the Bank of America reached similar deals, though details remained
unclear. Also unclear is what price the assets will eventually
fetch for the Bear funds and what types of losses investors, who
have been unable to redeem their investments since May, will
face.
The securities causing the most concern within the Bear Stearns
funds are known as collateralized debt obligations, or C.D.O. is a: - Care delivery organization in health care.
- Collateralized debt obligation in finance. The idea is to transfer the credit risk rather than the loan itself. The bank enters into a CDS on the loans with a SPV. The CDO allows the bank to shift its loans outside the reach of regulators. The CDO also can distribute the risk unevenly by tranching. Equity is most at risk. Then any subordinated debt.
s. Run by
portfolio managers these complex instruments are akin to mutual funds in
that they buy stakes in a variety of bonds backed by
mortgages.
They often invest in the riskiest portion of the bonds, usually with
a hundreds of millions or billions in borrowed money. About
$316 billion in C.D.Os specializing in mortgages were issued last
year, up from $178 billion in 2005.
One worry about the possible unwinding of the Bear funds is that it
will cascade into larger liquidations by other investors who hold
similar securities at far higher prices. Accounting rules
require investment banks to mark the
value of the investments to the price of similar assets trading in
the market. Many mortgage-related securities and C.D.O.s
in particular, do not trade frequently, making them hard to
value.
As a result Merrill
one of the lenders who have seized Bear assets is quietly showing
them to a small group of potential buyers. Such an approach
helps to keep the pricing of the securities under wraps, allowing
Wall Street firms to avoid marking down their own stakes.
Keeping the sales price quiet also means that the firms may not have
to add collateral immediately to shore up their portfolios.
Yet another worry is that the big investment banks that until now
have generously lent billions of dollars on good terms to traders
and portfolio managers are pulling back or demanding stricter
terms.
One industry executive, said the banks involved in the Bear funds
could collectively lose $1 billion on their lending to the Bear
funds. Lenders are already reducing the amount they are
willing to lend against C.D.O.s.
Feb 2019
NYT The Dollar Is Still King. How (in the World) Did That
Happen?
Peter Goodman reports a cursory assessment might find the United
States a less than ideal candidate for the job of managing the
planet's ultimate form of money.
It has built a $22 trillion national debt is a pool of payment promises developed to finance costly discrete and transient activities, Johnson & Kwak explain. Repayments of the capital and interest are made regularly through mechanisms such as a sinking fund. Charles Montague first setup such an indirect arrangement that allowed thirteen and a half million pounds in British war debt (using a million-pound loan serviced by 99 years of new excise duties sold to the public as annuities) to persist in 1693 and supported it with a sinking fund in 1696. This strategy was viewed as scandalous by conservatives at the time. The conservatives argued the debt should be liquidated but Montague's strategy allowed Britain to develop and sustain, until the 20th century, a triple-A fiscal reputation and allowed it to use financial leverage as a weapon of war. Montague's strategy was enabled by the revenues Britain's merchants were obtaining from its developing global trade. CAS theory looks at the pool as a collection of commitments to provide energy to the owners' of the promises. .
But he notes the US is the United States of America.
benefits from the status of the dollar, as the global reserve
currency, which is:
- Favored as a repository of global savings,
- The key form of exchange for trading in global commodities
- A safe haven in a crisis
US uses the
dollar to support its global policy aims detailed Paul Volcker's strategies for sustaining the US centric post Second World War economic network, once the US became a deficit generator & Bretton Woods could not be sustained. Volcker's goal was to enable the US to use other country's surpluses to support the network's operation under US control, in place of the disappearing US dollar surplus. The strategies included: - Push American interest rates up much higher than those of other linked economies, attracting global free capital to the US dollar.
- Ensure that Wall Street offered a more lucrative market for investors than London, Frankfurt, Tokyo, or Paris.
- Support US business that was impacted by this costly high interest rate environment by supporting the reduction of wage costs. Once Volcker became chairman of the Federal Reserve in 1979, he executed the strategies.
