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Patient details
Summary
In this page we discuss patient scenarios
Long-term care payment situations are included.
Introduction
This page looks at ways to think about patient references.
It reviews their concerns.
It includes associations based on geography and diagnosis/treatment;
Patient scenarios
- 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 policy
uncertainty
- Long-term care insurance uncertainty
- Mental health problems
- Aging wealth
gap
Patients by
geographic network
- Nations, States, Counties, Cities/Towns
- Denmark
- Iceland: 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
Jeff
Gulcher,
- UK
- Bracknell: Crafter GW;
- Fleet: Protector CG;
- Hove: Supervisor SM;
- London: Edutainer GW, Provider AL;
- USA
- Populations
- African
American: 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) rates;
- Diet:
- Alaska
- Arkansas
- CA
- Illinois
- Kentucky
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- New Jersey
- New York
- Ohio
- Oregon
- Pennsylvania
- Puerto Rico
- Tennessee
- Vermont
- West
Virginia
Patients by
disease type or treatment:
- Addiction results from changes in the operation of the brain's reward network's regulatory regions, altering the anticipation of rewards. Addictive drugs mediate the receptors of the reward network, increasing dopamine in the pleasure centers of the cortex. The learned association of the situation with the reward makes addiction highly prone to relapse, when the situation is subsequently experienced. This makes addiction a chronic disease, where the sufferer must remain vigilant to avoid relapse inducing situations. Repeated exposure to the addictive drug alters the reward network. The neurons that produce dopamine are impaired, no longer sending dopamine to the reward target areas, reducing the feeling of pleasure. But the situational association remains strong driving the addict to repeat the addictive activity. Destroying the memory of the pleasure inducer may provide a treatment for addiction in the future. Addiction has a genetic component, which supports inheritance. Some other compulsive disorders: eating, gambling, sexual behavior; are similar to drug addiction.
- Auto-immune
- 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).
- Brain: Opportunity of genetic markers;
- Breast 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):
DCIS is ductal carcinoma in situ where abnormal cells have been found piled up confined to the lining of the milk ducts of the breast. They are detectable in a mammogram and can look like cancer cells to a pathologist. The cells could be spread along the whole of the milk duct suggesting a need for mastectomy rather than lumpectomy analogous to cervical cancer treatments after a Pap test. It is now known that the DCIS may disappear over time, or stop growing and remain stable. Most women diagnosed with early stage DCIS have surgical or chemotherapy treatment, which does not alter their life expectancy (Aug 2015). No data is available detailing a correlation with breast cancer. But it is now understood that metastatic cancers are different from localized cancers.
strategy,
Rate among African
Americans;
- 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.
: stool
banking;
- Skin: Basal
cell Carcinoma;
- 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).
- Statins are serum cholesterol lowering drugs established as safe and effective at reducing the risk of heart-attacks, hemorrhagic & Ischemic strokes and deaths from atherosclerotic heart disease. They also reduce inflammation that can induce blood clots. They appear to stabilize plaque. About 5% of people, most with a specific allele of SLCO1B1, have muscle aches, and in some blood sugar increases. Statins inhibit HMG-CoA reductase which produces cholesterol in the liver. and 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.
control
- CHF is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands. There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). Treatments include: digoxin; : Louisville, Oakbrook;
- Heart attack is an AMI. It can induce cardiac arrest. Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI. Risk factors include: taking NSAID pain killers (May 2017). There is uncertainty about why AMI occur. Alternative hypotheses include:
- Plaques started to gather in the coronary arteries and grew until no blood flow was possible. If this is true it makes sense to preventatively treat the buildup with angioplasty.
- Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot. If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors.
:
Atlantic city hot
spot, Cambridge behavioral
hazard, Camden hot
spot, New York readmission,
Willow Glen Mercenary
HD;
- Depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult;: Ann
Arbor, Louisville;
- Development is a phase during the operation of a CAS agent. It allows for schematic strategies to be iteratively blended with environmental signals to solve the logistical issues of migrating newly built and transformed sub-agents. That is needed to achieve the adult configuration of the agent and optimize it for the proximate environment. Smiley includes examples of the developmental phase agents required in an emergent CAS. In situations where parents invest in the growth and memetic learning of their offspring the schematic grab bag can support optimizations to develop models, structures and actions to construct an adept adult. In humans, adolescence leverages neural plasticity, elder sibling advice and adult coaching to help prepare the deploying neuronal network and body to successfully compete.
- Diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections.
- Ebola is a viral disease discovered in 1976. It is an ancient virus branching 20 million years ago from other filoviruses. It mainly infects rodents and other mammals. It appears highly lethal when infecting Gorillas, and is also acute in humans, so we are not a reservoir for Ebola but a dead-end host. The death toll is very small compaired to influenza or Covid-19. A West African epidemic was probably reservoir hosted by forest dwelling bats and transferred to a boy. The 1976 northern Zaire (Yambuku) strain was able to spillover to humans with a case fatality rate of 88%. Sudan, Reston (Philippines), Bundibugyo (Uganda), and Tai Forest, Ebola like viruses have lower case fatality rates. The 1995 Zaire (Kikwit) outbreak was in a forest clearing close by a city of 200,000. A man who felled trees fell ill and died of hemorrhagic fever a week later. He had fatally infected three members of his family and ten of his friends. When it reached a local maternity hospital it infected a lab technician who was transferred to the general hospital where doctors, nurses and nuns were infected and the nuns and technician died. The CDC identified the pathogen as Ebola, which had killed 245 including 60 hospital staff members. The 2014 epidemic is seen as the result of a single infection. Evolutionary biologists consider it unlikely that natural selection will give the virus the ability to spread more easily. The size of the 2014 epidemic gives more potential for mutations but the current transmission mechanism is working for the virus so there is little obvious pressure for out-competition by a new transmission path. There are likely to be lots more viruses with similar infection model to Ebola. Typically an individual is not sick for three to five day after the onset of symptoms which can fool care givers. Then around day 5 to 7 they really crash. Their blood pressure goes down, they become stuporous to unresponsive, and they start to have renal and liver failure. This correlates with the enormous viral load (making it very contagious which is a significant risk to care givers), which is just attacking every organ in the body. Ebola patients lose enormous amounts of fluid from diarrhea and vomiting, as much as five to ten quarts a day during the worst phases of the illness which lasts about a week. Doctors struggle to rehydrate them, replace electrolytes and treat bleeding problems. Thomas Eric Duncan brought Ebola to Texas Health Presbyterian hospital, where the ED failed to identify his symptoms. : Dallas;
- Food or bite based poisoning: Spider bite, St.
Lukes and White Plains ED food poisoning;
- Herniated disk: Lenox
Hill;
- Long term treatment: rationing in Tennessee,
- Chronic: New york;
- Dementia:
- Medically complex
- Psychosocial
- Obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016).
- Parkinson's
disease corresponds to the breakdown of certain interneurons in the brain. It is not fully understood why this occurs. Dopamine system neuron breakdown generates the classical symptoms of tremors and rigidity. In some instances an uncommon LRRK2 gene mutation confers a high risk of Parkinson's disease. In rare cases Italian and Greek families are impacted in their early forties and fifties resulting from a single letter mutation in alpha-synuclein which alters the alpha-synuclein protein causing degeneration in the substantia nigra, after a build up of Lewy bodies in the neurons. But poisoning from MPTP has also been shown to destroy dopamine system neurons. DeLong showed that MPTP poisoning results in overactivity in the subthalamic nucleus. People who have an appendectomy in their 20s are at lower risk of developing Parkinson's disease. The Alpha-synuclein protein is known to build up in the appendix in association with changes in the gut microbiome. This buildup may support the 'flow' of alpha-synuclein from the gut along neurons that route to the brain. Paraquat has also been linked to Parkinson's disease. Parkinson's disease does not directly kill many sufferers. But it impacts swallowing which encourages development of pneumonia through inhaling or aspirating food. And it undermines balance which can increase the possibility of falls. Dememtia can also develop. Treatment with deep-brain stimulation, after surgical implantation of electrodes in the subthalamic nucleus removes the symptoms of Parkinson's disease in some patients.
: Patient enablement;
- Stress is a multi-faceted condition reflecting high cortisol levels. Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight. As these actions occur the levels of cortisol return to the baseline rate. A stressor is anything that disrupts the regular homeostatic balance. The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis.
- The short term response to the stressor
- activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response. The brain's acuity and cognition are stimulated. The immune system is stimulated with beta-endorphin and repair activities curtail. In order for the body to destroy bacteria in wounds, pro-inflammatory cytokines increase blood flow to the area. The induced inflammation signals the brain to activate the insula and through it the ACC. But when the stressor is
- long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues. Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in. Sustained stress provides an evolved amplifier of a position of dominance and status. It is a strategy in female aggression used to limit reproductive competition. Sustained stress:
- Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment!
- Activates the integration between the thalamus and amygdala.
- Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful.
- BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning.
- Makes it easier to learn a fear association and to consolidate it into long-term memory. Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala. And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces. Accuracy of assessing emotions from faces suffers. A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand. The activation of the amygdala seems to determine how the hippocampus responds.
- Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression.
- Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive. It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.
- Increases the risk of autoimmune disease (Jan 2017)
- During depression, stress inhibits dopamine signalling.
- Strategies for stress reduction include: Mindfulness.
The interplay of state regulation, insurance policy age,
shifting provider structure and business model interactions
limits patient satisfaction in long-term care.
Uncertainty
with 2013 ACA insurance policies
- Marketplaces
for health insurance suffer from difficulty with
comparison of alternative policies and implied risk of each
one (Oct
2015). The problem becomes acute by Aug
2016. And many marketplace policies are locked to
a particular state and don't provide access to key hospitals
and doctors (May
2016) leading people to push for 'single-payer is a healthcare architecture in which there is a single financing organization. Significant aspects of single-payer include:
- Strengths of single-payer:
- Removes the extensive replication of payer organizations and their different interfaces to the other healthcare entities and subscribers.
- One payment organization, removing the need to allow subscribers the yearly choice to change payer, encouraging payers to help subscribers remain healthy
- Single-payer instantiates a political monopoly on health insurance.
- Problematic implementation of single-payer in the US
- Undermines the alignment of the healthcare network, threatening profits, power structures and financial rewards. This limits the possibility of single-payer in the US: Lobbying juggernaut: Politicians, Providers, Doctors, Insurers; leveraging dislike of tax increases, The 9 out of 10 Americans who are employed or retired are satisfied with their situation, Current insurance costs are hidden from the insured: in lowered pay packages, spread over all tax payers reducing government revenues; Current private insurers would be forced to reduce costs;
- Alters one sixth of the US economy: Commercial health insurance replaced, investors impacted by transformation of business models; a huge change of high uncertainty, something evolution works to avoid by including mechanisms to force small incremental changes.
- A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations. Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016).
'
access to Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
.
The insurance policy is a highly flexible contract which can
vary in terms of its:
- Catastrophic coverage. 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.
allows people
in hardship or under 30 to obtain catastrophic coverage
only. Others are mandated to have full service
coverage.
