Economic situation

Summary

Introduction

• 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.  : 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:
• Cloud applications managed with SaaS is software as a service. 
  collaboration tools enable broader adoption of agile practices Stanford's Hinds notes (Nov 2016)
• 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.  
• Duke's Aaron Chatterji argues lower growth in local education and health care with shift to online: Coursera to offer University of Pennsylvania Wharton courses (Oct 2013)
• 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 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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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:
• CFPB is the Dodd-Frank act's Consumer Financial Protection Bureau. 
  and two state attorney generals: Illinois, Washington; file suit against Navient & Sallie Mae over student loan violations (Jan 2017) 
• 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). 
    
  fiscal crisis:
• US financial services firms: Goldman Sachs, Cerberus (strategies), Lone Star, Blackstone; become Europe's landlord (Dec 2016)
• US is the United States of America.   Private Equity is the pooling of money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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. 
  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.  But their performance is impacted when they are forced by changing conditions to sell assets at a loss (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.  But their performance is impacted when they are forced by changing conditions to sell assets at a loss (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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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.  But their performance is impacted when they are forced by changing conditions to sell assets at a loss (Jul 2018). 
  purchases are second in volume but much smaller (Oct 2018)
• 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 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). 
• 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,
• 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.  But their performance is impacted when they are forced by changing conditions to sell assets at a loss (Jul 2018). 
  s (Sep 2016). 
  
• 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:
  1. US - $2.9 billion, an amount the FDR administration could transfer from Exchange Stabilization Fund without any need to ask for Congress for funds. 
     
  2. UK - $1.45 billion
  3. USSR - slightly less than UK quota
  4. 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:
  1. US - $2.9 billion, an amount the FDR administration could transfer from Exchange Stabilization Fund without any need to ask for Congress for funds. 
     
  2. UK - $1.45 billion
  3. USSR - slightly less than UK quota
  4. 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:
  1. US - $2.9 billion, an amount the FDR administration could transfer from Exchange Stabilization Fund without any need to ask for Congress for funds. 
     
  2. UK - $1.45 billion
  3. USSR - slightly less than UK quota
  4. 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). 
    
  debt crisis.  
• Oct 2016 Legarde worried at lack of commitment to trade deals.
  
• Payer 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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
    
  • Diet
  • Exercise
  .  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-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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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)
  
• 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 health care architecture in which there is a single financing organization.  A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations.  Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016).  Politics undermines 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;
  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
  
• Nov 2015 USPSTF is United States preventative services task force.  It is an independent expert panel focused on prevention and evidence-based medicine appointed by HHS.   prostate 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
  screening (May 2016, 2) recommendations working but questioned by studies setup by ACS. 
• 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, 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 memory and thinking problems (MCI).  Variants include: late-onset sporadic; with risk factors - ApoE4, presenilin, androgen deprivation therapy (Dec 2015).  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; 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 and set off the formation of tangled thread-like tau protein.
  • Solanezumab aimed to inhibit plaque formation but clinical trials failed (Nov 2016).  
  • BACE inhibitors block an enzyme needed to form amyloid. 
    
  • 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. 
    
  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 a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, 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, 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
  

• Supply for genomics combines recombinant DNA, DNA 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. 
  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)
  

• 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 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). 
• 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 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)
  
• 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). 
• 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) 
• 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 (Jun 2018)
  
• Analysis suggests Amazon may not succeed in disruption of prescription drug distribution.  PillPack needs 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), distributor: AmerisourceBergen (part owned by Walgreens) (Jul 2018)
  
• 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)
• Drug prices continue to rise significantly.  Trump CMS is the centers for Medicare and Medicaid services.   helps by blocking states from constraining which drugs are provided by 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. 
  , while Pfizer is the only manufacturer that holds down prices for six months.  Novartis influences Trump plan (Jul 2018)
• Novartis joins Pfizer in freezing its drug prices until the end of the year, in response to President Trump (Jul 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:
  • 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.  
• 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. 
  : Pershing Square; provide the access to capital to support the catalysis. 
  
• 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 memory and thinking problems (MCI).  Variants include: late-onset sporadic; with risk factors - ApoE4, presenilin, androgen deprivation therapy (Dec 2015).  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; 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 and set off the formation of tangled thread-like tau protein.
  • Solanezumab aimed to inhibit plaque formation but clinical trials failed (Nov 2016).  
  • BACE inhibitors block an enzyme needed to form amyloid. 
    
  • 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. 
    
  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 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 and clinical data through a taxonomy based on a knowledge network 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 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 stimulating the immune system.  Targeted diseases include cancers -- immuno-oncology. 
  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.  While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity and supporting the use of regulation, or even its threat, that can drive their 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 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).  
• Mylan strategy associated with its executive incentives (Sep 2016)
• 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)
• 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). 
• 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)
• 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 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)

• 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 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)
  

• 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 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). 
    
  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). 
    
  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)
  

• Part of a broader trend with low rates (Nov 2016)

• 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 (Sep 2017)
  

• Amgen described the transformation.  
• BCBS Nebraska described how they are responding.  
• Independence BC explained their response.  
• Health Net described their position. 
  
• Express scripts see their 'big data' as able to focus suppliers strategies.  And they view genomic testing uses genomic analysis to diagnose genetic disorders - for example Genomic Health's Oncotype DX & Agendia's MammaPrint.  The desire to see the genetic risk factors identified by such tests should depend on the risk * burden * Possibility of intervention.  Early tests look at only single gene mutations, but big data research tools are showing promise with large gene algorithms (Aug 2018).  Genomic testing can be performed direct-to-consumer.  Data is being collated on the genetic components of most diseases to enable more sophisticated diagnosis in the future such as the OPHG (EGAPP initiative), USPSTF recommendations and NCBI (Genetic test registry).  While there is only limited identification of the significant mutations and limited patient bases misdiagnosis is a problem (Aug 2016). 
  as allowing them to stear their patients towards the most effective medicine. 
  
• Michael Chernew agreed that innovation must be affordable and financed.  He mentioned the alternative quality contract (AQC) is:
  
  • A 2009 payment arrangement developed by Blue Cross Blue Shield of Massachusetts.  It was developed to support change.  It differs from capitation in including upside measures for patient safety, appropriateness of care and patient satisfaction.  Its key components are:
  • Integration across the care continuum
  • Accountability for performance measures for ambulatory and inpatient care.  Includes a 10% incentive for performing. 
    
  • Performance measures are selected that are: Nationally accepted, Vary across providers, Include sufficient data on provider being measured, measured at the level that can influence the outcome. 
    
  • Global payment for all medical services with health status adjustment and with margin retention. 
    
  • Five year contract to create a sustained partnership 
  . 
  

