Adaptive business plan frame

Adaptive Business Outline

Summary


In this page we introduce the adaptive plan's overview and the environmental details covered in the frame

The 2015 - 17 health care provider demo adaptive plan is deployed as a dark web is a web site that is not open to the Internet.  It is a set of deployed HTML files in a directory which refer to each other via file based references relative to the directory.  .  This overview page provides traditional planning sections to allow quick reference linkages to the evolving:
The associated core operational goals provide a filtered view of the operational goals and current actions responding to the goals. 




Introduction


This business outline is adaptive because your organization, just like AWF is the adaptive web framework.   personnel, can iteratively change the AWF supplied source text used to generate is a Perl script, typically launched as a child process within the configuration editor, by clicking 'generate web', which executes frame configuration file instructions merging the configuration variables with an HTML template file to generate target web pages.  The configuration instructions can be tailored by filters from the configuration file specified filter file. 
this dark web is a web site that is not open to the Internet.  It is a set of deployed HTML files in a directory which refer to each other via file based references relative to the directory.  .  Your team can tailor all the sources to fit your current descriptions of your competitive environment and the company's needs.  AWF assumes your situation is complex and you will follow Professor Dorner's advice to observe your specific situation adapting, build a model and then iteratively plan.  This demo web page is generated from the template adaptive business outline of a nominal hospital system.  AWF has included generic summary details of the US health care environment based on recent health care news articles and an analysis, modeling the strategic shifts using complex adaptive system principles. 

Each page of this generated dark web's horizontal upper border has inter-frame links to allow readers to visit the:
Within any frame the left vertical border's intra-frame links allow readers to move about the detailed pages of each frame. 
In this frame readers can look at the descriptions of the business situation including the environment and current value delivery system.   




<Introduce the adaptive plan overview> 




This outline includes:




Problem statement

Strengths Weaknesses Opportunities & Threats
A SWOT is used to derive the execution clusters. 


2013 SWOT Analysis
  1. The legislative rule changes and executive action creates opportunities for new business strategy

Strengths:
  • 1: <strength>
  • 2: <strength>
  • 3: <strength>
  • 4: <strength>
  • 5: <strength>
Weaknesses
  • 1: <weakness>
  • 2: <weakness>
  • 3: <weakness>
  • 4: <weakness>
  • 5: <weakness>
  • 6: <weakness>
  • 7: <weakness>
  • 8: <weakness>
  • 9: <weakness>
  • 10: <weakness>
  • 11: <weakness>
  • 12: <weakness>
  • 13: <weakness>
  • 14: <weakness>
  • 15: <weakness>
  • 16: <weakness>
  • 17: <weakness>
  • 18: <weakness>
  • 19: <weakness>
  • 20: <weakness>
  • 21: <weakness>
  • 22: <weakness>
Opportunities: Threats
  • 1: <threat>
  • 2: Placing a menu hierarchy between a doctor and patient reduces efficiency and humanity. 
  • 3: Placing a menu hierarchy between a doctor and patient can replace expertise and intuition with cumbersome representations of standard operating procedures and searches of alternatives. 
  • 4: Classical symptoms map to a variety of actual causes of disease.  
  • 5: <threat>
  • 6: <threat>
  • 7: <threat>







Business situation


The current US is the United States of America.   health care network is costly and underperforming