:
- Treasury has many potential buyers of US savings bonds, who
are willing to accept low rates of interest
- Trade sanctions are amplified by the requirement to use
dollars in trading and leverage of the global financial network
- Sanctions on Iran & Venezuela are
more effective because banks will not jeopardize access
to the US infrastructure
- Sanctions on Russia
The Dollar has been gaining power:
- Increased from 10 to 14% of global economic output
- China attempted to introduce its currency as a dollar
alternative - championing the Asian Infrastructure Investment
Bank, setting up foreign exchange arrangements, financing with
the renminbi, the $1 trillion Belt and Roads global
infrastructure initiative - which will allow Chinese goods to
flow without depending on US policed global shipping lanes,
adding a renminbi oil trading system in Shanghai; but its
economic slowdown, soaring debt, constraints on capital exports,
detentions of foreign nationals have undermined its
attractiveness.
- The Euro is constrained by the lack of German debt to finance
spending, EU is European Union, the 1992 Maastricht Council of Ministers meeting agreed evolution of the ECSC & CAP cartels to include:
- A single market across the members' countries supporting the transformation of the ECSC. It maintained the CAP transfers assisting French farmers.
- A fixed currency 'snake' that allowed the ECSC to operate, binding the deutschmark to the other currencies of participating members: a mini Bretton Woods exchange rate mechanism; that became a single currency, the euro, managed by an independent ECB (based on the independent German Bundesbank); but tax gathering was allocated to the states whose leaders control the Council of Ministers and no effective mechanism was provided to reallocate revenues. This has left Germany with an advantage supported by the aggregate valuation of the euro and not having to flow tax revenues to the weaker economies of the south.
structural problems with handling 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. problems
within the Eurozone is the group of countries within the EU that use the euro currency. Economic decisions regarding the euro are centralized through the Eurogroup. .
- The UK is the United Kingdom of Great Britain and Northern Ireland. is struggling
with Brexit.
- The Federal Reserve has raised interest rates, attracting
investors by raising the return on dollar holdings.
- After 2008 all parts of the global financial system increased
reserves and dollar based reserves maintained their value, while
the euro has slipped against the dollar.
May 2016 NYT
A Choppy Year for Hedge Funds, but Chiefs Cashed In
Alexandra Stevenson reports JPMorgan Chase paid its chief executive,
Jamie Dimon, $27 million in 2015. In another Wall Street
universe, the hedge fund manager Kenneth C. Griffin [of Citadel] made $1.7
billion over the same year.
Institutional Investor's Alpha magazine reports the 25 best-paid
hedge fund managers together received $12.94 billion in
income. This is even as the funds struggled to perform.
The hedge fund industry is now $2.9 trillion in size.
James H. Simons of Renaissance
Technologies also took home $1.7 billion.
Leda Braga of Systematica
Investments got $60 million. Earlier she was at BlueCrest
Capital.
Five fund managers which lost money for their investors were in the
Alpha list:
May 2016
NYT Hedge Funds Reach for Hard Hats in Year of Collapsing Mergers
Leslie Picker reports while last year set a record for the amount of
money spent on corporate mergers -- $4.7 trillion -- this year is so
far setting a very different record: the dollar amount of deals that
have come undone.
$400 billion worth of corporate mergers has been withdrawn.
This is three times the 2007 record. Deals that have backed
out include:
- Staples & Office Depot $6.3 billion merger
- Halliburton and Baker Hughes $35 billion merger
- Pfizer and Allergan $152
billion merger
- Anbang Insurance and Starwood Hotels $14 billion
acquisition
- Energy Transfer equity and Williams Companies $38 billion - no
evidence of collapse of the deal but its being treated as
backing out by markets.
- Abbott labs
and Alere $5.8 billion acquisition - no evidence of collapse of
the deal but its being treated as backing out by markets.
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. that
focus on merger
arbitrage is a hedge fund strategy where for stock mergers of companies, the hedge fund will simultaneously purchase the target and short sell the acquirers stock, while for cash mergers the hedge fund purchases the target stock; to speculate on the successful completion of the deal, when the target's stock should reach the offer price, leveraging pricing inefficiencies awaiting the event. are seeing greater 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. in
their strategies. In April macro funds is a hedge fund strategy where bets are made on the direction of global economic trends. and
merger arbitrage were the worst performing hedge fund
strategies. Ramius was
impacted by the collapse in Allergan's share price.
Aug 2018 NYT The
Stock Market Is Shrinking. That's a Problem for
Everyone.
Jeff Sommer reports the American stock market has been
shrinking. It's been happening in slow motion -- so slow you
may not even have noticed. But by now the change is
unmistakable: The market is half the size of the mid-1990s peak and
25 percent smaller than it was in 1976.