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; 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, DNA 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 and clinical data through a taxonomy based on a knowledge network 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
  
• 2017 Jul Single-payer is a health care architecture in which there is a single financing organization.  A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations.  Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016).  Politics undermines 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;
  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-delivery integration across the health care spectrum 
• 2018 Feb University of Pennsylvania's Ezekiel Emanuel argues traditional hospital business model is under pressure
  
• 2014 Jan, Sep Patients' costs skyrocket as specialists incomes soar (infrastructure amplifier)
• 2018 Oct Private equity is the pooling of money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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
  
• 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 and prion infections such as Alzheimer's disease, 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 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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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.  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.  
  • 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 state which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels; and an accumulation of traumatic events.  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, 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.  There is an association between depression and particular brain regions: Hippocampal dendrite and spine number reductions, Dorsal raphe nucleus linked to loneliness, Abnormalities of the ACC.  Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable.  Treatments include: CBT, UMHS depression management.  As of 2010 drug treatments take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony.   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 and prion infections such as Alzheimer's disease, 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 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 memory and thinking problems (MCI).  Variants include: late-onset sporadic; with risk factors - ApoE4, presenilin, androgen deprivation therapy (Dec 2015).  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; 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 and set off the formation of tangled thread-like tau protein.
  • Solanezumab aimed to inhibit plaque formation but clinical trials failed (Nov 2016).  
  • BACE inhibitors block an enzyme needed to form amyloid. 
    
  • 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. 
    
  (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;  screening at 45, as people are increasingly getting: rectal cancer is also called colon cancer. 
  - 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.  
• 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.   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. 
  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; 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.
  
• 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) 
• 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. 
  
  1. It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.  
  2. Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments. 
     
  3. Care delivery must be re-architected to reduce costs and improve quality. 
     
  4. 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 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
  
• 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 
• 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 a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, 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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
    
  • Diet
  • Exercise
  
  
• 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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
    
  • Diet
  • Exercise
  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 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).   
• 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)
  .  
• 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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  Private equity companies were initially corporate raiders. 
  (Jun 2016). 
  
• 2017 Jul New York Private Equity is the pooling of money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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.  
• 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 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.  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:
  • A cramdown provision
    
  • 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);  
  • Coding : CVX, MVX;
    
  • Research on vaccines includes: 
  • NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.  
  • NCI:
  • Roswell Park clinical trial of immuno-oncology vaccine cimavax. 
    
  • Geisinger: effective process leverage in treatment. 
    
  • Stanford Edge immuno-oncology for cancer vaccines.  
  • P53-driven-cancer focused, gene therapy (Jun 2015). 
    
  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);  
  • Coding : CVX, MVX;
    
  • Research on vaccines includes: 
  • NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.  
  • NCI:
  • Roswell Park clinical trial of immuno-oncology vaccine cimavax. 
    
  • Geisinger: effective process leverage in treatment. 
    
  • Stanford Edge immuno-oncology for cancer vaccines.  
  • P53-driven-cancer focused, gene therapy (Jun 2015). 
    
  , 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);  
  • Coding : CVX, MVX;
    
  • Research on vaccines includes: 
  • NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.  
  • NCI:
  • Roswell Park clinical trial of immuno-oncology vaccine cimavax. 
    
  • Geisinger: effective process leverage in treatment. 
    
  • Stanford Edge immuno-oncology for cancer vaccines.  
  • P53-driven-cancer focused, gene therapy (Jun 2015). 
    
  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);  
  • Coding : CVX, MVX;
    
  • Research on vaccines includes: 
  • NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.  
  • NCI:
  • Roswell Park clinical trial of immuno-oncology vaccine cimavax. 
    
  • Geisinger: effective process leverage in treatment. 
    
  • Stanford Edge immuno-oncology for cancer vaccines.  
  • P53-driven-cancer focused, gene therapy (Jun 2015). 
    
  
  
• 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 aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group.  John Adair developed a 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 a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, 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 a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, 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 a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, 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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
    
  • Diet
  • Exercise
  ; 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 a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, 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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
    
  • Diet
  • Exercise
  
  
• 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 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 a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, 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 to nicotine and 4 times more likely to start smoking
  
• 2015 May Digital record sharing issues 
• 2015 Sep VW diesel deception impacts public health
• 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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  Private equity companies were initially corporate raiders. 
  company
  
• 2015 Dec Private equity is the pooling of money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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 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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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 amydala and learned fears which are mediated by the BLA which learns to fear a stimulus and then signals the central amygdala. 
  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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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 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.   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.  .  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 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.   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.  But their performance is impacted when they are forced by changing conditions to sell assets at a loss (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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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 health care architecture in which there is a single financing organization.  A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations.  Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016).  Politics undermines 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;
  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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  Private equity companies were initially corporate raiders. 
   
• 2016 Jul Private equity is the pooling of money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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

May 2016 NYT A Choppy Year for Hedge Funds, but Chiefs Cashed In

• Ray Dalio got $1.4 billion from Bridgewater Associates.
  
• Pobert Prince and Greg Jenson from Bridgewater
• Daniel Och got $140 million from Och-Ziff Capital.  
• Michael Platt got $260 million from BlueCrest Capital. 
  

May 2016 NYT Hedge Funds Reach for Hard Hats in Year of Collapsing Mergers

• 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. 
  

Aug 2018 NYT The Stock Market Is Shrinking.  That's a Problem for Everyone. 

• a National Bureau of Economic Research report by Ohio State's Rene Stulz who concludes the shrinking "is troubling for the economy 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.  , for innovation is the economic realization of invention and combinatorial exaptation.  While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity and supporting the use of regulation, or even its threat, that can drive their 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 money from partners to: buy companies, improve their acquisition's value and sell them again.  They gain competitive advantage from being lightly regulated.  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

Sep 2017 NYT How to Protect a Drug Patent? Sell it to a Native American Tribe

Oct 2017 NYT Pfizer Considers Spinning Off or Selling Consumer Health Unit

Aug 2016 NYT Pfizer Pays $14 Billion To Expand In Oncology

• Drug development enabling discoveries in genomics combines recombinant DNA, DNA 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. 
  

Nov 2016 NYT Rolling Up Deals While Rates Are Low And Confidence High

• 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.  

• The pharmaceutical giants captured drugs rather than developing them. 
• Snap's high valuation IPO will drive more activity in high technology. 
  

Nov 2016 NYT Swimming in a Rising Tide of Mortgage Debt

• A growing proportion of older homeowners (35%) now carry mortgage debt.  This is particularly true of Black and Hispanics without college degrees. 
  
• Three quarters of older Americans are home owners.  The homes are their largest capital asset.  But they have little equity because of second loans, or lines of credit, taken out on the houses. 
  
• The average amount of mortgage debt has doubled ($82,000).  

Nov 2016 NYT Wells Fargo Asks Federal Court to Force Customers to Arbitration in Fake Accounts Cases

• Denies customers legal protection of a court preceding including a right of appeal
• Helps conceal corporate misconduct from the public and regulators with no documents or hearings becoming public. 
  