Providers are being pressured by political actions to reduce medically driven unsustainable growth in the national debt, to move away from their low risk, is an assessment of the likelihood of an independent problem occurring.  It can be assigned an accurate probability since it is independent of other variables in the system.  As such it is different from uncertainty. 
FFS is fee-for-service payment.  For health care providers the high profits were made in hospitalizations, imaging and surgery.  Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment.   'shop' business model.  They can restructure from a focus on acute care hospital transactional services to leverage bundled payments is where the purchaser disburses a single predefined payment to cover certain combinations of hospital, physician, post-acute, or other services performed during an episode of care relating to a particular condition (unlike capitation).  This bundling is assumed 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.  
, or by tightly integrating with a PAC is a Post-Acute Care provider.  A three-day hospital admission and discharge are prerequisite requirements to receiving Medicare PAC services.  Acute care hospitals become portals to the PAC business.  Referrals are key.  PAC includes different types of facility focused on different severity of illness (high to low):
  • Long term care Hospital (LTCH),
  • Inpatient rehabilitation facility (IRF),
  • Skilled nursing facility (SNF),
  • Home health agency (HHA) - most acute care hospitals and EMR providers have strategies for integration with home based care,
  • Outpatient rehabilitation.  SNF and HHA represent 80% of discharges and expenditures. 
network, or as a PCMH is patient centered medical homes. 
or an ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Kaiser like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems.  Advocate health illustrates the idea.  The ACA regulates qualification to be a Medicare ACO.  Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS.  But the ACO is eligible for shared savings.  Within the shared savings program the CMS innovation center has setup advanced payment ACOs.  As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment.  CMS has established quality measures for ACOs for Medicare.  The CMS programs purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. 
  • CMS initiated its Physician Group Practice Demonstration in 2005.  By 2008 the congressional budget office reported on Bonus-eligible organizations. 
  • CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
  • CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing. 
  • CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.  
  • Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.  
.  The increased clinical and financial risk, is an assessment of the likelihood of an independent problem occurring.  It can be assigned an accurate probability since it is independent of other variables in the system.  As such it is different from uncertainty. 
/uncertainty is when a factor is hard to measure because it is dependent on many interconnected agents and may be affected by infrastructure and evolved amplifiers.  This is different from Risk.   taken on in this series of organizations must be managed.  In the limit we reach the total capitation is a global payment for all care for a patient during a specified time period.  It forces the provider of care to take a high risk.  Managing the risk implies successful population health management. 
(with an alternative quality contract (AQC) is:
  • A 2009 payment arrangement developed by Blue Cross Blue Shield of Massachusetts.  It was developed to support change.  It differs from capitation in including upside measures for patient safety, appropriateness of care and patient satisfaction.  Its key components are:
    • Integration across the care continuum
    • Accountability for performance measures for ambulatory and inpatient care.  Includes a 10% incentive for performing. 
      • Performance measures are selected that are: Nationally accepted, Vary across providers, Include sufficient data on provider being measured, measured at the level that can influence the outcome. 
    • Global payment for all medical services with health status adjustment and with margin retention. 
    • Five year contract to create a sustained partnership 
) blended integrated health systems.  The progress of the Vivity joint venture will demonstrate the opportunity and threat.  

The risk is heightened by the continuing increase in chronic illnesses with more than three interacting problems, described by Lehigh Valley health.  This growth in chronic problems could overwhelm the available number of bed and nurses and require particularly sophisticated treatment management to cope with the additional complexity.  Many hospitals are exploring how to counteract this trend in their patient base by improving wellness as described by Cleveland Clinic's CEO Toby Cosgrove. 

Analysis of CAS by Dorner indicates complex problems require time to observe and accurately model.  While individual doctors might agree: Laguna Honda's Dr. Sweet; the trend is to reduce the time spent with each patient and to respond quickly.   

Health care is a major component of the states' local job strategy. 

The merging of payers is likely to increase the pressure for health care providers to consolidate. 
Network effects are exacerbated by the development of narrow networks - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans.  This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans.  By limiting the number of providers/doctors offered in the plans the few that are included should get more business.  Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers).  In large cities narrow networks are even more common.  Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills.  There are problems induced by narrow network constraints:
  • Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts.  Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running.  If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.  
  • Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016). 

The low cost of capital, from 2008 to 2016, makes acquisition a highly attractive strategy to do any consolidation. 

The bundled payments restructuring allows hospitals to separate their 'diagnosis' oriented solution shop and value-added repair based businesses.  Cleveland Clinic's Cosgrove envisions increased leverage of transportation to deliver patients to the appropriate optimized hub for treatment.  Interstate licensing may facilitate this vision.