Sommer notes:
- a National Bureau of Economic Research report by Ohio State's
Rene Stulz who concludes the shrinking "is troubling for 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.
, for 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. and
for transparence."
- In the mid-1990s there were more than 8,000 publicly traded
companies. By 2016 there were only 3,627
- Companies on the exchanges are far larger, and fast-rising
growth companies are hard to find
- There are few opportunities for public investment in small
companies.
- Only the top 200 public corporations make a profit - with the top 5 making vast amounts
- There are fewer initial public offerings (IPO)s
currently.
- Private companies allow no visibility into what they are doing
- although they reveal details 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.
investors. This provides opportunities in the private
sector, while leaving public investors focused on a less diverse
set of companies.
- Small private company's asset values are far larger than
previously; lots of the increase reflects non GAAP is generally accepted accounting principles. These are a framework of standards and procedures for compiling internationally equivalent financial statements.
intellectual
property valuations, which are deducted from corporate income
when the companies become public and use GAAP accounting.
Oct 2018 NYT
The Biggest Buyers of American Stocks Are on the Sidelines Right
Now
Matt Philips reports there are plenty of potential catalysts for the
stock market sell-off that has swept through the markets this
week. They include rising interest rates, growing tensions
with China, expanding federal deficits and increasing regulatory
risks for technology companies.
But Philips notes the largest buyers: companies repurchasing their
own stocks; aren't buying as they get ready to report
earnings. Some of the large market dips of 2018 correspond to
these quarterly reporting periods.
Repurchasing has reached $770 billion this year. That's twice
the size of ETF is exchange traded fund, which tracks stock and bond indexes, adhering to a set of financial rules. These methods can be used to track any financial market segment. They are transparent, and low cost to operate, and invest in. ETFs are priced during normal trading hours. But their performance is impacted when they are forced by changing conditions to sell assets at a loss. Selling of an ETF by one investor to another does not redeem the ETF's underlying investments, limiting the capital gains tax distribution (Jul 2018). generated
demand for stocks.
Jan 2019 NYT
E.T.Fs Try to Lure Investors Into Ever Narrower Niches
Conrad De Aenlie reports E.T.F. is exchange traded fund, which tracks stock and bond indexes, adhering to a set of financial rules. These methods can be used to track any financial market segment. They are transparent, and low cost to operate, and invest in. ETFs are priced during normal trading hours. But their performance is impacted when they are forced by changing conditions to sell assets at a loss. Selling of an ETF by one investor to another does not redeem the ETF's underlying investments, limiting the capital gains tax distribution (Jul 2018). s
became the next big thing in portfolio management a couple of
decades ago by being cheaper and easier to trade than mutual funds.
Now managers are offering E.T.Fs representing small 'thematic' parts
of the stock market: gaming, Robotics, Medical devices, 5G, 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.
, artificial
intelligence, privacy & ciberthreats; supporting increased risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. and reduced
diversification.
FundX Investment Group's chief investment strategist, Jason Browne
does not recommend thematic E.T.F.s. "We would prefer that
someone build a portfolio around more diversified funds. If
you're an average investor, you will probably look back and think
this is something you were sold and not something thoughtfully
invested in that's aligned with our long-term goals." FundX
manages investments for wealthy individuals.
RegentAtlantic's chief investment officer, Christopher Cordaro, sees
more fund managers using thematic E.T.F.s. Bank of America
Merrill Lynch's
head of thematic investing, Haim Israel, sees some technologies
covered by E.T.F.s as long-term opportunities.
Investment advisers are dubious about thematic E.T.F.s. Most
technology forecasts are speculative. LJPR Financial Advisors
Leon LaBrecque noted "We've been around long enough to see a lot of
the "next big thing. Remember Blockbuster or Boston
Chicken? Anyone remember the first search engine? New
tech becomes old tech."
Feb 2019
NYT What's Really in Your Index Fund?