• Disuades customers with small claims if they have to fund an arbitration lawyer
• Cases do not set legal precedents

Apr 2016 NYT E.C.B. Is Worried, but Not Enough to Try 'Helicopter Money'

• Printing money to buy bonds issued by corporations
• Offering to pay banks to lend money. 
  
• Penalizing banks for hording cash. 
  

Jul 2018 NYT Fed Plays Down Trade Woes and Suggests Rosy Economic Outlook

• Economy 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.   robust allowing for four planned interest rate increases this year to drive short term rates back to historic levels,
  
• 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. 
  , while benefit costs such as health care have increased marginally
  
• Decline in work force participation among less educated Americans because of technology automating jobs,
  
• Women providing child-care rather than entering the work force impacting productivity: why would legislators & policy makers find this tradeoff acceptable?
  
• Oil prices increased domestically reducing American's disposable income, but oil is increasingly produced domestically reducing the export of dollars and the drag on GDP is:
  • Gross domestic product which measures the total of goods and services produced in a given year within the borders of a given country (output) according to Piketty.  Gordon argues to include products produced in the home & market-purchased goods and services, following Becker's theory of time use.  Gordon stresses innovation is the ultimate source of all growth in output per worker-hour.  GDP growth per person is equal to the growth in labor productivity + growth in hours worked per person.  GDP has many problems.  Gordon concludes that between 1870 and 1940 all available measures GDP is hugely understated because:
  • GDP is a poor measure of:
  • Value & wealth
    
  • Who gets what
  • Global supply chains
    
  • GDP excludes:
  • Reduction in infant mortality between 1890 (22%) and 1950 (1%)
    
  • Brightness & safety of electric light,
    
  • Increased variety of food including refrigeration transported fresh meat and processed food
  • Convenience and economies of scale of the department store and mail order catalog and resulting product price reductions
    
  • Services by house makers
  • Time & health gains from having flush toilets, integrated sewer networks; rather than having to physically remove effluent and cope with fecal-oral transmission
    
  • Leisure
  • Costs & benefits of different length work weeks
    
  • Speed and flexibility of motor vehicles - which were not included in the CPI until 1935, after the transformation had occurred.  And competition from improved foreign vehicles, while it provides purchaser/user with improved standard of living (less breakdowns, repairs, etc.) is measured as reduced domestic manufacture
    
  • Coercion and corruption to obtain resources 
  • Consumption impact of finite resources: coal, oil;
  • Destruction impact of loss of entire irreplaceable species
    
  • GDP includes items that should be excluded:
  • Cost of waste - cleaning up pollution (single use indestructible plastic bags), building prisons, commuting to work, and cars left parked most of the time; should be subtracted
    
  • Guanine-di-phosphate is a nucleotide base. 
    
  ,
  
• Trade war was handled effectively by the current Fed policies. 
  

2008 Mar A fed bailout crosses a line

• Weaker currency
• Rampant inflation
• Continuation of the slow bleed we have witnessed at banks and brokerage firms over the last year. 
  

1. The government does not have the money. 
   
2. The US systems reputation as the broadest, deepest, most transparent and properly regulated 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). 
   market in the world is impacted. 
   

Jun 2016 NYT Time Doesn't Heal Wounds Of Bad Loans

• Thousands of loans with exploding interest rates made to unsophisticated investors with no ability to repay them. 
• Abusive foreclosure practices that increased the burden on struggling people
• Shattered lives
• Interviews Mozilo had with government investigators where he maintained that his company had strong ethical standards. 
  
• Private communications between Mozilo and Countrywide where he criticized practices that resulted in the requirement to buy back troubled loans.  One in eight loans audited in Countrywide's six largest regions were 'severely unsatisfactory'. 
  
• Profit machine that Mozilo architected:
• Vertical integration allowed Countrywide to leverage fees (sometimes with more than a 100% markup) from each stage of the lending and loan servicing process. 
  
• In-house appraisals, Property maintenance, insurance;
• FTC - is either:
  
  • Federal Trade Commission.  Setup during the Wilson administration.  Its powers include blocking mergers due to antitrust concerns using the powers of the Clayton act. 
    
  • Follicular thyroid cancer. 
    
  case against Countrywide for the excessive fees where it determined the company overcharged about half a million customers.  The FTC concluded that the company's fees were designed to increase earnings from default-related services during an 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.   downturn.  FTC commissioner noted Countrywide's business model was "based on deceit and corruption, and the harm they caused to American consumers is absolutely massive and extraordinary." 
  
• Company ran roughshod over the nation's 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. 
  court system.  In one case the company levied improper fees, and twice claimed borrowers were behind on their payments when they were not.  Countrywide moved to seize the property and only withdrew when the proved wrong in court. 
  
• 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.   filed suit which Mozilo settled in October 2010.  Regulators contended that Mozilo and two former execs hid growing risks in Countrywide's operations from investors and generated improper profits on stock sales.  Mozilo did not admit or deny the claims but agreed to a permanent prohibition on serving as an officer or director of a public company and paid $22.5 million.  
• Point in the financial crisis when Bank of America paid $4 billion for Countrywide and later paid $50 billion in fines relating to its own and Countrywide's fines and settlements. 
  

Jul 2018 NYT How It Got Riskier to Own High-Quality Corporate Bonds

• Many investment grade rated companies used the low interest rate environment post 2008, to borrow heavily, locking in these rates over a long period. 
  
• The longer a bond's maturity the more its price will drop when interest rates rise (high duration)
• The potential for a recession is high, given the length of the current bull market, but this is not yet reflected in bond prices. 
  
• The overall quality of investment grade debt has dropped.  In 2007 27% was rated BBB or lower.  Now 50% is BBB or lower.  Companies have strategically decided to increase leverage.  This can be used in acquisitions: CVS merger with Aetna (Dec 2017), Bayer, AT&T, General Mills;
• In a recession year 10% of BBB investment grade bonds have historically become junk, causing the funds that track those bonds, such as E.T.F.s to sell them. 
  

Sep 2016 NYT This Man Oversees $5 Trillion

Jul 2017 Forum Sacramento Bee reporter discusses California situation: Revenue instability, CalPERs losses, Single Payer is a health care architecture in which there is a single financing organization.  A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations.  Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016).  Politics undermines 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;

• CalPERS had massive losses during the great recession.  They are still trying to make up for them, but with more conservative investment strategies this appears unlikely.  Result is huge pressure on California cities to fund pension short falls.  Consequently there is no money for updating infrastructure: Roads; which is aging badly. 
  
• As currently structured California does not have the revenues to support single-payer is a health care architecture in which there is a single financing organization.  A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations.  Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016).  Politics undermines 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;
  health insurance. 
  
• Sales taxes have eroded over many years. 
  