A core interest of the hospital group in extending back to 'employ or link in' the PCP is a Primary Care Physician.  PCPs are viewed by legislators and regulators as central to the effective management of care.  When coordinated care had worked the PCP is a key participant.  In most successful cases they are central.  In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements.  Working against this is the low FFS leverage of the PCP compared to specialists. 
and similarly out to the specialists is to capture patient referrals while limiting financial risk is composed of different aspects of the hospital systems overall risk.  It includes:
  • Contractuals
  • Patient accounting and collections
  • Risk based reimbursement


Disruption is an increasing threat for full service hospitals.  Lower cost business models: Urgent care centers is an efficient and less costly 'alternative' to the ER.  There is no accepted standard.  Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls.  Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones.  Unlike an ER they can not admit patients to a hospital.  Some also offer services like pre-employment drug screening and summer camp physicals. 
, Standalone surgery centers; are capturing business and investment. 



The government is in a position to support, constrain and coerce the public health and health care providers' actions.  With the inherent complexity of the health care transactions only the government can encourage broadly positive actions by providers, insurers, pharmaceutical, food, supplements, biotech and medical device manufacturers and discourage them from negative actions.  But classifying which actions are positive and negative is contentious and implementing effective controls is at best a complex endeavor (Jan 2014). 

The results of the enactment and deployment of the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
  • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
    • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
    • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
    • Children, allowed to, stay on their parents insurance until 26 years of age. 
  • Medicare solvency improvements. 
  • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's SCOTUS decision. 
  • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
  • Medical home models.  
  • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
  • Qualifications for ACOs.  Organizations must:
    • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
    • Participate in the MSSP for three or more years. 
    • Have a management structure. 
    • Have clinical and administrative systems. 
    • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
    • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
    • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
    • Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
  • CMMI Medicare payment experimentation.  
  • Requirements that pharmaceutical companies must report payments made to physicians. 
  • A requirement that chain restaurants must report calorie counts on their menus. 


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 SCOTUS decision. 
  • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
  • Medical home models.  
  • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
  • Qualifications for ACOs.  Organizations must:
    • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
    • Participate in the MSSP for three or more years. 
    • Have a management structure. 
    • Have clinical and administrative systems. 
    • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
    • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
    • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
    • Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
  • CMMI Medicare payment experimentation.  
  • Requirements that pharmaceutical companies must report payments made to physicians. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
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. 
builds resentment in the Democratic voting base pushing Kentucky to a Republican governor (Nov 2015).  The problem is structural and complex (Aug 2016):
  • People prioritize acute and immediate threats more highly than chronic issues, such as malaria, and long term investments such as health insurance premiums.  
  • The Southern U.S. provides a low cost environment to support U.S. based labor intensive competitive strategies.  Changes that increase the cost of labor result in push back from the other components because of extended alignment of the total value chain.  And many years of poor health and limited support from the states have resulted in the development of a high cost low profit health insurance subscriber base that will hurt insurers (Aug 2016). 

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 SCOTUS decision. 
  • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
  • Medical home models.  
  • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
  • Qualifications for ACOs.  Organizations must:
    • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
    • Participate in the MSSP for three or more years. 
    • Have a management structure. 
    • Have clinical and administrative systems. 
    • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
    • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
    • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
    • Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
  • CMMI Medicare payment experimentation.  
  • Requirements that pharmaceutical companies must report payments made to physicians. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
employer 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. 
, already modified by Congress (Sep 15, Oct 15) does not appear to be working with around 2% takeup (Oct 2015). 

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 SCOTUS decision. 
  • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
  • Medical home models.  
  • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
  • Qualifications for ACOs.  Organizations must:
    • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
    • Participate in the MSSP for three or more years. 
    • Have a management structure. 
    • Have clinical and administrative systems. 
    • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
    • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
    • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
    • Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
  • CMMI Medicare payment experimentation.  
  • Requirements that pharmaceutical companies must report payments made to physicians. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
has impacted hospitals by:

The government and health insurance
Republican policy aims to constrain 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 SCOTUS decision. 
  • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
  • Medical home models.  
  • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
  • Qualifications for ACOs.  Organizations must:
    • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
    • Participate in the MSSP for three or more years. 
    • Have a management structure. 
    • Have clinical and administrative systems. 
    • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
    • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
    • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
    • Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
  • CMMI Medicare payment experimentation.  
  • Requirements that pharmaceutical companies must report payments made to physicians. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
insurance exchange use.  Prior to the signup deadline they worked hard to limit access (Sep 2013) knowing that the services would be popular (Sep 2013 with some success (Dec 2013).  They feared that the services have the potential to become more attractive if the markets induce competition (Sep 2013).  Once a million Americans signup (Dec 2013, Dec 2015) they adjust their strategies (Dec 2013, Aug 2015) but must find a way to overcome the need for 60 Senate votes (Nov 2015).  Cutting startup funding to non-profit co-op state insurers by 60% helped over half the coops to fail (Nov 2015, 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). 
: Dec 2015). 

Additional funds used to offset expensive coverage have been constrained:
The exchanges have been technically challenged from the start.  The federal exchange (healthcare.gov) usability upgrades (Oct 2015) were once again problematic (Oct 2015). 

By Sep 2016, Oct 2016 the individual insurance exchanges' business models appear at risk in a number of states too. 


Health care political strategy
Presidential primaries encourage discussion of changes and replacements for the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
  • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
    • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
    • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
    • Children, allowed to, stay on their parents insurance until 26 years of age. 
  • Medicare solvency improvements. 
  • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's SCOTUS decision. 
  • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
  • Medical home models.  
  • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
  • Qualifications for ACOs.  Organizations must:
    • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
    • Participate in the MSSP for three or more years. 
    • Have a management structure. 
    • Have clinical and administrative systems. 
    • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
    • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
    • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
    • Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
  • CMMI Medicare payment experimentation.  
  • Requirements that pharmaceutical companies must report payments made to physicians. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
: Jeb Bush (replacement Oct 2015).  Speaker Paul Ryan's ACA replacement plan (Jun 2016). 

But while Congressional Republicans focus on repeal of the ACA, Republican state governors are pushing to accept Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program made state optional by the SCOTUS decision was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
expansion for their citizens (Dec 2015). 

Trump presidency is politically transformative (Nov 2016). 
  • Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program made state optional by the SCOTUS decision was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
    expansion shown to provide long term benefits to recipients (Sep 2016).  

  • HHS is the U.S. Department of Health and Human Services.   reports that health spending has accelerated again during 2014 (Dec 2015). 

    The government can deploy constraints to limit the relocation of corporations from the US to other lower tax domiciles.  Strategies include:




    The repeal of the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's SCOTUS decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians. 
    • A requirement that chain restaurants must report calorie counts on their menus. 





    With control of all three branches of government aspects of the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's SCOTUS decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians. 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    can be repealed:



    The results of the repeal and replacement of the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's SCOTUS decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians. 
    • A requirement that chain restaurants must report calorie counts on their menus. 






    Public Health
    Certain aspects of public health is the proactive planning, coordination and execution of strategies to improve and safeguard the wellbeing of the public.  Its global situation is discussed in The Great Escape by Deaton.  Public health in the US is coordinated by the PHS federally but is mainly executed at the state and local levels.  Public health includes:
    • Awareness campaigns about health threatening activities including: Smoking, Over-eating, Alcohol consumption, Contamination with poisons, Joint damage from over-exercise;
    • Research, monitoring and control of disease agents, processes and vectors by agencies including the CDC. 
    • Monitoring of the public's health by institutes including the NIH.  
    • Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.  
    • Development, deployment and maintenance of vaccination strategies. 
    • Regulation and constraint of foods, drugs and devices by agencies including the FDA. 
    policy have important effects on the health care markets. 