SEC is the Securities and Exchange Commission. It was provided with power to regulate the securities industry by the Securities act and Securities Exchange act. commissioner Robert
Jackson Jr. & UC
Berkeley law professor Steven Davidoff Solomon review index fund use simple rules to decide what assets to include in an investment fund: mutual fund or ETF. John Bogle leveraged the low cost and predictability of the approach to build Vanguard's index funds for consumer investors, explaining "My ideas are very simple. In investing, you get what you don't pay for. Costs matter, so intelligent investors will use low-cost index funds to build a diversified portfolio of stocks and bonds, and they will stay the course. And they won't be foolish enough to think they can consistently outsmart the market." University of Chicago economists: Renshaw, Feldstein, Samuelson; initially developed the indexing idea to obtain a diversified open-ended vehicle aligned with the assumed random operation of the market. Complexity economics undermines these ideas, suggesting index funds are an evolved amplifier leveraging captive 401K funds. Index funds are not guaranteed to be transparent and the selection process involves lightly regulated companies which can be open to conflict of interest - their selections will alter the demand for and price of the stocks (Feb 2019).
operations: John Bogle, the father of low-cost investing, once said
that the index fund was the "most successful innovation --
especially for investors-- in modern financial history."
Jackson and Solomon note index funds:
- Track a broad group of stocks
- Investors can buy a range of businesses and hold them to
capture the long-term growth of the market.
- Don't need great stock pickers, so they charge low fees.
But they assert index funds have a problem:
- The indexes the funds are based on are not always transparent
and neutral to bias. Firms: MSCI; develop the
indexes, with little regulatory scrutiny. The WSJ reported
MSCI was persuaded by the Chinese government to add Chinese
issuers to the MSCI Emerging Markets Index. MSCI asserted
to the WSJ that its process for choosing firms for the index was
"transparent and objective" and includes safeguards to maintain
those standards.
- Customized indexes have been developed for use by a single
fund - where the index and fund are frequently operated by the
same managers, which Jackson and Solomon suggest look less like
objective benchmarks that investors think they are
leveraging.
The Libor scandal showed the problem of benchmark manipulation,
where banks were able to derive excess profits while increasing
costs for homeowners and students. The CFTC responded to that
scandal by setting up a group to reform that benchmark. There
is no such group for stock market indexes.
Jackson and Solomon propose the SEC study index fund issues and make
necessary recommendations to Congress.
Jan 2019 NYT
The Hidden Automation Agenda of the Davos Elite
Kevin Roose reports they'll never admit it in public, but many of
your bosses want machines to replace you as soon as possible.
Roose, attending the World Economic Forum, concluded corporate
executives answers to AI questions depended on who was
listening.
In private the corporate executives promise they are automating away
their work forces agressively to stay ahead of the
competition. Billions of dollars are being spent to make
corporations lean, digital and highly automated. CEOs are
measured by the quarter.
UBS sees the market for
A.I. growint to $180 billion next year.
Consultants see aggressive plans being executed:
- Infosys president, Mohit Joshi, noted "Earlier they had
incremental 5 to 10 percent goals in reducing their work
force. Now they're saying, 'Why can't we do it with 1
percent of the people we have?'"
- IBM's "cognitive
solutions" unit, its second-largest division with $5.5 billion
in revenue last quarter, provides A.I. to help businesses
increase efficiency.
- Cognizant see profit driving automation, but CEOs are also
worried about a backlash.
- McKinsey's
Katy George noted the issue for corporations is "they will be disrupted if they don't" automate
agressively.
Asian firms are less worried about society reacting. China's
JD.com has the goal of being 100% automated in the future.
Taiwan's Foxconn wants to replace 80% of its workers within 5 to 10
years.
Their are examples of companies agressively retraining workers whose
jobs were automated away:
- Accenture
replaced 17,000 back-office processing jobs without layoffs in
2017
- Amazon replaced
16,000 warehouse workers but retrained them into nursing and
aircraft maintenance.
Most analysts see these as unscalable examples, with 1 in 4 being
retrained at best.
MIT is Massachusetts Institute of Technology. 's Erik
Brynjolfsson, suggests the CEO's choice is "between whether
you use the technology in a way that creates shared prosperity, or
more concentration of wealth."
Feb 2019 NYT
As McKinsey Sells Advice, Its Hedge Fund May Have a Stake in the
Outcome
Michael Forsythe, Walt Bogdanich and Bridget Hickey report the sins
of Valeant
Pharmaceuticals are well known. Instead of spending to
develop new drugs, Valeant bought out other drugmakers, then
increased prices of lifesaving medicines by as much as 5,785
percent. Patients had no choice but to pay.