• California's revenue is 70% based on an income tax (surcharge) on richest 1% but it's progressive and fails during recessions.  At that point there are no funds for schools, dependent poor, etc.
• Jerry Brown's rainy day fund is far to small to cope with a major recession's impact on the revenue as currently gathered. 
  
• No politician is willing to raise revenues via tax increases which the voters have signalled, 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. 
  would be rejected at the polls. 
  

Nov 2017 NYT Uwe Reinhardt, 80, Dies; a Listened-to Voice on Health Care Policy

• 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. 
    
  rather than using 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.  . 
  
• Penalizing the uninsured so they would not wait until they became ill to purchase insurance.  This 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. 
    
  was accepted by the architects of the ACA.  
• Subsidizing low-income families so they could afford mandated insurance. 
  
• Asserted US is the United States of America.   health care costs were due to: high prices; driven by a failed market with hidden expensive transactions, high priced prescription drugs, and inefficient interface to the health insurance network.  
• He did not see US doctor pay as an issue.  He argued that their collective take-home pay amounted to only 10% of national health spending.  Slicing that by 20% would reduce total national health spending by only 2%, in return for a wholly demoralized medical profession to which we so often look to save our lives. 
  

Apr 2018 NYT For Cancer Centers, Proton Therapy's Promise Is Undercut by Lagging Demand

• Reduce the scope and cost of the investments: Georgetown's proton center only has one treatment room & cost 'only' $40 million.  
• Share: New York's hospitals are partnering to help with patient capture: Memorial Sloan-Kettering, Mount Sinai Health, Montefiore Health; will all use the same large center in East Harlem.  
  
• Marketing their way through the crisis. 
  

Oct 2017 Intelligence Squared debate - Is the U.S. Healthcare System Terminally Broken?

• For the motion: Shannon Brownlee, Dr. Robert Pearl;
  
• Against: Dr. Ezekiel Emanuel, Dr. David Feinberg;

1. Brownlee:
• Two ideas:
  
• How broken?
  
• If it was a patient it would be in the 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. 
  . 
  
• Can reforms revive the system?
• [They] cant.  
• US health care network problems are very significant:
• Fragmented care
• Burned out physicians and nurses
• Quarter of a million people die from errors, nosocomial infections is a health care facility (hospital) acquired infection. 
  and adverse drug events each year
• Record drug recalls in last decade partly due to the F.D.A. Food and Drug Administration.   being captive to the pharmaceutical industries
• 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.   induces more care, and it is still the main way to pay for care
• Costs include lots of waste:
• $300 billion for unneeded services
• $1 trillion in total waste - 
• Massive over-investment in hospitals and too little investment and reward for PCP is a Primary Care Physician.  PCPs are viewed by legislators and regulators as central to the effective management of care.  When coordinated care had worked the PCP is a key participant.  In most successful cases they are central.  In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements.  Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. 
  s and community care.  
• FFS drives hospitals to focus on margins not mission
• Shannon highlights a typical issue - Hospital infrastructure competition results in unnecessary costly duplication:
• $100 million proton beam 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)
  systems for treating a handful of cancers is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure.  It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA.  In 2010 one third of Americans are likely to die of cancer.  Cell division rates did not predict likelihood of cancer.  Viral infections are associated.  Radiation and carcinogen exposure are associated.  Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).   are being built by hospitals
  
• 2 in Baltimore (30 miles from D.C.)
  
• 4 in Washington D.C. 
• Reforms are too small scale
  
• 2012 32 pioneer 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.  By 2017 only 8 left.  24 dropped out because of the risk profile. FFS limits shift.  
• Legacy players: hospitals, insurers, drug companies; are invested in the 'system.'  They push back against systemic fixes. 
• Scale of current solutions is too small to drive change.  
• Private plans are not incented to follow the CMS is the centers for Medicare and Medicaid services.   push to FFV is fee-for-value payment.  It may be a bundled payment for a set of services provided by a group of doctors and facilities, or full capitation.  In each case the risk has shifted from the payer to the providers of care. 
  . 
  
• Points of light appear: fantastic primary care, EMR refers to electronic medical records which are a synonym of EHR.  EMRs have strengths and weaknesses:
  • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
  • The EHR does not necessarily reflect the patient's situation accurately. 
    
  • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    
  • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    
  • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    
  s; but they are one offs that won't scale up when the legacy pushes back.  
• ACOs will not grow large enough to be effective. 
2. Emanuel:
• Everyone agrees that the system is broken.  There is $1 trillion of waste, $200 billion of unnecessary care, $130 billion of inefficient care.  We are underperforming.  But the question is whether it is terminally broken?  Dr. Emanuel jokes that he is an oncologist and is an expert about terminal conditions.  
• There are multiple points of light around the country: Mayo Clinic, Geisinger, Kaiser; but also
  
• CareMore 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. 
  plan, caring for very sick, chronically ill, elderly with 45% fewer hospital admissions: 10% 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. 
  vs Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
  
  • Benefits
  • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
    
  • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
    
  • Part C: Medicare Advantage 
  • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    
  • Eligibility
    
  • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
    
  • Persons under 65 with disabilities who receive SSDI. 
    
  • Persons with specific medical conditions:
  • Have end stage renal disease or need a kidney transplant. 
    
  • They have ALS. 
    
  • Some beneficiaries are dual eligible. 
    
  • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    
  • Sign-up
  • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
    
  • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    
  • Premiums
  • Part A premium
  • Part B insurance premium
    
  • Part C & D premiums are set by the commercial insurer.  
  's 17% average, and in their dialysis patients they have 85% fewer bed days; just one example. 
  
• In Hawaii a small group address behavioral health problems.  They co-locate psychologists in their practice four days a week.  They treat: depression is a debilitating state which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels; and an accumulation of traumatic events.  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, 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.  There is an association between depression and particular brain regions: Hippocampal dendrite and spine number reductions, Dorsal raphe nucleus linked to loneliness, Abnormalities of the ACC.  Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable.  Treatments include: CBT, UMHS depression management.  As of 2010 drug treatments take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony.   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;, anxiety is manifested in the amygdala mediating inhibition of dopamine rewards.  Major anxiety results in elevated glucocorticoids and reduces hippocampal dendrite & spine density.  Some estrogen receptor variants are associated with anxiety in women.  Michael Pollan concludes anxiety is fear of the future. 
  , smoking secession, insomnia, patients that are non-compliant with medical disorders.  They have substantially improved their performance. 
  
• In palliative care aims to relieve and prevent the suffering (symptoms, pain and stress of serious illness) of patients what ever their prognosis.  , an area where the US has underperformed for many years, and Emanuel explained he has studied for 35 years, there are now interesting groups entering the business.  In Nashville, Tennessee, there is a for profit group Aspire:
  
• Begins palliative care 12 months before death, sending out a nurse to the home
• Seen a 25% saving over that time.  
• This is a handfull of examples from thousands around the country.  
• How do we scale: By inducing behavior change of doctors and patients. 
  