    Sporadic local investment in public health capabilities will affect the development of local flare-ups of vectored diseases: Miami-Dade County (Zika is a Flaviviridae family virus.  It came from the Zika Forest of Uganda isolated in 1947.  It is related to dengue, yellow fever, Japanese encephalitis and West Nile.  Zika is transmitted sexually or via a daytime mosquito vector such as the Aedes genus.  It has resulted in a pandemic in South America.  Zika fever has been associated with a number of troubling complications:
    • Guillain-Barre syndrome
    • Microcephaly.  The mechanism may have been identified (May 2016)
    Apr 2016).  The federal government announced their plan to respond (Jun 2016). 
    Global increase in vectored diseases:

  • Understanding loneliness is an aversive signal like thirst, hunger or pain.  It has been associated with the dorsal raphe nucleus (Sep 2016).  Loneliness affects several important bodily functions through overstimulation of the stress response.  Chronic loneliness is associated with increased cortisol levels, hypertension and impaired production of white blood cells undermining the immune system. 
    : MIT is Massachusetts Institute of Technology.  's Tye implicates the raphe consists of a group of nuclei running through the core of the brain stem from the medulla to the back of the midbrain.  It projects to the tegmentum, accumbens, prefrontal cortex, & amygdala where serotonin enhances dopamine's effects on goal-directed behavior.  The raphe is associated with:
    • Neural mechanisms of sleep and waking.  Jouvet and Renault produced large lesions that destroyed 80 - 90 % of the raphe in cats inducing complete insomnia for 3-4 days.  Slow-wave, but not REM sleep, gradually returned, but never exceeded 2.5 hours a day.  Sleep amount correlates to the 5-HT concentration.  The neurons of the raphe nuclei are rich in serotonin (5-HT).  It is suspected that the dorsal raphe nuclei inhibit the phasic components of REM sleep and thus prevent them from occurring at inappropriate times.  The activity of serotonergic neurons is low during REM sleep and higher at other times.  The dorsal raphe nucleus has been associated with 
    • Depression.  
    • Impulsive aggression which is associated with relatively low serotonin levels.  
    , The UK's treatment strategies; process and treatments discussed (Sep 2016)


  • Prescription opioids (Oxycontin etc.) used ubiquitously in pain management is an iterative process, overseen by a doctor, to limit a patient's pain.  The process is doctor prescribed, RN managed, pharmacist validated, and patient administered.  The process may be coordinated by pain management specialists.  Pain management is central to modern surgery where it is supported by hospital infrastructure.  It is central to the perioperative process.  It is a major aspect of ED operations.  It has been extended out to discharged patients with chronic long term pain where it can lead to opioid dependency.  Treatments include: Opioids including: Fentanyl, Morphine, OxyContin, Percocet; NSAIDs, Cannabinoids, Acupuncture, Massage, CBT, and Mindfulness.   (May 2016) and leveraged up by an evolved amplifier enacted by members of Congress: EPAEDE; and sustained by campaign contributions and lobbying, have contributed to peaking suicide, addiction and death rates for poor, less educated Americans (Nov 2015). 
    The F.D.A. responds to the opioid epidemic:

    The D.E.A. is the Drug Enforcement Administration. 
    is constrained in its actions by Congressional regulation: EPAEDE


    Health is broadly affected by environmental impacts:
    Coal burning generates highly lethal particulate air pollution. 
    The conflict between the legislative strategies of producers of cigarettes and household chemicals and those of public health groups constrains progress on toxic household chemical constraints (Jul 2016). But:
    Similar conflicts of interest are induced in nonprofit health groups that receive support from the beverage and oil and gas industries:

    Antibiotics are compounds which kill bacteria, molds, etc.  The first antibiotic discovered was penicillin.  Antibiotics are central to modern health care supporting the processes of: Surgery, Wound management, Infection control; which makes the development of antibiotic resistance worrying.  Antibiotics are:
    • Economically problematic to develop and sell. 
      • Congress enacted GAIN to encourage development of new antibiotics.  But it has not developed any market-entry award scheme, which seems necessary to encourage new antibiotic R&D. 
      • Medicare has required hospitals and SNFs to execute plans to ensure correct use of antibiotics & prevent the spread of drug-resistant infections.  
      • C.D.C. is acting to stop the spread of resistant infections and reduce unnecessary use of antibiotics.  
      • F.D.A. has simplified approval standards.  It is working with industry to limit use of antibiotics in livestock. 
      • BARDA is promoting public-private partnerships to support promising research.
    • Impacting the microbiome of the recipient.  Stool banking is a solution  (Sloan-Kettering stool banking).  
    • Associated with obesity, although evidence suggests childhood obesity relates to the infections not the antibiotic treatments (Nov 2016). 
    • Monitored globally by W.H.O.
    • Regulated in the US by the F.D.A. who promote voluntary labeling by industry to discourage livestock fattening (Dec 2013).  
      • Customer demands have more effect - Perdue shifts to no antibiotics in premier chickens (Aug 2015). 
    and resistance results from plasmids and R factors: NDN1; which encode resistance properties for otherwise lethal antibiotics.  World leaders hope cooperation can preserve the power of last resort antibiotics: Carbapenems, Colistin (Oct 2016).  Worrying trends include: CRE (May 2016), C. diff. (May 2015), MDR & XDR TB; resulting in increased risk of sepsis and death.  The World Bank estimates full resistance would reduce the global economy in 2050 by between 1.1 and 3.8%. 