- Network of hospitals
- Network of X-ray providers
- Network of doctors - is there any coverage out of network?
Will out of network providers be able to balance
bill is when an out-of-network provider bills the patient for the balance of the bill not covered by the insurer. These charges are not capped by the ACA's out-of-pocket maximum. the patient? Is out of state care covered
for children living away at college?
- Narrow
network - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans. This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans. By limiting the number of providers/doctors offered in the plans the few that are included should get more business. Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers). In large cities narrow networks are even more common. Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills. There are problems induced by narrow network constraints:
- Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts. Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running. If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016).
strategies
- Services that are covered.
- Drugs that are
covered - As of Dec 2013 it is difficult to determine which
drugs are covered and what the out-of-pocket charges will be
on the Federal ACA web site. It should be possible for
the Federal web site to identify which policies best serve a
poarticular drug regimen but not so far. This is
provided on the web site for 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.
.
- Per capita drug spending increased by more than $100 in
2014. And more Americans are being asked to pay for
their medications even if they are insured.
- Americans are concerned about the unaffordable cost of
drugs for serious diseases and
- The increasing direct cost of prescription drugs which
is stopping them filling their doctor provided
prescriptions (Jun
2014, Jun
2015, Jul
2015, Aug
2015, Aug
2015, Sep
2015, Sep
2015).
- Fee of each service (discounted from the base price of the
service).
- UnitedHealth
(Nov
2015), Humana
and Aetna (Aug
2016) announce plans to leave the insurance
marketplaces.
- 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)
- 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'. Anthem
raises prices (May
2017)
- 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 appear robust: modest price increases overall,
insurers making money, regulators seeing few 'bare' markets (Jul
2018)
- 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 (Jul
2018)
- President Trump orders HHS is the U.S. Department of Health and Human Services.
Secretary
Azar to expand term of short-term, limited-duration
insurance, to replace 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.
plans (Feb
2018)
- 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.
chief actuary reports that limited-duration insurance plans,
will pull 1.4 million healthy people from 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
markets in their first year of operation and increase
overall costs by $38 billion over 10 years, due to the
increasing federal subsidies to sustain the ACA plan
prices. And since most of these limited-duration plans
do not cover prescription drugs it may constrain the drug
price containment strategies (May
2018)
- CMS is the centers for Medicare and Medicaid services. administrator
Verma to resume paying 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
market 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 (Jul
2018)
- CMS is the centers for Medicare and Medicaid services. administator
Verma releases rule allowing states to offer short-term
health insurance, and proposes regulations to allow companies to
provide health reimbursements for employees to use on personal
health plans (Oct
2018)
- Premium
- Copayments is a fixed payment for a covered service after any deductible has been met. It is a key strategy of the ACA to make subscribers aware of the costs of treatment and to put pressure on high cost health services. As such suppliers and providers are keen to undermine the copayment: value based health insurance, Paying the copayment (Oct 2015), Place on the USPSTF list of preventative services (Sep 2016);
- Coinsurance is where a patient's contract with the insurer requires the patient to pay a percentage of the amount billed for a particular drug or sevice. It may vary across the various networks and out of network situations.
makes it nearly impossible to estimate costs and hence
compare plans.
- Out-of-pocket maximum can be the most important criteria
for those with a high cost need.
- State specific required services
- New york requires an insurer whose policy does not cover
a referred procedure to charge for the out-of-service
procedure as if it is in network.
- Dropouts are a concern for 2016 (Oct
2015)
- Even Geisinger
health plan says
it's under pressure in the ACA exchanges
in 2016 and looks for steep rate rises (40%) in 2017 (Jun
2016). Oscar
requesting 20% premium increase in 2017 to cope with impacts
of individual health exchange 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.
(Jun
2016).
Uncertainty with
long-term care insurance policies
- Uncertainty with long-term care insurance policies NYT Jun
2013: 'The bottom line is that practices vary widely from
company to company and state to state. And whether you
can trust the company depends on regulation in the state --
and most states have limited regulation.'
- GE
results mixed: Power generation still a problem, $121 billion
debt to finance - so plans to cut it by $50 billion selling
assets: rail locomotive, oil field equipment, health care; GE
capital aviation services not for sale, jet engines sold well,
WMC sub-prime mortgage issues settled with DOJ - U.S. Department of Justice. with $1.5 billion
penalty. GE
Capital, still being investigated by S.E.C. is the Securities and Exchange Commission. It was provided with power to regulate the securities industry by the Securities act and Securities Exchange act. , set aside $15
billion reserves for higher
costs to reinsuring long-term
care policies at GE Capital (Feb
2019)
- Tenessee use of private long-term care ramps 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.
costs (Mar
2014)
- There is a mismatch between the patient's goal for
long-term care insurance and the current operation of these
policies. While the insured person hopes to avoid
burdening their family with having to finance or directly
provide care in some cases the result is a massive
administrative burden to understand the opportunity to
collect benefits the insured person thought they had paid
for.
- The elderly person who is ill and needs help is most
likely in no situation to perform the administrative
actions. Friends or family have to:
- Insured persons transitioning to 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.
, SNF is skilled nursing facility. or HHA is home health agency. are likely to
have purchased their policies many years ago. Often
those policies are more restrictive than policies offered
now. And many insurers have left the business after
mispricing the policies and failing to effectively model the
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. of
the industry. In such cases the companies hire third-party
administratorys to adjudicate claims and the interpretations
are often conservative. NYT were told that most top
rated insurers pay claims to 264,000 patients without issue
to the aggregate value of $6.6 Billion in 2012.
- Why are claims typically denied?
- Deductibles - policies often have waiting periods
measured in days and sometimes these days include only the
ones where care was administered, so waiting can become
lengthy and costly. Older policies often required a
3 day stay in hospital before any benefits would be
paid. These requirements must still be met (ERISA is the Employee Retirement Income Security Act of 1974 signed by President Ford. It regulated both pension and health benefit plans once an employer had established one. It setup the PBGC to support voluntary private defined benefit pension plans. Where self-funded health plans under ERISA are exempt from a state's insurance regulation there will be no solvency or consumer protection in place to support providers that do business with ERISA plans. States may consequently require provider networks that do business with employer self-insured ERISA plans be licensed as an insurance company (an HMO, medical insurance plan, preferred provider arrangement or general casualty insurer). ERISA section 404(a)(1)(B) defines the prudent person rule associating prudence with portfolio theory allowing pension funds to invest in stocks (index funds). The labor department's interpretation of an ERISA employer has been modified to support President Trump's executive order to enable more use of AHPs (Jan 2018).
) even if
state laws now forbid new policies to have these
constraints.
- Eligibility - to become eligible for benefits, patients
must need 'substantial assistance' for at least 90 days,
either because they are suffering from a form of dementia
for example or because they can't perform two basic daily
activities from a list that includes: bathing, getting
dressed, and eating. However, actually people may be
fine some days and then need the care on others.
That can get the claim denied.
- Licensed caregivers - While 'cash plans' may allow
benefits to be spent as the family sees fit other plans
require a licensed caregiver, although some states such as
California do not allow that constraint.
- Assisted living - The shifting definitions and licencing
of PAC providers often mis-matches with the old
contractual terms of the agreements. Potentially
only a SNF is skilled nursing facility.
is
covered. That means the family/friend has to explore
the array of care facilities to identify the ones that are
covered. Coverage may depend on the facilities
being: licensed by the state, providing care by a licensed
doctor and 24-hour nursing services and many other
items. And 24 hour services may become a point of
denial if the nurse is actually on call for 12 of the
hours.
- Alternate plan of care - if allowed provide some
additional flexibility, but the decision rests with the
insurer.
- Documentation - Every time the carer bills the insurer
they may deny payment if the required charts etc. have not
been filled in. This documentation does not have to
be specified in the policy. But it impacts the
family once the reimbursement in denied.
- Patients with mental health problems
- A.D.H.D. is attention-deficit/hyperactivity disorder, a chronic condition including hyperactivity, impulsiveness and low attention. Dopamine response profiles to temporal discounting tasks are abnormal for ADHD sufferers. Imaging studies show differences in the brains of ADHD sufferers. Stimulants have been found to have a calming effect on ADHD sufferers. However, overdiagnosis seems likely, with a strong correlation of diagnosis to age at time of school admission! Causally associated factors include:
- Family history
- Genetics
- May be influenced by high doses of Tylenol during pregnancy (Sep 2016).
- Environmental factors - a consistant daily schedule, praise for good behavior, clear bondaries, enough sleep and limiting distractions are all part of behavioral therapy for ADHD.
- CNS developmental problems.
rising
(Nov
2015); Treatment options expand (Nov
2015)
- High dose Tylenol
associated with 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 A.D.H.D. is attention-deficit/hyperactivity disorder, a chronic condition including hyperactivity, impulsiveness and low attention. Dopamine response profiles to temporal discounting tasks are abnormal for ADHD sufferers. Imaging studies show differences in the brains of ADHD sufferers. Stimulants have been found to have a calming effect on ADHD sufferers. However, overdiagnosis seems likely, with a strong correlation of diagnosis to age at time of school admission! Causally associated factors include: - Family history
- Genetics
- May be influenced by high doses of Tylenol during pregnancy (Sep 2016).
- Environmental factors - a consistant daily schedule, praise for good behavior, clear bondaries, enough sleep and limiting distractions are all part of behavioral therapy for ADHD.
- CNS developmental problems.
(Sep
2016)
- Remind provides
tools for secure teacher family communication that can support A.D.H.D. is attention-deficit/hyperactivity disorder, a chronic condition including hyperactivity, impulsiveness and low attention. Dopamine response profiles to temporal discounting tasks are abnormal for ADHD sufferers. Imaging studies show differences in the brains of ADHD sufferers. Stimulants have been found to have a calming effect on ADHD sufferers. However, overdiagnosis seems likely, with a strong correlation of diagnosis to age at time of school admission! Causally associated factors include:
- Family history
- Genetics
- May be influenced by high doses of Tylenol during pregnancy (Sep 2016).
- Environmental factors - a consistant daily schedule, praise for good behavior, clear bondaries, enough sleep and limiting distractions are all part of behavioral therapy for ADHD.