McKinsey is
unique in operating a 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. , MIO
Partners, that invests for its current and former
consultants. 401(k) plans make up make up 50% of MIOs
assets. The other $6 billion is 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). of McKinsey's
current and former partners. MIO, managed by chief investment
officer Todd Tibbetts, invested in Valeant
(now Bausch Health)
as McKinsey advised then CEO J.
Michael Pearson, a former McKinsey consultant, on
strategy.
MIO was initially setup to counter Wall Street
hiring the best graduates, but it had built in conflicts of
interest, providing advice to clients it could invest in or
against.
MIO was incorporated in the Channel Island of Guernsey, opaquely
through Barfield Nominees, but had to reveal, to judge Kevin
Huennekens, that the head of the bankruptcy practice, Jon Garcia,
was one of 9 current or former McKinsey consultants on the 11 person
MIO board of directors.
MIOs flagship fund is the Compass Special Situations Fund.
MIO invested in bonds in Puerto Rico as McKinsey advised the Island's
oversight board, and McKinsey's conflict of interest
statement, reviewed by Congress, was opaque about MIO links and
activity.
McKinsey asserts "MIO and McKinsey employ separate staffs. MIO
staff have no nonpublic knowledge of McKinsey clients. For the
vast majority of assets under management, decisions about specific
investments are made by third-party managers."
Jan 2019
NYT The $238 Million Penthouse, and the Hedge Fund Billionaire Who
May Rarely Live There
NIkita Stewart and David Gelles report in Manhattan, where
multimillion-dollar real estate sales are downright routine, a 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. tycoon
has managed to set a new standard for conspicuous consumption by
paying a fortune for an unfinished piece of property in the
sky.
Citadel founder Kenneth
C. Griffin, spent $238 million for a penthouse at 220 Central Park
South that is still being built on space the landlord evicted the
rent-stabilized apartments.
Griffin:
- Is based in Chicago.
- Is now worth $10 billion. Has three children
- Invests in art: Jasper Johns, Jackson Pollock, de Kooning;
philanthropy giving away $700 million: $150 million to Harvard,
$125 million to University
of Chicago; & as a board member of the Whitney, real
estate
Feb 2019
NYT It Started With a Jolt: How New York Became a Tech Town
Steve Lohr reports Euan Robertson started his job with New York
City's economic development team at an ominous moment. It was
Monday Sept. 15, 2008, the day Lehman Brothers
filed for bankruptcy and ignited the financial crisis.
The Lehman collapse encouraged NYC Mayor Bloomberg's leadership
team, to develop a "game changers" plan, including: start-up
incubators, networking events, training, internships and development
of a new graduate school; to build an 'applied science' Silicon
Alley talent engine to draw coders and companies to New York.
These would help generate new technologies supporting its key
industries: finance, fashion, design, advertising, law, consulting
and media; to be developed in the city. The plan encouraged
new courses at Columbia,
NY University
& the Cornell Tech graduate school where graduate students work
on real-world problems of local companies.
Lohr notes Silicon Alley, which emerged
during the 1990s Internet boom, is fed by smart people's interest in
coming to NCY to live well: museums, theater, opera, dance, jazz,
art galleries, bars, restaurants; and work: entrepreneurs,
technologists, corporate execs; in the city's key industries - there
are twice the technology jobs in these than in the technology
industry.
Google initially
entered NYC to gain access to its advertising industry cluster, a
move that was strengthened by its 2007 purchase of DoubleClick for
$3.1 billion from its private equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors. Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges. Private equity companies were initially corporate raiders.
company. At this point digital advertising took off in New
York.
Google engineers wishing to live in NYC joined an additional
'technology node' which linked in researchers from local companies
including Bell Labs, Google research now
employs 200 scientists in New York. As these clusters grow,
fed by Game Changers post graduates, VC is venture capital, venture companies invest in startups with intangable assets driven genetic operations occur enabling serial
new startup formation. Former DoubleClick CEO Kevin Ryan,
founded six companies including: Zola -- built from the failure of
flash sale site Gilt, Business Insider and MongoDB.
J. P. Morgan
Chase has now hired Apoorv Saxena, an A.I. product manager
from Google to lead the bank's A.I. product development and Manuela
Veloso from Carnegie Mellon to head an A.I. research team. Wall Street
sees an opportunity to move beyond its 2008
cloud as Silicon Valley Social Media companies become the new
misfits.