• Already moving off 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.  .  There are 32 million Americans who are using 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 today through Medicare and commercial plans.  
• Bundled payments is where the purchaser disburses a single predefined payment to cover certain combinations of hospital, physician, post-acute, or other services performed during an episode of care relating to a particular condition (unlike capitation).  This bundling is assumed (Sep 2018) to allow the value delivery system to optimize around low cost high quality long term health care.  With one bundled payment physicians & hospitals must coordinate care and reduce the unit costs to remain profitable.  And to avoid taking on risk of expensive complications physicians & hospitals are incented to standardize and focus on quality.  This optimization is dependent on quantifying the value of the outcome of the episode of care.  Previously FFS payments induced excessive treatment activity.  Bundled payment is included in CMS ACE demonstrations and BPCI initiatives.  There are significant impacts on IT. 
  
  1. It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.  
  2. Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments. 
     
  3. Care delivery must be re-architected to reduce costs and improve quality. 
     
  4. Monitoring sensors can be used to feed reports to ensure re-architected operations conform.  
  bringing improved efficiency, bringing down cost
  
• Most importantly MACRA is Medicare Access and CHIP Reauthorization Act of 2015 is designed to encourage physicians to move to FFV and to link Medicare payment to quality & value.  It alters the way Medicare pays for part B physician services encouraging physicians and other ECs to conform to one of two value based payment schemes: Advanced APMs (where the EC can become a QP) or MIPS.  MACRA does not apply to hospitals which have their own meaningful use.  MACRA is designed to promote transformation and includes: Data reporting by ECs, New practice models, Changing clinical standards, and Physician evaluations; with hundreds of millions of dollars in penalties and bonuses.  It authorizes CMS to develop and deploy new rules.  It provides for PCPs in PCMHs to qualify as advanced APMs via a special lower risk pathway.  It replaced the problematic physician SGR formula. 
  is incentivising doctors to move from FFS or have very high pay-for-performance up or down 9% to improve quality and be responsible for the cost of care.  
  
• We need to be thoughtful about the timeline.  Its a $3.4 Trillion dollar industry.  The right timeline is 2030
  
3. Pearl:
• Solutions are inadequate
• Robert Pearl's father, Jack Pearl, was son of two immigrants.  He fought in the Second World War.  Later in life he developed heamolytic anaemia is a condition where red blood cells are destroyed and removed from the blood stream faster than the bone marrow is replenishing them.  Treatment can involve splenectomy for extravascular or hereditary heamolytic anaemia. 
  .  He had to have his spleen is a primary blood filter, but it also holds reserves of blood and monocytes being a central node in the mononuclear phagocyte system.  It:
  
  • Is a major node of the active immune response
    
  • It filters antibody covered bacteria and blood cells from the blood and lymph circulations.  
  • Removes old erythrocytes.  It metabolizes hemoglobin from the senescent erythrocytes recycling iron.  During gestation it also produces erythrocytes. 
  removed.  Robert's brother, Chair of anesthesia is the temporary removal of sensation.  It can be local, regional or general. 
  at Stanford, and Robert, handpicked the doctors to treat their father.  Jack spent half his year in New York and half in Florida so they selected two geographically split groups.  They were all excellent physicians who knew that after the splenectomy is a surgical procedure where the spleen is partially or totally removed.  The splenectomy increases the risk of sepsis.  The risk can be mitigated with pneumococcal conjugate vaccine. 
  Jack must be vaccinated 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);  
  • Coding : CVX, MVX;
    
  • Research on vaccines includes: 
  • NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.  
  • NCI:
  • Roswell Park clinical trial of immuno-oncology vaccine cimavax. 
    
  • Geisinger: effective process leverage in treatment. 
    
  • Stanford Edge immuno-oncology for cancer vaccines.  
  • P53-driven-cancer focused, gene therapy (Jun 2015). 
    
  against pneumococcus.  But the doctors in each region thought the other group had given him the treatment.  Jack died one morning after arriving to visit Robert and his brother.  He was one of 200,000 people who die every year from preventable medical errors.  
• 92% of physicians are paid with 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.  .  They are rewarded for splenectomy.  They are not rewarded for thinking about how Jack got the vaccine. 
  
• Cost and quality improvement require a shift from FFS to total capitation is a global payment for all care for a patient during a specified time period.  It forces the provider of care to take a high risk.  Managing the risk implies successful population health management. 
  .  
• Difficult but anything less will be incomplete.  
• 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. 
  
  1. It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.  
  2. Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments. 
     
  3. Care delivery must be re-architected to reduce costs and improve quality. 
     
  4. Monitoring sensors can be used to feed reports to ensure re-architected operations conform.  
  evidence says costs come down on a unit basis but doctors do more. 
  
• When hospitals and doctors consolidate what do we see happening?  They don't use the restructuring to improve efficiency and effectiveness of care.  Instead they use it to raise the price by controlling the market place. 
  
• The alphabet soup of Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
  
  • Benefits
  • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
    
  • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
    
  • Part C: Medicare Advantage 
  • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    
  • Eligibility
    
  • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
    
  • Persons under 65 with disabilities who receive SSDI. 
    
  • Persons with specific medical conditions:
  • Have end stage renal disease or need a kidney transplant. 
    
  • They have ALS. 
    
  • Some beneficiaries are dual eligible. 
    
  • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    
  • Sign-up
  • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
    
  • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    
  • Premiums
  • Part A premium
  • Part B insurance premium
    
  • Part C & D premiums are set by the commercial insurer.  
  : MACRA is Medicare Access and CHIP Reauthorization Act of 2015 is designed to encourage physicians to move to FFV and to link Medicare payment to quality & value.  It alters the way Medicare pays for part B physician services encouraging physicians and other ECs to conform to one of two value based payment schemes: Advanced APMs (where the EC can become a QP) or MIPS.  MACRA does not apply to hospitals which have their own meaningful use.  MACRA is designed to promote transformation and includes: Data reporting by ECs, New practice models, Changing clinical standards, and Physician evaluations; with hundreds of millions of dollars in penalties and bonuses.  It authorizes CMS to develop and deploy new rules.  It provides for PCPs in PCMHs to qualify as advanced APMs via a special lower risk pathway.  It replaced the problematic physician SGR formula. 
  , MIPS is merit based incentive payment system, a MACRA legislated, CMS regulated, patient outcome based Medicare part B payment system for ECs.  It is an alternative value based payment scheme when physicians aren't setup to work in an advanced APM, such as an ACO.  It is seen as a training route to the EC becoming a QP in an advanced APM.  It includes a new reporting category: clinical practice improvement activities - which can be selected from an approved list.  Doctors are scored in four areas: cost of care, quality of care, activities that improve clinical practice, and how they use EHR in exchanging clinical information.  Small medical practices may struggle to resource, & gain expertise necessary for, the quality reporting to registries and compliance requirements.  MIPS repurposes current CMS mechanisms:
  
  • MU becomes MIPS ACI. 
    