- CNS developmental problems.
sufferers (2018)
- Can be difficult to deal with
- Dementia is a classification of memory impairment, constrained feelings and enfeebled or extinct intellect. The most common form for people under 60 is FTD. Dementia has multiple causes including: vascular disease (inducing VCI) including strokes, head trauma, syphilis and mercury poisoning for treating syphilis, alcoholism, B12 deficiency (Sep 2016), privation, Androgen deprivation therapy (Oct 2016), stress, Parkinson's disease, Alzheimer's disease, and prion infections such as CJD and kuru. The condition is typically chronic and treatment long term (Laguna Honda ward) and is predicted by Stanley Prusiner to become a major burden on the health system. It may be possible to constrain the development some forms of dementia by: physical activity, hypertension management, and ongoing cognitive training. Dementia appears to develop faster in women than men. very
costly (Oct
2015)
- B12 absorption issues associated with dementia is a classification of memory impairment, constrained feelings and enfeebled or extinct intellect. The most common form for people under 60 is FTD. Dementia has multiple causes including: vascular disease (inducing VCI) including strokes, head trauma, syphilis and mercury poisoning for treating syphilis, alcoholism, B12 deficiency (Sep 2016), privation, Androgen deprivation therapy (Oct 2016), stress, Parkinson's disease, Alzheimer's disease, and prion infections such as CJD and kuru. The condition is typically chronic and treatment long term (Laguna Honda ward) and is predicted by Stanley Prusiner to become a major burden on the health system. It may be possible to constrain the development some forms of dementia by: physical activity, hypertension management, and ongoing cognitive training. Dementia appears to develop faster in women than men. and depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult; (Sep
2016)
- 200 prescription drugs including: beta blockers stop the action of beta-adrenergic signals and hence slow the heart. ,
P.P.I. is proton pump inhibitor, which irreversibly block operation of gastric parietal cells' hydrogen/potassium ATPase, used as a medication: esomeprazole; to treat GERD. They are among the most widely prescribed drugs in the world.
s, birth control
pills, corticosteroids, anticonvulsants, prescription-strength
ibuprofen, interferon; have depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult; as a
side effect, drugs which one-third of American's take (Jun
2018)
- Often find them in half-way houses or other institutions
that stretch the typical workflows
- NYT
Dec 2013 E.R. 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).
Costs for Mentally Ill Soar, And Hospitals Seek Better Way
- Instead of taking homeless, bipolar, schizophrenics
having trouble with their medications to the ED Raleigh
paramedics are trained to be able to triage the patients
to a commercial psychiatric facility. That saves the
hospital ED resources and places the patients under more
appropriate care.
- The '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 are a key focus of the strategy.
- More than 5 percent of the 6.4 million visits 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).
in 2010
involved patients whose primary diagnosis was a mental
health condition or substance abuse. That is up 28
percent from 2006. Federal estimates of spending by
general hospitals to care for these patients is expected
to double to $38.5 billion by 2014, from 20.3 billion in
2003.
- Problem was exacerbated by replacement of state
mental hospitals with poorly funded community care.
Hospital EDs became the default point of care.
- There are difficulties with expanding the program.
Many states have laws a protocols that require patients
may only be transported by ambulence to hospital
EDs. And Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births.
and Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
do not provide reimbursement for transportation to
nonhospital facilities.
- The most accute, agressive and chronic patients still
end up in the hospitals where they need continuous
supervision, consume expensive resources and present a
daily risk to the hospital staff. WakeMed
introduced sitters, who watch the most aggressive patients
continuously. They use special transportation to
move the patients around to the distributed community care
infrastructure.
- Poor age badly due to complex set of system factors (Oct
2015)
- Poor middle aged white American's drug addiction results from changes in the operation of the brain's reward network's regulatory regions, altering the anticipation of rewards. Addictive drugs mediate the receptors of the reward network, increasing dopamine in the pleasure centers of the cortex. The learned association of the situation with the reward makes addiction highly prone to relapse, when the situation is subsequently experienced. This makes addiction a chronic disease, where the sufferer must remain vigilant to avoid relapse inducing situations. Repeated exposure to the addictive drug alters the reward network. The neurons that produce dopamine are impaired, no longer sending dopamine to the reward target areas, reducing the feeling of pleasure. But the situational association remains strong driving the addict to repeat the addictive activity. Destroying the memory of the pleasure inducer may provide a treatment for addiction in the future. Addiction has a genetic component, which supports inheritance. Some other compulsive disorders: eating, gambling, sexual behavior; are similar to drug addiction.
based
fatalities contribute to lower life expectancy (Apr
2016)
- Case & Deaton correlate: failed expectations, mental
health problems, poor path
choices; to alcohol opioid and suicide driven increased
death rate in poor whites (Nov
2015)
- Black Americans are living longer, but advance threatened by
Trump administration policies (May
2017)
- Demographic bulge helps increase spend on health care by 2025
(Jul
2016).
- Age related B12 absorption issues, atrophic
gastritis is a condition of aging where the acid-producing cells in the stomach gradually cease to function. It is associated with chronic inflammation of the stomach mucosa, leading to loss of gastric glandular cells and their replacement by intestinal and fibrous tissues.
, associated with dementia is a classification of memory impairment, constrained feelings and enfeebled or extinct intellect. The most common form for people under 60 is FTD. Dementia has multiple causes including: vascular disease (inducing VCI) including strokes, head trauma, syphilis and mercury poisoning for treating syphilis, alcoholism, B12 deficiency (Sep 2016), privation, Androgen deprivation therapy (Oct 2016), stress, Parkinson's disease, Alzheimer's disease, and prion infections such as CJD and kuru. The condition is typically chronic and treatment long term (Laguna Honda ward) and is predicted by Stanley Prusiner to become a major burden on the health system. It may be possible to constrain the development some forms of dementia by: physical activity, hypertension management, and ongoing cognitive training. Dementia appears to develop faster in women than men. and depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult; (Sep
2016)
U.S. Health
- Lifestyle and cell situation affect likelihood 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).
(Jul
2016)
- 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 trials
history detailed, including: Saint
Judes's Dr.
Campana - Juno, University
of Pennsylvania's Dr.
June - Novartis;
Trials progressing (Aug
2016)
- PD-1 is programmed cell death protein 1 (CD279) is encoded by the PDCD1 gene. It is a cell surface receptor that belongs to the immunoglobulin superfamily. It is expressed on T-cells and pro-B cells. It acts as an immune checkpoint preventing the activation of T-cells to help self-tolerance and reduce autoimmunity. When it fails people can suffer from: Lupus, Crohn's disease, Rheumatoid arthritis. PD-1 inhibitor drugs activate the immune system to attack tumors. PD-1 inhibitors are being approved for Melanoma and squamous-cell form of lung cancer. inhibitors
help in remission but not certain cure for cancer (Aug
2016).
- Additional years of treatment with aromatase
inhibitors limit the synthesis of estrogen by aromatase. Breast and ovarian cancers grow more stimulated by estrogen.
reduced [re-]occurrence of 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)
but did not reduce mortality in postmenopausal women (Jun
2016).
- NCI is the national cancer institute.
's Rosenberg's
TIL is tumor infiltrating lymphocyte, a class of lymphocyte that is considered to invade tumors and attack them. TILs are isolated from the patient's tumors and cloned in large numbers. Once the patient's native lymphocytes have been depleted with chemotherapy the TILs are infused in combination with interleukin-2 to attack the tumor. therapy kills six
KRAS is a gene that encodes the GTPase KRas, which is part of many signal transduction pathways that propagate growth factors. Mutations in KRAS are essential for the development of many cancers. tumors (Dec
2016)
- 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). after 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
surgery found in NCI is the national cancer institute.
study to save lives after reccurence (Feb
2017)
- NCI is the national cancer institute.
sponsored Washington
University School
of Medicine designed clinical trial - BMS Opdivo treatment
of HTLV-1 is human T-cell leukemia virus type 1, a human retrovirus, which causes adult T-cell leukemia/lymphoma and a demyelinating disease. It infects millions of people in: Japan, Africa, South America, Caribbean, Australia; but only 5% of those infected develop the cancer. It is transmitted between humans by: sex, breast-feeding, needle-sharing, transfusions, and transplants. virus
induced adult T-cell 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. -lymphoma is when lymphocytes continue reproducing, and do not die - a blood cancer. , an 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.
checkpoint
inhibitor release the immune system's checkpoints: PD-1, CTLA-4; on attacking host cells: by 1) stopping T-cell division and 2) reducing their life spans. They are used in immuno-oncology where, in 2016: They are approved for treatment of: Advanced melanoma, HL, lung, kidney, liver cancer; They have a general success rate of 20 - 40% and higher for melanoma. Checkpoint inhibitors work best for tumors that have many mutations: melanomas, lung and bladder cancers. They are enhanced by adjunct treatments that kill tumor cells generating debris to stimulate the immune system. The drugs include: ipilimumab (CTLA-4 inhbition), nivolumab, pembrolizumab, atezolizumab (PD-1 inhibitors); They are costly and often have high copayments. They cause auto-immune side effects including inflammation, rheumatoid arthritis and damage to glands: Adrenal, Thyroid, Pituitary. Powerful steroids such as prednisone can help reduce the inflammation. Damaged glands require sustained hormone treatment. Checkpoint inhibitor research is funded by the CRI. treatment, failed (Jun
2018)
- BMS/NCI is the national cancer institute.
funded PD-1 is programmed cell death protein 1 (CD279) is encoded by the PDCD1 gene. It is a cell surface receptor that belongs to the immunoglobulin superfamily. It is expressed on T-cells and pro-B cells. It acts as an immune checkpoint preventing the activation of T-cells to help self-tolerance and reduce autoimmunity. When it fails people can suffer from: Lupus, Crohn's disease, Rheumatoid arthritis. PD-1 inhibitor drugs activate the immune system to attack tumors. PD-1 inhibitors are being approved for Melanoma and squamous-cell form of lung cancer. checkpoint
inhibitor release the immune system's checkpoints: PD-1, CTLA-4; on attacking host cells: by 1) stopping T-cell division and 2) reducing their life spans. They are used in immuno-oncology where, in 2016: They are approved for treatment of: Advanced melanoma, HL, lung, kidney, liver cancer; They have a general success rate of 20 - 40% and higher for melanoma. Checkpoint inhibitors work best for tumors that have many mutations: melanomas, lung and bladder cancers. They are enhanced by adjunct treatments that kill tumor cells generating debris to stimulate the immune system. The drugs include: ipilimumab (CTLA-4 inhbition), nivolumab, pembrolizumab, atezolizumab (PD-1 inhibitors); They are costly and often have high copayments. They cause auto-immune side effects including inflammation, rheumatoid arthritis and damage to glands: Adrenal, Thyroid, Pituitary. Powerful steroids such as prednisone can help reduce the inflammation. Damaged glands require sustained hormone treatment. Checkpoint inhibitor research is funded by the CRI. 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.
study by MD
Anderson's Dr. Hussain Tawbi reports Opdivo & Yervoy combination
used to treat melanoma is a cancer of the melanocytes. It is a less common form of skin cancer but is the most deadly once it has invaded deeply into layers of skin. It is primarily caused by UV light. It is tied to mutations in the signalling pathway (BRAF) and regulatory genes (P53) with a key dependency on crestin reactivation (Jan 2016).
(and likely other cancers of 200,000 people a year) patients
with consequent metastatic brain cancers, at 28 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); s: MS-KCC;
find survival rate expands beyond a year, like Jimmy Carter
after he was treated with Keytruda.