Jan 2019 NYT
Health Care May Not Cure What Ails Portfolios This Time
Ryan Derousseau reports health care stocks have traditionally done
well during market downturns. But whether they can repeat the
feat with continuing uncertainty about the future of health
insurance in the US is the United States of America. is a
big question.
Derousseau argues:
- When the stock market recently started to decline, healthcare
did not resist the fall: health care invested Mutual funds
and ETF is exchange traded fund, which tracks stock and bond indexes, adhering to a set of financial rules. These methods can be used to track any financial market segment. They are transparent, and low cost to operate, and invest in. ETFs are priced during normal trading hours. But their performance is impacted when they are forced by changing conditions to sell assets at a loss. Selling of an ETF by one investor to another does not redeem the ETF's underlying investments, limiting the capital gains tax distribution (Jul 2018).
s fell 14.6%
compared with the S&P 500 drop 13.3%.
- Health care has been historically counter cyclical noted Vanguard Health Care
fund portfolio manager, Wellington Management's Jean
Hayes. But it has recently outperformed limiting its near
term potential:
- S&P Health care index grew 14.3% annualized vs. the full
S&P's 11.6% because
- 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.
allowed
more people to use health care services (35% increased spend
between 2010 and 2017) including for inpatient beds &
prescription drugs. Market owned hospital groups: HCA
grew its beds 11% and revenue 36%;
- Health care stocks PEs increased to 20 vs. 17.7 for the full
index.
- During the last recession health care didn't perform well
due to uncertainty about health insurance.
- And more recently Congressional Republicans and President
Trump have
added to the uncertainty while a federal judge has
declared the ACA unconstitutional (Dec
2018).
- Even during downturns people still get ill & hurt,
maintaining demand for health care services. That has been
true in all recessions since 1974 with health care losing 11%
while the broad S&P 500 lost 39%
Sep 2017 NYT
How to Protect a Drug Patent? Sell it to a Native American Tribe
Katie Thomas reports the drug maker Allergan announced
Friday tht it had transferred its patents on a best-selling eye drug
to the Saint Regis Mohawk Tribe in upstate New York--an unusual
gambit to protect the drug from a patent dispute.
Allergan agreed to sell
& lease back the patents for Restasis to
the Saint Regis Mohawk Tribe. The tribe will be paid $13.75
million by Allergan to claim sovereign immunity as grounds to
dismiss a patent challenge filled by generic drug makers: Teva; under
the AIA is the Leahy-Smith America Invents Act of 2011 which aimed to modernize the patent system. A key provision of AIA was the creation of the Inter Partes Review process which third parties can use to contest the validity of a patent (for not being novel & non-obvious) within 9 months of its issuance to the Patent Trial and Appeal Board. . The lease
back will provide the tribe with $13 million annually as long as the
patents remain valid.
Allergan's Brent Saunders siad that the company made the move to
avoid what he described as the "double jeopardy" of having the same
issue heard in two venues. "We did this to really make sure
that we can defend these patents in only one forum."
Restasis 2nd quarter 2017 revenues were $336.4 million.
Botox was Allergan's
leading product by 2017 2nd quarter revenue.
The novel legal strategy was devised by Shore Chan DePumpo,
following a similar successful defense they developed for the
University of Florida which owned a patent being challenged by
Covidien (now part of Medtronic).
Shore Chan argued successfully to the patent review panel that the
University was an arm of the state of Florida and had sovereign
immunity.
Allergan's patents on Restasis are being challenged under the AIA
and in US District Court in Texas. If the court finds the
patents invalid the AIA avoidance strategy will be irrelevant.
Oct 2017
NYT Pfizer Considers Spinning Off or Selling Consumer Health Unit
Amie Tsang reports the pharmaceutical giant Pfizer said [] that it had
begun a strategic review of its consumer
health care division that could result in the consumer health
unit[] being spun off or sold.
The 2016 $3.4 billion revenue unit's products include Advil, Centrum
supplements and ChapStick.
Ian Read has been reviewing Pfizer's business strategy alignment for
over a year. An extensive evaluation resulted in Pfizer
concluding that it should not split up its Innovative Health and
Essential Health divisions into separately traded companies.
Ian Read commented "Although there is a strong connection between
consumer health care and elements of our core biopharmaceutical
businesses, it is also distinct enough from our core business that
there is potential for its value to be more fully realized outside
the company."