  • PQRS will become MIPS quality category.  
  • VBPM becomes MIPS resource use. 
    
  , APM is alternative payment model, Medicare's risk based payments to organizations set up as ACOs.  It includes track 1 ACOs which are not risk bearing.  APMs have to report various measures to CMS. 
  ; doctors don't understand them.  They won't change the way they provide care.  In part because they do not have the information that would be needed. 
  
• Every American needs full information at every point of contact with the health care network.  It could be done with APMs but it won't be, because the EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
  • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
  • The EHR does not necessarily reflect the patient's situation accurately. 
    
  • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    
  • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    
  • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    
  interfaces will remain closed to sustain the suppliers power over the users.  
• 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 are overwhelmed, seeing 20 to 30 patients every day.  
• All these things say the American health care system is terminally broken.  The fixes described by Zeek will make a small amount of improvement.  They are one offs that will only be done in some areas. 
  
• Change all of American medicine - How it's: organized, reimbursed 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.  
  , led, technologically supported;
  
• Vote for the motion so the work can begin
  
4. Feinberg:
• We could fix every problem in health care immediately (50% of the cost) if we:
• Eat right
  
• Didn't use illegal drugs
  
• Drank alcohol in moderation 
• Wore seat belts 
  
• Don't shoot one another; Overnight we would fix the health care debate. 
  
• All we hear about MIPS is merit based incentive payment system, a MACRA legislated, CMS regulated, patient outcome based Medicare part B payment system for ECs.  It is an alternative value based payment scheme when physicians aren't setup to work in an advanced APM, such as an ACO.  It is seen as a training route to the EC becoming a QP in an advanced APM.  It includes a new reporting category: clinical practice improvement activities - which can be selected from an approved list.  Doctors are scored in four areas: cost of care, quality of care, activities that improve clinical practice, and how they use EHR in exchanging clinical information.  Small medical practices may struggle to resource, & gain expertise necessary for, the quality reporting to registries and compliance requirements.  MIPS repurposes current CMS mechanisms:
  
  • MU becomes MIPS ACI. 
    
  • PQRS will become MIPS quality category.  
  • VBPM becomes MIPS resource use. 
    
  and MACRA is Medicare Access and CHIP Reauthorization Act of 2015 is designed to encourage physicians to move to FFV and to link Medicare payment to quality & value.  It alters the way Medicare pays for part B physician services encouraging physicians and other ECs to conform to one of two value based payment schemes: Advanced APMs (where the EC can become a QP) or MIPS.  MACRA does not apply to hospitals which have their own meaningful use.  MACRA is designed to promote transformation and includes: Data reporting by ECs, New practice models, Changing clinical standards, and Physician evaluations; with hundreds of millions of dollars in penalties and bonuses.  It authorizes CMS to develop and deploy new rules.  It provides for PCPs in PCMHs to qualify as advanced APMs via a special lower risk pathway.  It replaced the problematic physician SGR formula. 
  , that is mumbo-jumbo. 
  
• Argument that the United states spends more on health care with bad outcomes than any other industrialized nations the comparison is flawed because the US spends much less on social services.  Once you add the two sums together the US is in the middle of the pack.  
• Could spend more on social services, or use health care system to provide those services.  Robert [Pearl]'s Kaiser Permanente showed the country how to do this the right way.  Kaiser, from Oakland, & Geisinger, from Danville, are examples that illustrate the solution does not come from Washington D.C.  They show it comes from:
  
• Communities that are committed to the people who are living there,
  
• Who understand the problems,
• Engage in creative and innovative is the economic realization of invention and combinatorial exaptation.  While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity and supporting the use of regulation, or even its threat, that can drive their creations across the economy. 
  solutions to make things better; so that every patient gets care that is compassionate, safe, dignified, and low cost. 
  
• At Geisinger we have sequenced describes methods of DNA sequencing, that replace traditional Sanger sequencing, which have been implemented in commercial DNA sequencers after 2000.  The methods include:
  • Base-by-base is stepwise sequencing where there are 3' removable blockers on the DNA arrays. 
    
  • Pyrosequencing,  
  • Sequencing by synthesis,
    
  • Sequencing by ligation,
    
  • SMRT,
    
  • DNA colony sequencing,
  • DNA nanoball, 
  • Nanopore sequencing,
    
  • MPSS was the first of the next generation sequencing methods,
  • Polony sequencing.  
  100,000 people's entire 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. 
  for free.  They are now looking at the DNA and find 4% of the people have conditions where Geisinger can intervene before the bad thing happens.  
• Health care is not just about getting to the doctor and getting to the hospital.  It's about understanding your genetic code and your zip code. 
  
• We have towns like Shamokin, Pennsylvania, where 80% of the kids are on subsidized lunch and the rate of diabetes includes type 1 and type 2.  Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections.   of 1 in 4 to 1 in 5.  Guess what happens when we bring those people in and we say to them "here is food: fresh fruit, vegetables, lean meat.  We are going to teach you about your diabetes and give you and your family this food to eat."  
• Every single patient has seen improvements in: A1c is a blood test that assesses a person's average level of blood glucose over a 3 month period.  Because glucose attaches to hemoglobin the 3 month lifetime of red blood cells can be used as a buffer of blood glucose. 
  , blood pressure 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.  , weight;  If it were a pill it would be multi-billion dollar pill.  We can use food as medicine. 
  
• When you go to the dermatologist at Kaiser and check in, they close all detected care gaps; Primary interventions are used that save millions of lives. 
  
• Shannon asked are these just pilots and can they scale? They are much more:
  
• People across the country are interested in doing the same thing as Geisinger & Kaiser.  
• Bundles 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. 
  
  1. It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.  
  2. Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments. 
     
  3. Care delivery must be re-architected to reduce costs and improve quality. 
     
  4. Monitoring sensors can be used to feed reports to ensure re-architected operations conform.  
  are spreading across the country.  
• Health care reform begins with the doctors, nurses the patients, the moms, the brothers and sisters, the community coming together taking care of one another, scaling these great ideas and making sure every patient gets the exact kind of care that you would want for everyone in your family.  

1. Brownlee:
• Points of light have always been pushed back by the legacy agents.  Why will it be different this time?
• Emanuel:
• Mid 90s push to control health care costs after the failure of the Clinton health reform plan -- 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. 
  was 1-800-just-say-no, to which the public just revolted, management was removed and costs went up.  Now the public is upset about a different problem: affordability; a frustration for the public and employers which will drive needed policy change across the system. 
  
• Feinberg: 
• We have data: EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
  • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
  • The EHR does not necessarily reflect the patient's situation accurately. 
    
  • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    
  • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    
  • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    
  may be clunky; but it helps with effective decisions. 
  