    The F.D.A. is constrained by DSHEA is the Dietary Supplement Health and Education Act of 1994.  It prevents the FDA from approving or evaluating most supplements before they are sold.  The agency must wait until consumers are harmed before officials can remove them from stores.   in its powers over the food supplement industry.  There is evidence (Dec 2013) that the supplement industry is failing to provide safe products with ingredients that match the labels. 

    Health regulation leadership 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. 
    drifts towards industry positions

    Health regulation and high technology business models clash:


    F.D.A. Food and Drug Administration. 
    monitoring and control of consumer products conflicts with manufacturer's goals:
    D.O.A. - U.S. Department of Agriculture. 
    monitoring and control of consumer food network:

    W.H.O is World Health Organization a United Nations organization.  . activities and campaigns:

    Trials funded and focused by NIH is the National Institute of Health, Bethesda Maryland.  It is the primary federal agency for the support and conduct of biomedical and behavioral research.  It is also one of the four US special containment units of the CDC.  's NCI is the national cancer institute. 
    :



    Heights and health:
    • Decline in many countries.  US average heights peaked in 1996 (men) and 1998 (women) (Jul 2016)

    Long lasting segregationist political effects limit support to African-American communities (Dec 2013, sickle-cell anemia is a recessive single gene disease where the sufferer's hemoglobin causes the red blood cells to distort.  It is a side effect of the evolved protection from malaria provided by sickle cell trait.  Potential treatments include gene therapy and drugs that block the sickling of red blood cells.  Carrier screening was undermined by there being no effective prenatal test limiting the benefit of the information and because the white doctors were not trusted by their black patients.  In the future iPS cells could have the problem mutations replaced with ex vivo gene therapy. 
    carrier screening can provide powerful information for recessively inherited conditions.  It has been used for: Tay-Sachs disease, sickle-cell trait, cystic fibrosis, spinal muscular atrophy; with differing effects.  As more people have complete DNA sequencing carrier screening prior to pregnancy will make increasing sense.  Carrier screening:
    • Is being considered for: 
      • SMA but this requires a complicated and costly genetic test, 
      • Fragile X syndrome may be offered to all females,
    • Requires informed consent since it can result in difficult choices. 
    • Test reliability depends on the number of potential mutations are involved and how many of these are tested for in the screen.  As of 2010 even cystic fibrosis CFTR gene screening only looks at the 23 most common of the 1000 potential mutations. 
    , May 2016 public education: ESEA is the Elementary and Secondary Education Act of 1965 signed by LBJ.  It is the framework later used to develop 'No child left behind'.  ESEA's original titles include:
    1. Provides funding to local school districts to improve the academic achievement of disadvantaged students.  The original authors worried that local and state authorities might use the federal money to replace rather than supplement their budgets to poor schools.  When this was found to be the case Congress amended the act in 1970 requiring districts to spend Title 1 dollars on additional education for poor children (supplement), above and beyond what they already received from other sources (not supplant). 
    2. Preparing, training and recruiting high quality teachers and principals
    3. Language instruction for limited English proficient and immigrant students
    4. Educational research and training
    5. Grants to strengthen state departments of education
    6. Aid to handicapped children
    title 1 fund allocation). 