Aug 2016
NYT Pfizer Pays $14 Billion To Expand In Oncology
Andre Pollack and Lesie Picker report Medivation, which
makes the big-selling drug Xtandi to
treat prostate
cancer is cancer of the prostate gland. Genomics detected several common DNA variants associated with increased risk of prostate cancer. Dr. Francis Collins explains that a cluster of these risk variants lies in a stretch of 1 million DNA base pairs on chromosome 8. The cluster contains seven or more risk variants, each of which can raise the risk of prostate cancer by 10 to 30%. The high risk variants occur more frequently in African-American men than European or Asians. African-Americans die from prostate cancer at more than twice the rate of Europeans. Research in mice may explain a link between obesity and prostate cancer (Jan 2018). The average diagnosis is at age 66. Worldwide in 2012 there were 1.1 million cases from which 307,000 died. A common life-saving (Feb 2017) treatment is androgen deprivation therapy, but it has worrying side effects. Various classically defined types of cancer can occur. The most common is adenocarcinoma associated with the epithelial gland cells that generate seminal fluid. Epithelial cell differentiation potency makes these significant cancer agents. Other very rare types of cancer that can start in the prostate are: - Sarcomas
- Small cell carcinomas
- Neuroendocrine tumors
- Transitional cell carcinomas
, has finally found its buyer in a fellow American drug
maker, Pfizer. The
deal is subject to regulatory clearance and Medivation shareholder
agreement to tender their shares.
Medivation put its self up for auction to avoid a board takover
threatened by Sanofi,
after its bid for the company was rejected (Apr
2016).
Most pharmaceutical giants are pushing into oncology to leverage:
- Drug development enabling discoveries in genomics combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes. and 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.
.
- High product prices that have resisted insurers'
cost-cutting efforts.
Pfizer's oncology strategy has been weak until Ibrance became a
hit. Now Xtandi will add another hit, although the global
sales will be shared with Astellas Pharma.
Xtandi competes with Johnson &
Johnson's Zytiga
and J&J's follow on drug development apalutamide is a non-steroidal androgen receptor competitive inhibitor developed to treat prostate cancer. It is structurally similar to enzalutamide. .
And Medivation's 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.
drug developments may allow Pfizer to attack BMS and Merck's 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. Different evolved personality types reinforced during development provided hunter-gatherer bands with alternate adult capabilities for coping with the various challenges of the African savanna. As the situation changed different personalities would prove most helpful in leading the band. Big men, chiefs and leaders of early states leveraged their power over the flow of resources to capture and redistribute wealth to their supporters. As the environmental state changed and began threatening the polity's fitness, one leader would be abandoned, replaced by another who the group hoped might improve the situation for all. Sapolsky observes the disconnect that occurs between power hierarchies and wisdom in apes. In modern Anglo-American style corporations, which typically follow Malthus, and are disconnected from the superOrganism nest site, the goal of leadership has become detached from the needs of this broader polity, instead: seeking market and revenue growth, hiring and firing workers, and leveraging power to reduce these commitments further. Dorner notes that corporate executives show an appreciation of how to control a CAS. Robert Iger with personality types: Reformer, Achiever, Investigator; describes his time as Disney CEO, where he experienced a highly aligned environment, working to nurture the good and manage the bad. He notes something is always coming up. Leadership requires the ability to adapt to challenges while compartmentalizing. John Boyd: Achiever, Investigator, Challenger; could not align with the military hierarchy but developed an innovative systematic perspective which his supporters championed and politicians leveraged. John Adair developed a modern leadership methodology based on the three-circles model.
positions. Its late stage PARP Inhibitor stops single stranded repair of DNA. In cells with BRCA1/2 and PALB2 mutations this additional DNA repair inhibition will increase the likeliood that the cancer cells will die.
may allow Pfizer to attack AstraZeneca's 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)
lead (Lynparza).
AbbVie similarly acquired
Pharmacyclics for $21 billion in 2015 and Stemcentrx for $5.8
billion in Apr
2016.
Jan 2019 NYT
Bristol-Myers to Acquire Celgene in Deal Worth $74 Billion
Tiffany Hsu & Katie Thomas report Bristol-Myers
Squibb said [] that it would buy Celgene, a
maker 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). -fighting
drugs, in a cash-and-stock deal valued at $74 billion, the first
major pharmaceutical deal of 2019.