• Pearl:
• Bundled payments is where the purchaser disburses a single predefined payment to cover certain combinations of hospital, physician, post-acute, or other services performed during an episode of care relating to a particular condition (unlike capitation).  This bundling is assumed (Sep 2018) to allow the value delivery system to optimize around low cost high quality long term health care.  With one bundled payment physicians & hospitals must coordinate care and reduce the unit costs to remain profitable.  And to avoid taking on risk of expensive complications physicians & hospitals are incented to standardize and focus on quality.  This optimization is dependent on quantifying the value of the outcome of the episode of care.  Previously FFS payments induced excessive treatment activity.  Bundled payment is included in CMS ACE demonstrations and BPCI initiatives.  There are significant impacts on IT. 
  
  1. It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.  
  2. Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments. 
     
  3. Care delivery must be re-architected to reduce costs and improve quality. 
     
  4. Monitoring sensors can be used to feed reports to ensure re-architected operations conform.  
  - lowers unit price, but physicians do more total joints and spine surgeons do more complex procedures resulting in higher overall costs from the complexity. 
  
• Geisinger, Kaiser, Mayo have been working for 100 years to be excellent.  How can you take the 19th century cottage industry using 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.   spread in pockets across America and turn it into Geisinger?  It can be done but not across the whole country.  
• Feinberg:
• Quoting from Robert Pearl's book; it can transform: 1. Patients become aware of how they are being mistreated, 2. Leverage youthful optimism, 3. Years of hard work. 4. Free American health care industry from the 19th century problems. 
  
• Brownlee:
  
• Need to read the whole book :)  And that won't happen in Pittsburgh. 
  
• One state - Maryland with its All-Payer model is an annual, global hospital budget that includes inpatient and outpatient hospital services.  It operates under an agreement between Maryland and CMS that exempts Maryland hospitals from IPPS and OPPS.  The agreement requires Maryland:
  • Limit all-payer per capita inpatient and outpatient hospital cost growth to the previous 10-year growth in gross state product. 
    
  • Generate $330 million in savings to Medicare over 5 years comparing Maryland to the US overall. 
    
  • Reduce 30-day readmission rate to the unadjusted national Medicare average.  
  • Reduce the rate of admissions for potentially preventable conditions by nearly 30% over 5 years. 
    
  • Submit an annual report (Oct 2016) demonstrating performance over various population health measures. 
    
  - has globally budgeted all its hospitals, resulting in no 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.   Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
  
  • Benefits
  • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
    
  • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
    
  • Part C: Medicare Advantage 
  • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    
  • Eligibility
    
  • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
    
  • Persons under 65 with disabilities who receive SSDI. 
    
  • Persons with specific medical conditions:
  • Have end stage renal disease or need a kidney transplant. 
    
  • They have ALS. 
    
  • Some beneficiaries are dual eligible. 
    
  • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    
  • Sign-up
  • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
    
  • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    
  • Premiums
  • Part A premium
  • Part B insurance premium
    
  • Part C & D premiums are set by the commercial insurer.  
  reimbursements is the payment process for much of US health care.  Reimbursement is the centralizing mechanism in the US Health care network.  It associates reward flows with central planning requirements such as HITECH.  Different payment methods apportion risk differently between the payer and the provider.  The payment methods include:
  • Fee-for-service,
    
  • Per Diem,
    
  • Episode of Care Payment, 
  • Multi-provider bundled EPC,
    
  • Condition-specific capitation,
    
  • Full capitation.  
  [to the hospitals].  It is getting there but requires change from the top. 
  
• Emanuel:
• Its synergistic: innovative is the economic realization of invention and combinatorial exaptation.  While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity and supporting the use of regulation, or even its threat, that can drive their creations across the economy. 
  hospitals and doctors from below, Leaders altering financial incentives from above. 
  
• An example where there has been massive change.  Incentives for EHRs drove them into all hospitals over 7 years. 
  
• Pearl:
• But fewer than 20% of physicians' offices can communicate with the hospital EHR next door.  Thats a big leap. 
  
• Everything can't be an exception!
  
• Brownlee:
• Innovation can bubble up from below.  But the
  
• Shift in payment must come from above.  Who is going to do this?  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.  
  hasn't done it yet.  It may eventually move to global budgeting.  But when will the private plans move in this direction?  
• Pearl:
• From my experience working in an AMC is Academic medical center.  They perform education, research and patient care.  They include one or more health professions schools, such as a medical school and a hospital.  The major AMCs are represented by the United HealthSystem Consortium.   The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems.  AMCs offer researchers clinical research support: Virus vectors (Nov 2017);
  and an integrated delivery health system, the culture is how we do and think about things, transmitted by non-genetic means as defined by Frans de Waal.  CAS theory views cultures as operating via memetic schemata evolved by memetic operators to support a cultural superorganism.  Evolutionary psychology asserts that human culture reflects adaptations generated while hunting and gathering.  Dehaene views culture as essentially human, shaped by exaptations and reading, transmitted with support of the neuronal workspace and stabilized by neuronal recycling.  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.  
  • Produces consciousness according to Dennet. 
    
  takes years to develop.  If just push it there will be disaster.  
• Lets see what happens in Maryland. 
  
• Emanuel:
• Private payers (insurance companies) are driving some of this. 
  
• Public plans working towards FFV is fee-for-value payment.  It may be a bundled payment for a set of services provided by a group of doctors and facilities, or full capitation.  In each case the risk has shifted from the payer to the providers of care. 
  
  
• Various 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 - for example
  
• Medicare oncology bundle announced by Medicare - 15% of oncologosts signed up voluntarily for the chemotherapy program, so they can shift.  
• Pearl:
• Drug industry spent $150 million in six months in 2017 to ensure no change.  Revolution must be made. 
  
2. Audience - Is it just the health care system or are there other aspects of this problem?
   
• Feinberg:
• When a community says to get healthy, health care will transform. 
  
• Emanuel:
  
• Health care costs are taking budget away from state education.  Health costs must be got under control. 
  
• Brownlee
  
• Health care is taking away money for roads and education. 
  
• What is the mechanism for the transfer of money to back to communities?  It won't be venture capital, since they will keep the money they capture back from $1 trillion in waste. 
  
3. Audience - How is money flowing back from the profitable private integrated health care companies to their communities?  
• Feinberg:
• We are giving food, housing, health literacy;
  
• Brownlee:
  
• Hospital giving back is a bandaid.  Health care is robing our federal, state & local social services so you can't leave the money in the health care system
  
• Feinberg:
• Kaiser spent 3% of revenue on giving back to communities: Walkways, affordable housing, farmers markets; social determinants. 
  
• Pearl:
• Its legally required too. 
  
• Major intervention is needed to drive the system in the right direction.  Show me a hospital thats not expanding & buying high cost technology.  The money is going to silicon valley. 
  