    Economically deprived areas of the US under increasing stress is a multi-faceted condition reflecting high cortisol levels.  Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight.  As these actions occur the levels of cortisol return to the baseline rate.  A stressor is anything that disrupts the regular homeostatic balance.  The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis. 
    • The short term response to the stressor
      • activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response.  The brain's acuity and cognition are stimulated.  The immune system is stimulated with beta-endorphin and repair activities curtail.  But when the stressor is
    • long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues.  Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in.  Sustained stress provides an evolved amplifier of a position of dominance and status.  It is a strategy in female aggression used to limit reproductive competition.  Sustained stress:
      • Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment! 
      • Activates the integration between the thalamus and amygdala. 
        • Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful. 
        • BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning. 
      • Makes it easier to learn a fear association and to consolidate it into long-term memory.  Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala.  And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces.  Accuracy of assessing emotions from faces suffers.  A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand.  The activation of the amygdala seems to determine how the hippocampus responds. 
      • Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression. 
      • Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive.  It also desynchronizes activation in different frontal lobe regions impacting shifting of attention. 
    • During depression, stress inhibits dopamine signalling. 
    • Strategies for stress reduction include: Mindfulness. 
    (May 2016).  Most notable are:

    CDC is the HHS's center for disease control and prevention based in Atlanta Georgia.  
    reports:
    Independently researchers have found locality affects life expectency for poor Americans (Apr 2016). 

    WHO is World Health Organization a United Nations organization.   reports:
    Harvard school of public health
    • Releases study showing continued strong evidence of health issues with saturated fats (Nov 2016). 

    Vaccines are a core strategy of public health and have significantly extended global wellbeing over 200 years.  Recent successes include: HPV vaccine.  They induce active acquired immunity to a particular disease.  But the development and deployment of vaccines is complex:
    • The business model for vaccine development has been failing (Aug 2015): 
      • No Zika vaccine was available as the epidemic grew (Mar 2016).  No vaccine for: CMV;
      • Major foundations: Michael J. Fox, Gates, Wellcome; are working to improve the situation including sponsorship of the GAVI alliance.  A geographic cluster is forming in Seattle including PATH (Apr 2016). 
      • Commercial developers include: Affiris, Cell Genesis, Chiron, CSL, Sanofi, Valeant;
    • Vaccine deployment traditionally benefited from centrally managed vertical health programs.  But political issues are now constraining success with less than 95-99% coverage required for herd immunity (Aug 2015, Sep 2015, Nov 2015, Nov 2016).  
      • Where clinics have been driven into local neighborhoods health improves (Apr 2016).  
      • Retail clinics (Mar 2016): CVS Minute Clinics focus on vaccination.  
    • Key vaccines include: BCG, C. difficile (May 2015), Cholera (El Tor), Dengvaxia (Mexico Dec 2015), Gvax, Malaria vaccine, Provenge;
    • Regulation involves: FDA (CBER), with CMS monitoring (star ratings, PACE (Aug 2016), Report cards (Sep 2015)) & CDC promoting vaccines: as a sepsis measure, To control C. difficile (May 2015);  
      • Coding : CVX, MVX;
    • Research on vaccines includes: 
      • NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.  
        • NCI:
          • Roswell Park clinical trial of immuno-oncology vaccine cimavax. 
      • Geisinger: effective process leverage in treatment. 
      • Stanford Edge immuno-oncology for cancer vaccines.  
      • P53-driven-cancer focused, gene therapy (Jun 2015). 
    :

    Climate science attacked by fossil fuels interests





    Medical errors
    Medical errors are a significant impact on the health care environment.  They include political and technical aspects:

    Supplements
    Supplements provide a less regulated delivery process for biologically active chemicals.  They include political, socialogical and economic aspects:





    Major political actions aim to limit health care costs while developing, defending and undermining alternative directions of the future network:





    Dramatic economic shifts suggest major transformations of health care:





    Subtle socio-cultural effects influence the complex diseases of modern health care:




    Expected technological advances, some discussed by 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.   director Francis Collins, suggest major transformations & powerful justification of health care:



    The influence of suppliers

    The suppliers influence the value delivery network through a variety of actions:



    Competitor analysis