But 50% of patients had significant side effects of which 20%
quit the treatment (Aug
2018)
- Obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016).
still
rising in the U.S. despite efforts to fight it (Nov
2015)
- Nhanes is the National Health and Nutrition Examination Survey, a program that continuously monitors the health and nutritional status of Americans.
finds obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). rates
increasing in the US is the United States of America.
for adults 2015 to 2016, correlating with a rise in the sale of
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. (Mar
2018)
- Boston
Children's Ludwig & Harvard's
Rogoff note that US is the United States of America. obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016).
is still
rising - CDC is the HHS's center for disease control and prevention based in Atlanta Georgia. data
shows a doubling in adults from 1970 to 2000 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 Midwest, reducing life expectancy is a measure of the average life time of a new born baby. Without public health assistance many children die in the first five years of life significantly lowering the life expectancy of the whole group. There are representational and data capture problems with the model: - Not knowing the risk of dying in the newborn's future, demographers use the risks present at that time to predict impacts in the future of the person. No adjustment can be made for increased wellbeing.
- Saving the lives of children has a far larger effect on increasing life expectancy than extending the lives of the elderly
- Impacts that occur in a particular year, such as a epidemic or pandemic, are treated as permanent effects for that years life expectancy even though they may be handled by public health strategies and hence be transients. For life expectancy calculations in subsequent years the impact is ignored.
- Programs that reduced the impacts of infectious diseases, such as antibiotics and vaccine deployment, have reduced the variability of life expectancy following their introduction.
- Vital registration systems gather accurate data for life expectancy. But most countries do not have the infrastructure and instead estimates are generated from demographic and health surveys.
& ADA
shows increasing 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.
impacts (Aug
2018)
- New diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include:
- Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
cases trending down (Dec
2015)
- UCL finds obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016).
and diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections.
linked to 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).
(Dec
2017)
- Pancreatic
cancer is most often an exocrine tumor. Islet cell tumors are less common. These are rare cancers: less than 200,000 US cases per year, but the five year survival rates are extremely low 3%. They all have KRAS mutations. They are associated with obesity. Diagnostics are starting to leverage genomics and big databases (23 and me). Treatments include: will trend to the 2nd most deadly in the US is the United States of America. by 2030. Given
the drop in smoking, research has been seeking a cause for the
rise: obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016).
, type 2 diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
,
metabolic
syndrome is an inadequate ability to store fat. The body aims to store excess energy in the form of fats in adipose tissue. It there is not enough the fat is stored in other organs: liver, heart, muscles and pancreas where it poisons the organs resulting in metabolic syndrome. Obese people do not have enough adipose tissue to cope and so develop metabolic syndrome. Ceramide and diacylglycerol buildup in tissues appear to inhibit insulin signalling. They are suspected to be the poisons in metabolic syndrome. Modified dinitrophenol may safely inhibit diacylglycerol buildup, stopping type-2-diabetes and fatty liver development. ; are all epidemics is the rapid spread of infectious disease: AIDS (Oct 2016), Cholera (2010), Clostridium difficile (May 2015), Ebola, Influenza, Polio, SARS, Tuberculosis, Typhoid (Apr 2018), Malaria, Yellow fever, Zika; to large numbers of people in a population within a short period of time -- two weeks or less. Epidemics are studied and monitored by: NIAID, CDC, WHO; but are managed by states in the US. Infection control escalation is supported by biocontainment units: Emory, Nebraska. Once memes are included in the set of infectious schematic materials, human addictions can present as epidemics concludes Dr. Nora Volkow of the NIDA. CEPI aims to ensure public health networks are effectively prepared for epidemics. PHCPI aims to strengthen PCPs globally to improve responsiveness to epidemics. GAVI helps catalyze the development and deployment of vaccines. Sporadic investment in public health enables development of conditions for vector development: Mosquitos. The increasing demands of the global population are altering the planet: Climate change is shifting mosquito bases, Forests are being invaded bringing wildlife and their diseases in contact with human networks. Globalized travel acts as an infection amplifier: Ebola to Texas. Health clinics have also acted as amplifiers: AIDS in Haiti, C. diff & MRSA infections enabled & amplified by hospitals. Haiti earthquake support from the UN similarly introduced Cholera. (Jul
2018)
- Maternal deaths (Sep
2016)
- Being fat and fit definitively leaves the person at risk
of premature death (Dec
2015)
- Doctors and hospitals failing to treat the obese (Sep
2016)
- Surgeon's (ASMBS)
promote surgery as a solution (Nov
2016)
- In line with weight associations with America's large
serving sizes
- Large baby bottles associated with fatter babies (Jun
2016)
- 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.
enabled pre-diabetes is a condition where the subject's blood sugar levels are higher than normal but they are not yet suffering from irreversible type 2 diabetes. In 2016 the CDC estimates 86 million adults, including at least 22 million people 65 or older, are pre-diabetic increasing their risk of heart disease, stroke and diabetes. Doctors test for pre-diabetes with a blood test: FPG, OGTT, A1C; with fasting required in the first two. Pre-diabetes is treatable but only about 10 percent with the condition are aware they have it. Left untreated, up to one-third of people with pre-diabetes will develop diabetes within five years. The YMCA developed a pre-diabetes treatment program. People can use a test devised by the CDC to assess their risk of pre-diabetes.
program to deploy nationally (Mar
2016)
- DTRC
pre is a condition where the subject's blood sugar levels are higher than normal but they are not yet suffering from irreversible type 2 diabetes. In 2016 the CDC estimates 86 million adults, including at least 22 million people 65 or older, are pre-diabetic increasing their risk of heart disease, stroke and diabetes. Doctors test for pre-diabetes with a blood test: FPG, OGTT, A1C; with fasting required in the first two. Pre-diabetes is treatable but only about 10 percent with the condition are aware they have it. Left untreated, up to one-third of people with pre-diabetes will develop diabetes within five years. The YMCA developed a pre-diabetes treatment program. People can use a test devised by the CDC to assess their risk of pre-diabetes. -diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections.
research
initially funded 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.
- 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.
compliant 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. programs
can impose significant financial penalties on employees (Oct
2015).
- AARP challenges EEOC is the equal employment opportunity commission. It is the federal agency with oversight of employer actions and develops the rules that implement employment legislation, including: wellness.
final rules on 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. programs
(Oct
2016)
- AIDS is acquired auto-immune deficiency syndrome, a pandemic disease caused by the HIV. It also amplifies the threat of tuberculosis. Initially deadly, infecting and destroying the T-lymphocytes of the immune system, it can now be treated with HAART to become a chronic disease. And with an understanding of HIV's mode of entry into the T-cells, through its binding to CCR5 and CD4 encoded transmembrane proteins, AIDS may be susceptible to treatment with recombinant DNA to alter the CCR5 binding site, or with drugs that bind to the CCR5 cell surface protein preventing binding by the virus. Future optimization of drug delivery may leverage nanoscale research (May 2016).
war may be
lost (Dec
2015)
- PRWORA is the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. Bill Clinton followed through on a campaign promise to reshape welfare with the signing of a key aspect of Newt Gingrich's "Contract with America" the PRWORA. It ended the AFDC federal guarantee of direct cash payments to the needy substituting TANF which limited assistance to five years and allowed the states broad freedom in designing their own welfare programs. Clinton said it was unfair to bar legal immigrants from food stamps, medical assistance and other benefits but would sign. Congressional Democratic leaders Gephardt and Daschle voted against the act but the Democratic Governors were pleased with the provision of additional state power and regular Americans broadly supported the plan. It is argued that the act set federal goals for the states to implement. The goals included:
- Put people to work,
- Discourage child birth,
- Promote marriage.
food
stamp restrictions reintroduced (Apr
2016).
- Opioid crisis:
- 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 are major
hubs for initiating addiction results from changes in the operation of the brain's reward network's regulatory regions, altering the anticipation of rewards. Addictive drugs mediate the receptors of the reward network, increasing dopamine in the pleasure centers of the cortex. The learned association of the situation with the reward makes addiction highly prone to relapse, when the situation is subsequently experienced. This makes addiction a chronic disease, where the sufferer must remain vigilant to avoid relapse inducing situations. Repeated exposure to the addictive drug alters the reward network. The neurons that produce dopamine are impaired, no longer sending dopamine to the reward target areas, reducing the feeling of pleasure. But the situational association remains strong driving the addict to repeat the addictive activity. Destroying the memory of the pleasure inducer may provide a treatment for addiction in the future. Addiction has a genetic component, which supports inheritance. Some other compulsive disorders: eating, gambling, sexual behavior; are similar to drug addiction. .
Some are reducing overuse of opioids (Jun
2016).
- Overdose death rates increasing faster than before, amplified
by fentanyl is a synthetic opioid pain medication that acts on micro-opioid receptors in the brain. It is 50 times more potent than morphine. It was originally manufactured by Janssen Pharmaceutica in 1959 which was acquired by Johnson & Johnson. It is branded as: Sublimaze, Actiq, Durogesic, Duragesic, Fentora, Matrifen, Subsys, Instanyl, Abstral, Lazanda; with a variety of deployment formulations. It is often used, in a transdermal patch such as durogesic, to treat severe ongoing pain which can be induced by cancer. It has followed heroin into the back-street opioid epidemic (Jun 2017).
and
equivalents on the east coast (Jun
2017)
- Congress concludes Chinese distributors ship fentanyl is a synthetic opioid pain medication that acts on micro-opioid receptors in the brain. It is 50 times more potent than morphine. It was originally manufactured by Janssen Pharmaceutica in 1959 which was acquired by Johnson & Johnson. It is branded as: Sublimaze, Actiq, Durogesic, Duragesic, Fentora, Matrifen, Subsys, Instanyl, Abstral, Lazanda; with a variety of deployment formulations. It is often used, in a transdermal patch such as durogesic, to treat severe ongoing pain which can be induced by cancer. It has followed heroin into the back-street opioid epidemic (Jun 2017).
via
e-commerce: UPS,
FEDEX, USPS; via third countries, to buyers in US is the United States of America. : Ohio, Pennsylvania,
Florida; who pay with Bitcoins is a set of open-source software, used to provide infrastructure that supports a distributed cryptocurrency and payment system, based on the blockchain. All transaction inputs are unspent outputs from previous transactions. All transaction inputs are signed. Change is provided in an additional output to the transaction.
(Jan
2018)
- F.D.A. Food and Drug Administration. asks Endo to
withdraw Opana
ER. Commissioner
Gottlieb
notes its a high priority to take regulatory steps against
products fueling the epidemic is the rapid spread of infectious disease: AIDS (Oct 2016), Cholera (2010), Clostridium difficile (May 2015), Ebola, Influenza, Polio, SARS, Tuberculosis, Typhoid (Apr 2018), Malaria, Yellow fever, Zika; to large numbers of people in a population within a short period of time -- two weeks or less. Epidemics are studied and monitored by: NIAID, CDC, WHO; but are managed by states in the US. Infection control escalation is supported by biocontainment units: Emory, Nebraska. Once memes are included in the set of infectious schematic materials, human addictions can present as epidemics concludes Dr. Nora Volkow of the NIDA. CEPI aims to ensure public health networks are effectively prepared for epidemics. PHCPI aims to strengthen PCPs globally to improve responsiveness to epidemics. GAVI helps catalyze the development and deployment of vaccines. Sporadic investment in public health enables development of conditions for vector development: Mosquitos. The increasing demands of the global population are altering the planet: Climate change is shifting mosquito bases, Forests are being invaded bringing wildlife and their diseases in contact with human networks. Globalized travel acts as an infection amplifier: Ebola to Texas. Health clinics have also acted as amplifiers: AIDS in Haiti, C. diff & MRSA infections enabled & amplified by hospitals. Haiti earthquake support from the UN similarly introduced Cholera.