The combined organization will produce nine blockbuster drugs with
sales of more than $1 billion. It is hoped that combining will
support their work in oncology, 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).
, immunology and inflammation.
BMS CEO & Chairman Giovanni Caforio said "We are very excited
about this."
Celgene:
- Is near the top of Trump F.D.A. Food and Drug Administration. 's shame
list,
- Cancelled its REVOLVE Crohn's disease is an IBD which results in abdominal pain, diarrhea, weight loss, anemia, skin rashes, arthritis, colon cancer. There are genetic risk factors: PD-1 failure, and mutations of LRRK2, SLC11A1. Treatments include: Natalizumab, Remicade;
drug trial,
- Makes Thalomid which is 2/3 of the companies revenues, but is
on the edge of a patent cliff, and Celgene is resisting
providing samples to generic drug makers) & Revlimid,
- Acquired Impact Biomedicines & Juno
Therapeutics;
BMS's Opdivo sales
have lagged Merck's Keytruda
Mar 2019 NYT
Big Pharma's Hunt for New Drugs Is Pushing Up Cost of Deals
Stephen Grocer reports acquisitions of American biotech companies
are surging, and so are the prices that buyers are willing to
pay.
In 2019:
- $146 billion in biotech deals have already accrued
- In two months more deals were announced than in 2016 - 2018
- Drug
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.
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.
have eased, stocks are cheaper after Q4 2018 & windfall
cash has built from the tax cut of 2017 is the Republican tax cut signed into law by President Trump. The act includes: - Permanent tax cuts for corporations
- Temporary tax cuts for individuals expiring in 2025; and will increase the size of the economy 0.7% between 2018 and 2028. It will add $1.8 trillion to the deficits during that period from reduced tax revenue and higher interest payments.
- Repeal of the individual mandate of the ACA.
- Limiting deductions for state and local income tax and property taxes - impacting high tax Democratic leaning states
- Reducing the AMT for individuals and eliminating it for corporations
- Reducing the number of states affected by the estate tax
,
- Major drug makers are seeking blockbuster drugs, in
development at biotech and pharmaceutical companies
- The competition has driven up the prices being asked and
paid. On average acquirers are paying 120% above 30 day
stock price.
Nov 2016 NYT
Rolling Up Deals While Rates Are Low And Confidence High
Steven Davidoff Solomon reports world-changing corporate
transactions just seem to keep coming. It won't last,
however.
Huge numbers of multibillion-dollar deals, $329 billion in the US,
have been announced in October 2016:
- AT&T's acquisition of Time Warner for $85.4 billion, to
gain control of content to compete with Facebook and Google.
- General
Electric with Baker Hughes.
- BAT $47 billion acquisition of Reynolds American.
- Qualcomm's $38.5 billion acquisition of NXP
semiconductor.
Earlier in the year was the $56 billion acquisition by Bayer of Monsanto.
Microsoft acquired LinkedIn for $26.2 billion to maintain its
Internet reach. And soon should come the restructuring of
Viacom and CBS.
Davidoff Solomon notes that cheap money (interest rates at a 400
year low and liquidity looking for any yield) is the conventional
explanation. Hence AT&T can easily borrow $40
billion. He concedes the banks are limiting their leverage in
lending. But he asserts that confidence is high since all the
major trading blocks are exhibiting stability. He reasons that
in this low growth 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. ,
with massive technological transformations CEOs are using
consolidation to justify their positions. The acquisitions are
an easy way to grow, capture products/services and reduce
competition before additional anti-trust rules are introduced in
response to the development of oligopolies:
- The pharmaceutical giants captured drugs rather than
developing them.
- Snap's high valuation IPO will drive more activity in high
technology.
But Davidoff Solomon worries that inefficient conglomerates are
returning which may destroy capital if caught in a bursting bubble,
as interest rates rise, a market destabilizes or another catastrophe
occurs.
Nov 2016
NYT Swimming in a Rising Tide of Mortgage Debt
Paula Span reports the proportion of older adults still paying off
homes is climbing, as is what they owe.
Prior to the housing bubble and
consequent financial
crisis of 2008 a majority of older couples: 65 year old
husband and 62 year old wife; would be expecting to retire in their
fully paid for house. But now increasing percentages are
amassing ever more mortgage debt and see selling their house as the
only way to escape.
Two recent studies: Urban Institute, Boston College group; indicate:
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