• Feinberg:
• In central Pennsylvania we are converting hospitals, getting rid of cath labs is a catheterization laboratory which is an examination room with diagnostic imaging equipment for visualizing the arteries and chambers of the heart so that can treat problems identified.   and making multi-purpose clinics focused on primary and secondary care.   
• Emanuel:
• Hospital beds are going down in the US.  Peak of hospitalizations was in 1981 (170 hospitalizations per 1000 -> 109 now).  Getting people out of the hospitals, closing beds
  
4. Audience - Isolated solutions to heal health care, but will the overall fix happen soon enough?
• Emanuel:
• Its 13 years; we are well on our way to changing how we pay and getting practices with higher quality and lower cost. 
  
• Its not impossible.  Todays newly trained will be 45 and will dominate the decisions in 13 years. 
  
• Feinberg:
• Huge transformation of number insured
  
• Pearl:
• Had health care costs parallel GDP is:
  • Gross domestic product which measures the total of goods and services produced in a given year within the borders of a given country (output) according to Piketty.  Gordon argues to include products produced in the home & market-purchased goods and services, following Becker's theory of time use.  Gordon stresses innovation is the ultimate source of all growth in output per worker-hour.  GDP growth per person is equal to the growth in labor productivity + growth in hours worked per person.  GDP has many problems.  Gordon concludes that between 1870 and 1940 all available measures GDP is hugely understated because:
  • GDP is a poor measure of:
  • Value & wealth
    
  • Who gets what
  • Global supply chains
    
  • GDP excludes:
  • Reduction in infant mortality between 1890 (22%) and 1950 (1%)
    
  • Brightness & safety of electric light,
    
  • Increased variety of food including refrigeration transported fresh meat and processed food
  • Convenience and economies of scale of the department store and mail order catalog and resulting product price reductions
    
  • Services by house makers
  • Time & health gains from having flush toilets, integrated sewer networks; rather than having to physically remove effluent and cope with fecal-oral transmission
    
  • Leisure
  • Costs & benefits of different length work weeks
    
  • Speed and flexibility of motor vehicles - which were not included in the CPI until 1935, after the transformation had occurred.  And competition from improved foreign vehicles, while it provides purchaser/user with improved standard of living (less breakdowns, repairs, etc.) is measured as reduced domestic manufacture
    
  • Coercion and corruption to obtain resources 
  • Consumption impact of finite resources: coal, oil;
  • Destruction impact of loss of entire irreplaceable species
    
  • GDP includes items that should be excluded:
  • Cost of waste - cleaning up pollution (single use indestructible plastic bags), building prisons, commuting to work, and cars left parked most of the time; should be subtracted
    
  • Guanine-di-phosphate is a nucleotide base. 
    
  for last 20 years we would have had 5 million less jobs, and less hospitals - very traumatic.  Upton Sinclair noted people don't understand what impacts their income.  Hospitals, doctors & drug companies are consolidating, finding ways to raise prices, Resistance to painful changes
  
• Emanuel:
• Health care cost data have been flat since 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. 
    
  passed - 17.5% of GDP is:
  • Gross domestic product which measures the total of goods and services produced in a given year within the borders of a given country (output) according to Piketty.  Gordon argues to include products produced in the home & market-purchased goods and services, following Becker's theory of time use.  Gordon stresses innovation is the ultimate source of all growth in output per worker-hour.  GDP growth per person is equal to the growth in labor productivity + growth in hours worked per person.  GDP has many problems.  Gordon concludes that between 1870 and 1940 all available measures GDP is hugely understated because:
  • GDP is a poor measure of:
  • Value & wealth
    
  • Who gets what
  • Global supply chains
    
  • GDP excludes:
  • Reduction in infant mortality between 1890 (22%) and 1950 (1%)
    
  • Brightness & safety of electric light,
    
  • Increased variety of food including refrigeration transported fresh meat and processed food
  • Convenience and economies of scale of the department store and mail order catalog and resulting product price reductions
    
  • Services by house makers
  • Time & health gains from having flush toilets, integrated sewer networks; rather than having to physically remove effluent and cope with fecal-oral transmission
    
  • Leisure
  • Costs & benefits of different length work weeks
    
  • Speed and flexibility of motor vehicles - which were not included in the CPI until 1935, after the transformation had occurred.  And competition from improved foreign vehicles, while it provides purchaser/user with improved standard of living (less breakdowns, repairs, etc.) is measured as reduced domestic manufacture
    
  • Coercion and corruption to obtain resources 
  • Consumption impact of finite resources: coal, oil;
  • Destruction impact of loss of entire irreplaceable species
    
  • GDP includes items that should be excluded:
  • Cost of waste - cleaning up pollution (single use indestructible plastic bags), building prisons, commuting to work, and cars left parked most of the time; should be subtracted
    
  • Guanine-di-phosphate is a nucleotide base. 
    
  in 2010 through 2016.  Shifting a $3.4 trillion ship takes 10 years.   
5. Audience - In regard to MACRA is Medicare Access and CHIP Reauthorization Act of 2015 is designed to encourage physicians to move to FFV and to link Medicare payment to quality & value.  It alters the way Medicare pays for part B physician services encouraging physicians and other ECs to conform to one of two value based payment schemes: Advanced APMs (where the EC can become a QP) or MIPS.  MACRA does not apply to hospitals which have their own meaningful use.  MACRA is designed to promote transformation and includes: Data reporting by ECs, New practice models, Changing clinical standards, and Physician evaluations; with hundreds of millions of dollars in penalties and bonuses.  It authorizes CMS to develop and deploy new rules.  It provides for PCPs in PCMHs to qualify as advanced APMs via a special lower risk pathway.  It replaced the problematic physician SGR formula. 
   and other quality metrics, Dr. Pearl said quality will not reduce overall costs.  Why are we spending so much resource to measure it? 
   
• Pearl:
• MACRA is so complex.  People don't understand it.  They do it to reach the metrics they are measured on.  Achieving quality saves lives not costs. 
  
• Brownlee:
• Another problem with the quality metrics is that they are just what we have, not what would matter to patients health.  Todays metrics drive physicians to be counter productive. 
  
• Emanuel:
• We are moving from checklists and process to outcomes.  It is happening (disagreeing with Brownlee).  
6. Audience - If all the providers become good risk bearing entities and become good at managing risk will it solve the issues with health care?
• Pearl:
• If it works, it will have a great impact.  Pearl thinks agents won't change. 
  
• Feinberg:
• If everyone starts doing the right thing less doctors will be needed, helping reduce the impact of the provider shortage.  Rural and underserved don't have access to PCP is a Primary Care Physician.  PCPs are viewed by legislators and regulators as central to the effective management of care.  When coordinated care had worked the PCP is a key participant.  In most successful cases they are central.  In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements.  Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. 
  , pediatrics;  Choosing wisely is an example of doing the right thing, coming from the bottom up. 
  
• Pearl:
• Its not a shortage, its misallocation.  Philidelphia has seven medical centers.  Need two times the number of PCPs.