(Jun
2017)
- Northern District of Ohio Judge Dan Polster's opioid MDL is multidistrict litigation, where many legal cases are consolidated to improve efficiency & reduce costs.
has multiple types
of defendent: Pharmaceutical companies: Purdue Pharma,
J&J,
and others; Distributors: McKesson, Cardinal Health;
Pharmacy chains: Walgreens,
CVS Health; and includes
a DOJ - U.S. Department of Justice. statement of
interest (Mar
2018)
- 5 New York doctors are charged in Insys
medical education scam to fund broad prescribing of Subsys (Mar
2018)
Women's health
- Women's birth control
- Women use long-lasting birth control methods increases (Nov
2015)
Denmark
Antibiotics
In 2012, Danish researchers identified 170,504 case of type 2 diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
and matched them with 1,364,008 controls without diabetes.
They associated Danish government records on antibiotic are compounds which kill bacteria, molds, etc. Sulfur dye stuffs were found to be effective antibiotics. The first evolved antibiotic discovered was penicillin. Antibiotics are central to modern health care supporting the processes of: Surgery, Wound management, Infection control; which makes the development of antibiotic resistance worrying. Antibiotics are: - Economically problematic to develop and sell.
- Congress enacted GAIN to encourage development of new antibiotics. But it has not developed any market-entry award scheme, which seems necessary to encourage new antibiotic R&D.
- Medicare has required hospitals and SNFs to execute plans to ensure correct use of antibiotics & prevent the spread of drug-resistant infections.
- C.D.C. is acting to stop the spread of resistant infections and reduce unnecessary use of antibiotics.
- F.D.A. has simplified approval standards. It is working with industry to limit use of antibiotics in livestock.
- BARDA is promoting public-private partnerships to support promising research.
- Impacting the microbiome of the recipient. Stool banking is a solution (Sloan-Kettering stool banking).
- Associated with obesity, although evidence suggests childhood obesity relates to the infections not the antibiotic treatments (Nov 2016).
- Monitored globally by W.H.O.
- Regulated in the US by the F.D.A. who promote voluntary labeling by industry to discourage livestock fattening (Dec 2013).
- Customer demands have more effect - Perdue shifts to no antibiotics in premier chickens (Aug 2015).
use over
the previous 13 years.
They reported in the Journal of Clinical Endocrinology and
Metabolism that those who had filled two to four prescriptions had a
23 percent higher risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty.
of diabetes than those who had not used antibiotics. Those who
filled five or more had a 53% higher risk. The association
could imply that diabetes caused more use of antibiotics but the
risk was apparent up to 15 years before a diabetes diagnosis.
The scientists proposed that antibiotics disrupt gut biota, the trillions of bacteria and viruses that live inside higher animals' guts, on their skin etc. These bacteria and viruses seem to play a role in: immune responses, digesting food, making nutrients, controlling mental health and maintaining a healthy weight. The signals from the gut microbiota are relayed by major nerve fibers: vagus; to the central nervous system. The symbiotic relationship must be actively managed. Human armpits include glands which provide food favoring certain symbionts who build a defensive shield above the skin. In the human gut: Barriers are setup: Mucus secretions form a physical constraint and provide sites for bacteriophages to anchor and attack pathogenic bacteria; Symbiont tailored nourishment: Plant-heavy food creates opportunities for fibre specialists like Bacteroides thetaiotaomicron; is provided, Selective binding sites are provided, Poisons are deployed against the unwelcome, and Temperature, acidity and oxygenation are managed. High throughput sequencing allows the characterization of bacterial populations inside guts. Beginning at birth, as they pass down the birth canal infants are supplied with a microbiome from their mothers. If they are borne via cesarean they never receive some of the key bacteria: Bifidobaterium infantis which is also dependent on oligosaccharides in breast milk; from their mothers. A variety of diseases may be caused by changes in the microbiome: - Eczema can be related to changes in the skin microbiome.
- Obesity can be induced by changes to the gut microbiome.
- Chronic inflammation
- Allergies
- Type 1 diabetes
, causing
changes in 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)
sensitivity and glucose tolerance which can lead to diabetes.
USA
Diet
Over eating slows
Margot Sanger-Katz reports that US adult daily calorie consumption
peaked in 2003 and is now in a sustained decline for the first time
since Federal records have been kept.
The declines include higher and lower income families, blacks and
whites. They are most substantial in households with
children. There is no decline amongst the heaviest
Americans. The public health is the proactive planning, coordination and execution of strategies to improve and safeguard the wellbeing of the public. Its global situation is discussed in The Great Escape by Deaton. Public health in the US is coordinated by the PHS federally but is mainly executed at the state and local levels. Public health includes: - Awareness campaigns about health threatening activities including: Smoking, Over-eating, Alcohol consumption, Contamination with poisons: lead; Joint damage from over-exercise;
- Research, monitoring and control of: disease agents, reservoir and amplifier hosts, spillover and other processes, and vectors; by agencies including the CDC.
- Monitoring of the public's health by institutes including the NIH. This includes screening for cancer & heart disease.
- Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.
- Development, deployment and maintenance of vaccination strategies.
- Development, deployment and maintenance of fluoridation.
- Development, deployment and maintenance of family planning services.
- Regulation and constraint of foods, drugs and devices by agencies including the FDA.
emphasis on childhood obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016).
is driving the changes.
The amount of full-calorie soda drunk by the average American has
dropped 25% since the late 1990s.
Obesity rates appear to have stopped rising in adults and school-age
children and have come down for the youngest children suggesting
calorie reductions make a difference.
The reversal appears to be due to people realizing they were harming
their health by eating and drinking too much. This awareness
built in the 1990s with public health campaigns. A CDC is the HHS's center for disease control and prevention based in Atlanta Georgia. study published in JAMA
in 1999 showed blight blue maps illustrating worsening obesity rates
in all 50 states in the 1980s and 90s. This was followed in
2001 by the Surgeon General issuing a call to action. By 2003
60% of Americans said they wanted to lose weight.
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.
required chain
restaurants to publish calorie counts.
The anti-obesity messages have focused on soda more than anything
else. In 1998 Americans, on average purchased 40 gallons of
full-calorie soda a year. In 2013 that had fallen to 30
gallons.
But outside of beverages there were few clear trends.
But this is not an end to the obesity epidemic is the rapid spread of infectious disease: AIDS (Oct 2016), Cholera (2010), Clostridium difficile (May 2015), Ebola, Influenza, Polio, SARS, Tuberculosis, Typhoid (Apr 2018), Malaria, Yellow fever, Zika; to large numbers of people in a population within a short period of time -- two weeks or less. Epidemics are studied and monitored by: NIAID, CDC, WHO; but are managed by states in the US. Infection control escalation is supported by biocontainment units: Emory, Nebraska. Once memes are included in the set of infectious schematic materials, human addictions can present as epidemics concludes Dr. Nora Volkow of the NIDA. CEPI aims to ensure public health networks are effectively prepared for epidemics. PHCPI aims to strengthen PCPs globally to improve responsiveness to epidemics. GAVI helps catalyze the development and deployment of vaccines. Sporadic investment in public health enables development of conditions for vector development: Mosquitos. The increasing demands of the global population are altering the planet: Climate change is shifting mosquito bases, Forests are being invaded bringing wildlife and their diseases in contact with human networks. Globalized travel acts as an infection amplifier: Ebola to Texas. Health clinics have also acted as amplifiers: AIDS in Haiti, C. diff & MRSA infections enabled & amplified by hospitals. Haiti earthquake support from the UN similarly introduced Cholera. . More
than a third of American adults are considered obese. And
Americans still eat too few fruits and vegetables and too much junk
food -- just less! They would need to reduce their calorie
intake by 220 a day. The current reductions are a fraction of
that.
The data came from:
- Food diaries tracked by government scientists.
- Food bar codes
- Estimates of food production.
Diet recommendations used flawed analysis
Federal diet recommendations drive eating norms and school meal
policies. For two decades Americans have been warned to eat
fewer eggs and other animal products to limit dietary cholesterol
intake and animal fat intake.
Now the low fat diet recommendation has been removed. And caps
on cholesterol intake have been removed. It has finally been
concluded in the first new Federal diet guidelines in five years
that there is 'no appreciable relationship' between dietary
cholesterol and blood cholesterol.
While the food industry has consistantly lobbied for high profit
recommendations Nina Teicholz argues that nutrition policy has been
too dependent on epidemiological studies patterns, causes and effects of health and disease in populations. It identifies risk factors for disease and focuses on preventative health care. Being observational it suffers from a core limitation. It can only show association, not causation. It can suggest hypothesis but it can not disprove them.
studies to develop its policies and guidelines. In particular
she argues Harvard's
school
of public health's epidemiological studies have driven the
governments dietary advice. It has taken a long time for
contrary clinical trials to alter the direction:
Teicholz argues that by removing meat, eggs and shell fish from
diets the space was made available for additional
carbohydrates. Fat has been reduced by 25% and carbohydate
increased 30% over the last 50 years. Teicholz notes that high
carbohydrate diets increase the risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. of obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). , diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
, and
heart disease.
Teicholz criticises the current guidelines: They recommend
reducing red and processed meat. She argues that most
Americans will have little choice but to replace the meats with
carbohydrates. If the result was increased vegitarian diet use
would be beneficial but Teicholz notes that once again experimental
clinical trials are lacking to backup the epidemiological
logic.
African American
NYT Dec
2013 Racial Gap in Breast Cancer Survival
Over all, black women with a 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)
diagnosis will die three years sooner than their white
counterparts. While nearly 70 percent of white women live at
least five years after diagnosis, only 56 percent of black women
do. And some research suggests that institutions providing mammograms is an X-ray record of the breast used for screening and diagnosis of breast cancer. Mammograms have become progressively more sensitive allowing detection of smaller tumors. This has allowed aggressive treatment practices which may be counterproductive (Aug 2015). Mammography policies are defined by: ACOG, ACS, NCCN, USPSTF; mainly to
black patients miss as many as half of breast 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). s compared with
the expected detection rates at academic hospitals.
Gap between breast cancer mortality rates
- Tennessee +13.8
- Mississippi +12.8
- Texas + 12.6
- D.C. +11.9
- Michigan + 11.6
- Louisiana +11.4
- Illinois +10.8
- Arkansas +10.8
- Virginia +10.7
- Alabama +10.6
- Kentucky +10.2
- Maryland +9.3
- California +9.0
- Pennsylvania +8.8
- Florida +8.7
- South Carolina +8.5
- North Carolina +8.4
- Georgia +8.2
- Indiana +8.2
- Ohio +7.6
- New Jersey +5.8
- Connecticut +5.8
- New York +3.3
- Massachusetts +2.0
The gap in cancer survival cannot be explained away by biological
differences in cancer between blacks and whites, researchers
say. While African-American women are at greater risk of a
more aggressive form of cancer know as triple negative, those
cancers account for only 10 percent of diagnosis.
Memphis is often the epicenter of any disease, be it diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
, heart failure is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands. There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). Treatments include: digoxin; -- there are
a lot of health issues in Memphis. But the breast cancer
results are even more troubling.
The problem is complex:
- 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.
disparities that disproportionately affect African-Americans
explain some of it. Poor people do not have the luxury of
being sick. They have to take off work and find someone to
give them a ride.
- Years of racial discrimination and distrust and trust are evolved responses to sham emotions. Having detected a sham the person will be distrusted.
of the
medical establishment dating back to the Tuskegee Alabama
syphilis experiments on black men in the 1930s continue to
influence health decisions made by African-American families in
the South.
- Black women in Memphis do not seek health care at all.
They do not undergo mammograms is an X-ray record of the breast used for screening and diagnosis of breast cancer. Mammograms have become progressively more sensitive allowing detection of smaller tumors. This has allowed aggressive treatment practices which may be counterproductive (Aug 2015). Mammography policies are defined by: ACOG, ACS, NCCN, USPSTF;
for screening or see a doctor when the earliest signs of breast
cancer develop. Even among women 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.
coverage,
black women were significantly less likely than white women to
have seen a PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. in
the 6 to 18 months before diagnosis and had far lower rates of
breast cancer screening (23.5 vs 35.7).
- Lack of health insurance among low-income and self-employed
women was also cited as an obstacle to timely care.
- Black women often arrive at the hospital with cancers so
advanced, that they rival the late-stage disease that doctors
see among women in developing nations. JAMA is the journal of the American medical association.
reported that 20
percent of African-American women with breast cancer did not
learn of their disease until it had advanced to Stage 3 or
4. That is true of only 11 percent of white
women.
- Black women treated at the Methodist System
were found to begin treatment a month later after diagnosis than
white women.
- Systemic research issues mean misdiagnosis affects minorities
more (Aug
2016)
Methodist's approach to solving the problem involved forming Congregational
Health Network to outreach, educate and support health care
provision. When backed up with 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 cover 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.
it
may start to reduce the gap. Only time will tell.
Genetic traits
Improved treatment
Benedict Carey reports
doctors can more effectively treat many brain tumors using precision
medicine is the integration of molecular research: genomics, proteomics, transcriptomics, metabolomics, cell signalling; and clinical data through a taxonomy based on CAS modeling overlaid on an information commons. It aims to support treatment of disease and remove the organ and symptom based methodological flaws in the ICD. Supporters of the D.S.M. note the aggressive shift to precision medicine at the NIMH under Dr. Insel, constrained useful clinical research (Nov 2015). diagnosis and treatments based on the tumor's genetic
characteristics according to two reports (Mayo Clinic/UCSF and 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. studies) in the New
England Journal of Medicine on gliomas which account for one third
of these tumors.
Both teams found that the glioma tumors could be grouped into a few
categories, which could be determined by looking at a few genetic
mutations:
Genotyping will make trials more focused onto one category of
tumor.
"Prognosis is going to be more accurately delineated by these kinds
of genetic subtypes, outstripping the value of looking through a
microscope," said Dr. David Sanger, the chief of neurosurgery at Lenox Hill
Hospital in New York.
23,000 Americans develop a brain tumor each year and 14,000 die
annually.
Alaska
Anchorage
David Wright
Mr. David Wright, a retired oil engineer from Anchorage, Alaska,
developed bladder
cancer affects 77,000 new people each year in the US. And there are 16,000 deaths. It is typically fast growing, and is often associated with mutated Ras, which may indicate it can be treated by reducing the methylation of the DNA (Dec 2015). A rare form is plasmacytoid. Bladder cancer is traditionally treated with surgery, chemotherapy and radiation but these have not been effective with the advanced disease. New treatments are being deployed: - Immuno-oncology immune checkpoint inhibitor Tecentriq (May 2016) is approved for locally advanced or metastatic urothelial carcenoma which accounts for 90% of bladder cancers, where the disease is not controlled by platinum chemotherapy. Bladder cancer tends to result in many mutations which typically present to the immune system making it a good candidate for immuno-oncology.
. During treatment it was discovered that Mr.
Wright had the very aggressive plasmacytoid
bladder cancer is a rare and aggressive bladder cancer. . Chemotherapy is the treatment of cancers by highly cytotoxic chemicals: Paclitaxel, Platinum, 6-mercaptopurine; assuming that cancer cells are unusually active and will be differentially poisoned. It has been successful in offering treatments when no other course was available, but non-specificity means that healthy cells also get poisoned resulting in side effects which increase with age: Permanent nerve damage, heart failure (4-5%) and leukemia (0.5-1%). and
experimental gene
therapy is the deployment of genes into patient's cells to treat or prevent diseases. It can be performed outside the body (ex vivo) or in place (in vivo). It requires a vector such as a: Virus, Ligandal style nanoparticle, electric field (Jul 2018); to perform the deployment. But viruses are: Difficult to sanitize (bringing in oncogenes etc.) and hard to target as needed, Unable to target where the DNA is deployed into the target cell chromosomes, Key targets of the immune system. The process is disease specific: - Blood cancers: NHL; can be treated with ex vivo CAR-T (Jul 2017, Oct 2017)
- Cystic fibrosis requires a virus that infects the airways and then deploys a non-cystic fibrosis allele into the nucleus of the patient's cells. The obstacles to this process have been challenging:
- The virus must not have any problematic effects. In the case of cystic fibrosis one virus activated a cancer gene leaving several trial subjects with leukemia.
- Efficiency of delivery has to be very high and this has not proved possible as of 2015.
- The newly delivered DNA must remain intact and be replicated and transcribed. This has not proved to be the case.
- The process has not been able to avoid an immune response. Gene therapy has consequently been of limited value for cystic fibrosis.
- Hemophilia A and B; virus delivered in vivo therapies enter final stage trials (Aug 2018)
- ADA based SCID was the first human treatment with gene therapy. A normal ADA gene was inserted ex vivo into immune system cells. Initially the updated cells did not live as long as needed.
- Sickle-cell anemia requires a non-sickle-cell trait allele of the hemoglobin gene to be vectored into the bone marrow of the affected person.
- T-lymphocyte DNA updates for: mutation induced autoimmune diseases, melanoma treatment; using gene editing delivered with an electric field.
cleared his lungs and shrank the plasmacytoid but did
not get rid of it. In June 2014, Mr. Wright was the first M.D.
Anderson bladder cancer patient to receive Yervoy and Opdivo. He flies
from Anchorage every two weeks for the treatments. The tumor
shrank and then disappeared. Mr. Wright is still treated with
Opdivo every two weeks although he shows no signs of cancer.
And a side effect of the immunotherapy is indirect treatment of disease by altering the immune system. Targeted diseases include: cancers -- immuno-oncology, organ transplants. is
that he itches all the time for which he uses antihistamines.
Arkansas
Heber springs
Kim Little
The Arkansas
skin cancer center provides outpatient procedures for
treatment of skin cancer. Kim Little had attended the clinic
to check some moles on her arms. The physician's assistant
noticed a whitish bump -- like a tiny fragment of thread -- on her
face. Her family 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.
argued it was a clogged pore. Following a biopsy the clinic
referred Kim
Little for a skin cancer treatment to Baptist
Health Medical Center.
Even minor 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.
procedures can lead to big bills.
Kim Little was sent to Baptist
Health MC from Arkansas
Skin Cancer Center where a biopsy had confirmed a cancerous 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). growth.
She read up on the Mohs
technique, involves slicing off a skin cancer in layers under local anesthesia with microscopic pathology performed between each "stage" until the growth has been removed. It is useful when the removal of a skin cancer is complicated or in a sensitive area since it allows the dermatologist to be confident that all the cancerous cells have been removed while it takes less tissue and leaves less scars. It is not typically used for melanomas, which require more extensive cutting. they had recommended for treatment.
She spent 'a day long medical odyssey several weeks later, through
different private offices on the manicured campus at Baptist Health
MC that involved a dermatologist 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. ,
an anesthesioogist is a physician who has completed an accredited residency program in anesthesiology and is trained in anesthesia and perioperative medicine.
and an opthalmologist deals with the anatomy, physiology and diseases of the eye.
who practices plastic surgery. It generated bills of more than
$25,000' writes Elisabeth Rosenthal of the NYT.
Ms Little had been told before hand that she would just need a
couple of stitches. "I didn't have any clue how much they were
going to bill. I had no idea it would cost so much."
Since she was pressed for time she had asked why she needed the
specialized surgery? The dermatologist Dr. Randall Breau, who
is part owner of the Arkansas
Skin Cancer and Dermatology Center, said the growth was near
her eyelid, an area where Mohs surgery is always required.
They persisted even as she pointed out that the growth was on her
cheekbone below her eye are major sensors in primates, based on opsins deployed in the retina & especially fovea, signalling the visual system: Superior colliculi, Thalamus (LGN), Primary visual cortex; and indirectly the amygdala. They also signal [social] emotional state to other people. And they have implicit censorious power with pictures of eyes encouraging people within their view to act more honorably. Eyes are poor scanners and use a saccade to present detail slowly to the fovea. The eye's optical structures and retina are supported by RPE. Eyes do not connect to the brain through the brain stem and so still operate in locked-in syndrome. Evo-devo shows eyes have deep homology. High pressure within the eye can result in glaucoma. Genetic inheritance can result in retinoblastoma. Age is associated with AMD. .
After the 30 minute removal, the dermatologist told her that she
would have to go across the street to the Arcansas Center for
Oculoplastic Surgery, another private doctors office on the Campus,
to have the wound closed by a plastic surgeon with "a couple of
stitches." Ms. Little protested that she did not want a
plastic surgeon and did not care about having a tiny scar, the
doctor told her she had no choice, she said. He refused to
stitch her cut. In fact the vast majority of Mohs surgeries
are sown up by the dermatologist or left to heal. But for Ms.
Little the 'required' plastic surgeon used an OR is operating room. , sedating is the inducement of a relaxed state with a Valium-like drug (a benzodiazepine) or a low dose of Propofol. In most countries sedative mixes are administered in offices and hospitals by a wide range of doctor and nurses unlike general anesthesia which typically requires a specialist. Sedation in traumatic situations such as are typical in ICUs has been correlated with subsequent PTSD. her requiring
an anesthesiologist and administering of an IV line.
Her bills included:
- $1,833 for the Mohs surgery adjusted to -> $1,400
- $14,407 for the plastic surgeon adjusted to -> $1,375
- $1000 for the anesthesiologist adjusted to -> $765
- $8,774 for the hospital charges. adjusted to
$1,050.
Ms Little had the least dangerous form of skin cancer, a basal cell
carcinoma is the most common form of cancer. It rarely metastasizes or kills unlike melanoma. It does cause destruction and disfigurement by invading surrounding tissue so it is considered malignant. There are a number of types: Aberrant, Cicatricial, Cystic, Fibroepithelioma of Pinkus, Infiltrative, Micronodular,Nodular which can become a Rodent ulcer, Pigmented, Polypoid, Pore-like, Superficial. . The big bills were due to the involvement of
three doctors from specialties that are among the highest
compensated in medicine, and it was done on the grounds of a
hospital.
Records of the procedure do not include before and after
photos. She was outraged to have paid $3000 out of pocket
costs.
Baptist Health
Mohs surgery
The procedure performed on Ms Little, is called Mohs surgery, involves slicing off a skin cancer in layers under local anesthesia with microscopic pathology performed between each "stage" until the growth has been removed. It is useful when the removal of a skin cancer is complicated or in a sensitive area since it allows the dermatologist to be confident that all the cancerous cells have been removed while it takes less tissue and leaves less scars. It is not typically used for melanomas, which require more extensive cutting. ,
While it offers clear advantages in certain cases, it is more
expensive than simply cutting or freezing off a lesion. It
also drove
up Hospital salaries according to Becker's
Hospital Review.
Use of the surgery has skyrocketed in the US -- over 400% in 10
years -- so that Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
put it at the top of its "potentially misvalued" list of overused or
overpriced procedures. Even the AAD is the American academy of Dermatology. agrees that the surgery
is sometime used inappropriately. Still Dr. Brett Coldiron,
president-elect of the AAD, defended skin
doctors use of Mohs surgery arguing about an epidemic of skin
cancer.
Guidelines for which treatement to adopt are typically fuzzy.
California
San Francisco
Laguna honda
Laguna Honda's
wards were organized into the admitting and a series of other wards,
the diagnosis based clusters: chronic,
psychosocial, dementia, medically complex;
LH - Chronic
No medical problems, just old age. If we live long enough we
will mostly end up here over time.
LH - Psychosocial
Mentally and medically ill.
Such as ward E4: Each dementia ward corresponded to a different
stage of dementia, which overall is the gradual loss of memory,
understanding, and intelligence. 1. Patient forgets where he
is and starts to wander. 2. Patient forgets how to talk. 3.
Last stage where patient forgets how to eat. Can be due to 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). s, head trauma,
syphilis, mercury poisoning (to treat the syphilis), alcoholism
(Korsakoff's dementia), Parkinson's
disease corresponds to the breakdown of certain interneurons in the brain. It is not fully understood why this occurs. Dopamine system neuron breakdown generates the classical symptoms of tremors and rigidity. In some instances an uncommon LRRK2 gene mutation confers a high risk of Parkinson's disease. In rare cases Italian and Greek families are impacted in their early forties and fifties resulting from a single letter mutation in alpha-synuclein which alters the alpha-synuclein protein causing degeneration in the substantia nigra, after a build up of Lewy bodies in the neurons. But poisoning from MPTP has also been shown to destroy dopamine system neurons. DeLong showed that MPTP poisoning results in overactivity in the subthalamic nucleus. People who have an appendectomy in their 20s are at lower risk of developing Parkinson's disease. The Alpha-synuclein protein is known to build up in the appendix in association with changes in the gut microbiome. This buildup may support the 'flow' of alpha-synuclein from the gut along neurons that route to the brain. Paraquat has also been linked to Parkinson's disease. Parkinson's disease does not directly kill many sufferers. But it impacts swallowing which encourages development of pneumonia through inhaling or aspirating food. And it undermines balance which can increase the possibility of falls. Dememtia can also develop. Treatment with deep-brain stimulation, after surgical implantation of electrodes in the subthalamic nucleus removes the symptoms of Parkinson's disease in some patients. , errors of regime and trials, disappointments and
privation, or often a series of these. Classical Alzheimer's is a dementia which correlates with deposition of amyloid plaques in the neurons. As of 2015 there are 5 million Alzheimer's patients in the USA. It was originally defined as starting in middle age which is rare, so it was a rare dementia. But in 1980s it was redefined as any dementia without another known cause. Early indications include mood and behavioral changes (MBI) and declarative memory and thinking problems (MCI). Specific cells within the hippocampal circuitry and its gateway, the entorhinal cortex, are damaged. The amygdala, cerebelum and other areas supporting implicit memory are not impacted during the early stages of the disease. Grid cell destruction results in a sense of being lost. The default mode network is disrupted. Variants include: late-onset sporadic; with risk factors - ApoE4 for late onset Alzheimer's, presenilin, androgen deprivation therapy (Dec 2015), type 2 diabetes. There are multiple theories of the mechanism of Alzheimer's during aging: Allen Roses argues that it is due to gene alleles that limit the capacity of mitochondria to support neuron operation, Neurons of sporadic Alzheimer's sufferers show greater APP gene diversity due to somatic recombination; It may be initiated by: stress induced HHV-6a, HHV7 herpes activation (Jun 2018) and or an increasingly leaky blood-brain barrier; and a subsequent innate immune response to the infections (May 2016). The Alzheimer's pathway follows: - Plaques form. These are seen in fMRIs 10 to 15 years prior to detecting memory and thinking changes. APP deployed in the cell membrane is cut into three parts. The external part becomes amyloid-beta peptide which aggregates into Amyloid plaques, external to the neurons, if too much is generated or it is not removed fast enough.
- Solanezumab aimed to inhibit plaque formation but clinical trials failed (Nov 2016).
- Encouraging the garbage collection of amyloid and tau with gamma rhythms stimulation retards Alzheimer's in mice studies (Mar 2019)
- BACE inhibitors block an enzyme needed to form amyloid.
- Mutation driven misfolded Tau proteins can form tangles within the cytoplasm of neurons. The Tau tangles kill nerve cells. LMTX is a drug treatment targeted at these tangles.
- The brain becomes inflamed resulting in the killing of many more nerve cells. The hippocampus disintegrates and the brain loses critical functions and memory loss becomes noticeable.
was 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. As time to diagnose became
limited more diagnoses of Alzheimer's appeared! It had the
unfortunate side effect that treatment plans and medications for the
original definition were often used for patients diagnosed with the
new definition. Chaos! Note these patients still had
strong wills, sensibilities and feelings.
- Traumatic brain injury (blood vessel burst in brain) ->
dementia,
- Depressed alcoholic damaged brain with gun -> dementia,
- Diabetic had overtreated 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.
with 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)
-> hypoglycemia starving the brain of glucose (Nov
2015) -> dementia,
- Strokes (high
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. (Ischemic is a clot that occurs as a result of an Ischemia within a blood vessel supplying blood to the brain. They account for 87% of all strokes. There are two main types:
- Thrombotic - where cerebral arteries become diseased or damaged and then blocked by a blood clot within the brain.
- Embolic - where a blood clot or plaque fragment forms outside the brain (usually the heart) and travels to the brain where it blocks a blood vessel.
& Hemorragic is the hemorrhage of a weakened blood vessel causing blood to leak into and around the brain creating swelling and pressure, damaging cells and tissue in the brain. There are two main types: - Intracerebral - where the hemorrhage is in small arteries or arterioles within the brain.
- Subarachnoid - where the hemorrhage is in a blood vessel just outside the brain leading to the skull filling with blood.
))
-> dementia;
- Classic Alzheimer's -> early rapidly progressive
dementia. Possibly treatable with Aricept is an inhibitor of acetylcholine breakdown. It is a treatment for classical Alzheimer's disease. .
LH - Medically complex
Such as ward E6, a men's ward:
- Main problem - Paralyzed by 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).
s or car
accidents, Multiple
sclerosis is caused by collapse of the protective covering of certain neurons. It is the most common disabling neurologic disease of young adults. It may be due to problems with the Schwann cells that generate the myelin sheath or an autoimmune response where the myelin sheath covering of certain neurons are attacked. Somatic DNA editing provides one direction for treatment adding surface signals which will tell the immune system cells to ignore the neurons. Multipe sclerosis has been linked to Epstein-Barr virus which establishes a lifelong, mostly asymptomatic, infection in the majority of adults. Harvard's Alberto Ascherio argues analogous to the late Polio infection induced paralysis model, that early infection with Epstein-Barr virus protects against M.S. while if infected in adolescence or adulthood the risk of M.S. doubles. M.S. has been treated with Glatiramer acetate. , Parkinson's
disease corresponds to the breakdown of certain interneurons in the brain. It is not fully understood why this occurs. Dopamine system neuron breakdown generates the classical symptoms of tremors and rigidity. In some instances an uncommon LRRK2 gene mutation confers a high risk of Parkinson's disease. In rare cases Italian and Greek families are impacted in their early forties and fifties resulting from a single letter mutation in alpha-synuclein which alters the alpha-synuclein protein causing degeneration in the substantia nigra, after a build up of Lewy bodies in the neurons. But poisoning from MPTP has also been shown to destroy dopamine system neurons. DeLong showed that MPTP poisoning results in overactivity in the subthalamic nucleus. People who have an appendectomy in their 20s are at lower risk of developing Parkinson's disease. The Alpha-synuclein protein is known to build up in the appendix in association with changes in the gut microbiome. This buildup may support the 'flow' of alpha-synuclein from the gut along neurons that route to the brain. Paraquat has also been linked to Parkinson's disease. Parkinson's disease does not directly kill many sufferers. But it impacts swallowing which encourages development of pneumonia through inhaling or aspirating food. And it undermines balance which can increase the possibility of falls. Dememtia can also develop. Treatment with deep-brain stimulation, after surgical implantation of electrodes in the subthalamic nucleus removes the symptoms of Parkinson's disease in some patients. , Head trauma, Spinal chord injury,
- Secondary complications: diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections.
,
seizures, chronic pain emerged as a mental experience, Damasio asserts, constructed by the mind using mapping structures and events provided by nervous systems. But feeling pain is supported by older biological functions that support homeostasis. These capabilities reflect the organism's underlying emotive processes that respond to wounds: antibacterial and analgesic chemical deployment, flinching and evading actions; that occur in organisms without nervous systems. Later in evolution, after organisms with nervous systems were able to map non-neural events, the components of this complex response were 'imageable'. Today, a wound induced by an internal disease is reported by old, unmyelinated C nerve fibers. A wound created by an external cut is signalled by evolutionarily recent myelinated fibers that result in a sharp well-localized report, that initially flows to the dorsal root ganglia, then to the spinal cord, where the signals are mixed within the dorsal and ventral horns, and then are transmitted to the brain stem nuclei, thalamus and cerebral cortex. The pain of a cut is located, but it is also felt through an emotive response that stops us in our tracks. Pain amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so. Fear of pain is a significant contributor to female anxiety. Pain is the main reason people visit the ED in the US. Pain is mediated by the thalamus and nucleus accumbens, unless undermined by sleep deprivation. ,
lung disease, heart
disease is cardiovascular disease which refers to:
- Conditions where narrowed and blocked blood vessels
result in angina, hypertension,
CHD and heart
attacks and hemorrhagic/ischemic strokes.
Mutations of the gene PCSK9 have
been implicated in cardiovascular disease. Rare
families with dominant inheritence of the mutations have
an overactive protein, very high levels of blood
cholesterol and cardiac disease. Other rare PCSK9
mutations result in an 88% reduced risk from heart disease.
Inflammation is associated with cardiovascular disease (Aug
2017).
, kidney
disease is chronic kidney disease - Where there is permanent damage to the Kidneys. Diabetes and high blood pressure are the leading causes of CKD. This has driven up the percentage of American's suffering from CKD.
- CKD is diagnosed via a GFR of less than 60, or another marker such as protein in the urine, for atleast three months.
- The disease, classed as having five stages, causes no symptoms until the later stages. The fifth stage of CKD is ESRD. CKD is associated with: Atherosclerosis, Cardiovascular disease, Iron deficiency anemia from reduced EPO synthesis, Fluid volume overload, Hyperphosphatemia, Hypertension, Metabolic acidosis, Mineral bone disorder, Potassium accumulation, & Urea accumulation.
;
- Almost all had a psychiatric diagnosis: schizophrenia is a chronic, psychotic, brain disorder impacting thinking and decision making that affects 1.1 percent of the adult U.S. population. It is characterized by hallucinations, delusions: paranoid, feel they are being sent special messages, feel have special powers; disorganized and unusual thinking, social withdrawal, lack of motivation and cognitive decline: executive functions & working memory; that begins with the first episode and continues throughout life. Children who eventually struggle with schizophrenia have normal working memory at age seven but are found with impairments by age 13. MRIs show that people with schizophrenia have lateral ventricles that are enlarged, a thinner cerebral cortex and smaller hippocampus. The default mode network is disrupted. It seems to be caused by over pruning of prefrontal cortex pyramidal neurons (Jan 2016), hippocampal pyramidal cells and sometimes thalamus neuron dendrites. A dopaminergic network is impacted: mesolimbic; suggesting too much dopamine signalling. Columbia University psychiatrist Franz Kallman found that a person with schizophrenia is much more likely, than non sufferers, to have a parent or sibling with the disorder. And identical twins are even more likely to share the disorder. Swedish researchers studying thousands of families in 2009 showed a strong hereditary link between bipolar disorder and schizophrenia, which was corroborated in 2012. Many of the genes associated with schizophrenia act on the developing fetal brain. MHC C4 gene supports immunity and synaptic pruning where it tags the synapses to be pruned. Variant C4-A is associated with schizophrenia where too many synapses are tagged. DISC1 translocation mutations have greatly increased the risk of schizophrenia. DISC1 supports the migration of neurons during development. There is evidence that some cases occur because of particular CNVs in the DNA of the sufferers: ZNF804A. Autism and schizophrenia risk increases with one particular chromosome 7 CNV. And de Novo mutations increase the risk. Treatments include: psychotherapy, chlorpromazine which blocks dopamine receptors of the mesolimbic pathway removing 'positive' characteristics of schizophrenia but it also impacts the nigrostriatal pathway target receptors inducing Parkinson's disease like symptoms;
,
bipolar
disorder also termed manic-depression is an episodic developmental disorder beginning in late adolescence, which can stimulate great creativity during the manic phase and suicide in the depressive phase. Vincent van Gough suffered from depression for much of his adult life, and killed himself at thirty seven. He produced three hundred of his greatest art works, using color to convey mood, while struggling with psychotic depression and mania in the last two years of his life. Only the first manic phase requires a significant positive or negative stressful situation. Type I bipolar includes more manic situations which may include psychosis. Type II does not include psychosis. Some people suffer 'mixed state' where mania and depression occur at the same time. Sleep deprivation activates the amygdala and can induce mania in some people with bipolar disorder. It affects 3 million Americans. The amygdala is more active in people with bipolar disorder. Franz Kallman found identical twins are likely (70% chance) to share the disorder. Swedish researchers studying thousands of families in 2009 showed a strong hereditary link between bipolar disorder and schizophrenia, which was corroborated in 2012. Genetic analysis of 2.3 million different regions of DNA of 9,747 people with bipolar disorder and 14,278 comparable people without, found five regions that appear connected with bipolar disorder. Gene ADCY2, was identified, supports production of an enzyme facilitating neural signalling, and correlates with observed impairment of communication in certain brain regions in bipolar disorder. GWAS implicate ANK3 and CACNA1C SNPs in bipolar disorder. And de Novo mutations increase the risk. Lithium limits the extremes of the mood swings in some patients but has side effects. Anti-psychotic medications are prescribed. , and often a personality describes the operation of the mind from the perspective of psychological models and tests based on them. Early 'Western' models of personality resulted in a simple segmentation noting the tension between: individual desires and group needs, and developing models and performing actions. Dualistic 'Eastern' philosophies promote the legitimacy of an essence which Riso & Hudson argue is hidden within a shell of personality types and is only reached by developing presence. The logic of a coherent essence is in conflict with the evolved nature of emotions outlined by Pinker. Terman's studies of personality identified types which Friedman and Martin link to healthy and unhealthy pathways. Current psychiatric models highlight at least five key aspects: - Extroversion-introversion - whether the person gains mental dynamism from socializing or retiring
- Neuroticism-stability - does a person worry or are they calm and self-satisfied
- Agreeableness-antagonism - is a person courteous & trusting or rude and suspicious
- Conscientiousness-un-directedness - is a person careful or careless
- Openness-non-openness - are they daring or conforming
disorder too - borderline, schizoid, histrionic or
obsessive-compulsive.
- Plus a few with birth conditions that left them as near
'vegetables'.
The closing of the state mental institutions left many of them with
no place to stay. On the streets they treated their
psychiatric disorders with cocaine and heroin, and then treated the
side effects of these drugs with alcohol. This added extra
complications.
Most of the patients were complicated
to nurse due to tubes (shunts in their brains, PICC is peripherally inserted central catheter which is a long tube that is inserted into a vein to enable long-term intravenous antibiotic, medication, nutrition support. lines in veins, PEG
tubes in stomachs, nephrostomy tubes in kidneys provides multiple vital functions. It: Produces renin which supports negative feedback, Removes excess organic molecules from the blood, Regulates electrolytes in the blood, Maintains pH homeostasis, Regulates fluid balance, Regulates blood pressure, monitors blood oxygen concentration and signals erythropoiesis with EPO, Reabsorbs water, glucose (SGLT2) and amino acids. Kidney function is monitored with the GFR. Kidneys can fail acutely or chronically. Kidneys are affected by a variety of cancers including: advanced kidney cancer, von Hippel Landau; some of which are induced by PFAS. Multiple myeloma, type 2 diabetes, TB and drug treatments for MDR TB place a strain on the kidneys and can induce failure. , and catheters is a thin tube that can be inserted into the body. in bladders)
that had to be managed and open sores.
Men had mainly survived due to flirtatious, happy is an emotion which functions to mobilize the mind to seek capabilities and resources that support Darwinian fitness. Today happiness is associated with Epicurean ideas that were rediscovered during the renaissance and promoted by Thomas Jefferson. But natural selection has 'designed' happiness to support hunter-gatherer fitness in the African savanna. It is assessed: Relative to other's situations, Based on small gains or losses relative to one's current situation; and so what makes us [un-]happy and our responses can seem a counter-productive treadmill. For Pleistocene hunter-gatherers in the savanna there were many ways for losses to undermine fitness and so losses still make us very unhappy. Smoking, drinking and excessive eating were not significant and so don't make us unhappy even though they impact longevity. personalities
and good looks, which ensured that others helped them through each
crisis.
The head
nurse who knit at Laguna Honda (p74)
There was a head nurse who sat at the head of her ward and knit all
day.
...
It was a little-old-lady ward, with thirty-six little old
ladies--white haired, tiny, and old--and sure enough, almost every
one was wrapped in or had on her bed a hand-knit blanket: white and
green, white and red, white and yellow. And there was the head
nurse, sitting in her chair in the nursing station, answering the
phone, fussing with the charts, observing her charges, and knitting
one of the few blankets remaining to be done.
What Sweet asserts is - The blankets made me pay attention.
Marked out that head nurse as especially attentive, especially
present, especially caring. It put me and everyone else on
notice.
It's not that the ladies for whom they were knitted appreciated them
or even noticed them. Who did notice was -- everyone
else. Visiting family noticed. Looking down the center
aisle, they saw two rows of little white-haired ladies--their
mothers, great aunts, and sisters--each lady bundled up in a bright,
many colored, hand-knit blanket. They also saw that each had
makeup on, and her hair done and her nails polished, by the nurses
who knew that, down at the end of the ward, was the head nurse,
knitting. This was a head nurse who cared. She was
knitting because everything that was supposed to be done has been
done.
The efficiency experts saw a head nurse just knitting. They
recommended placing just one head nurse for two wards. That
meant that no head nurse was in a position to carefully observe what
was happening and rapidly correct any issues.
When the system was optimized the remaining staff learned to answer
the phones, tidy the charts, talk to families, help the doctors,
survey the ward, and support one another at the same time as they
were looking on the computer or filling out forms that the new nurse
managers created. But explains Sweet the new system had a
cost. It was stressful is a multi-faceted condition reflecting high cortisol levels. Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight. As these actions occur the levels of cortisol return to the baseline rate. A stressor is anything that disrupts the regular homeostatic balance. The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis. - The short term response to the stressor
- activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response. The brain's acuity and cognition are stimulated. The immune system is stimulated with beta-endorphin and repair activities curtail. In order for the body to destroy bacteria in wounds, pro-inflammatory cytokines increase blood flow to the area. The induced inflammation signals the brain to activate the insula and through it the ACC. But when the stressor is
- long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues. Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in. Sustained stress provides an evolved amplifier of a position of dominance and status. It is a strategy in female aggression used to limit reproductive competition. Sustained stress:
- Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment!
- Activates the integration between the thalamus and amygdala.
- Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful.
- BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning.
- Makes it easier to learn a fear association and to consolidate it into long-term memory. Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala. And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces. Accuracy of assessing emotions from faces suffers. A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand. The activation of the amygdala seems to determine how the hippocampus responds.
- Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression.
- Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive. It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.
- Increases the risk of autoimmune disease (Jan 2017)
- During depression, stress inhibits dopamine signalling.
- Strategies for stress reduction include: Mindfulness.
.
After the number of head nurses were cut in half, there were more
illnesses and more sick days among the staff; there were more
injuries, more disabilities, and earlier retirements. Among
the patients, there were more falls, more bedsores, more fights, and
more tears. And this, in the broader scheme of things--even of
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. --is not
efficient.
Santa Clara
Owl RL
One hard shove in the middle of Owl RL's back during middle school
displaced vertebrae so that all subsequent growth was slightly
offset. But human upright walking uses feedback about the
positioning of the head over the body to coordinate balance.
An offset spine thus demands the head be held as expected by the
hind brain and ears thrusting the spine forwards slightly in Owl
RL's case. Walking, standing erect, while breathing very
deeply forces the head and spine to reseat correctly which saves on
osteopathy bills.
Genetic high cholesterol and 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.
forced Owl RL to take statins are serum cholesterol lowering drugs established as safe and effective at reducing the risk of heart-attacks, hemorrhagic & Ischemic strokes and deaths from atherosclerotic heart disease. They also reduce inflammation that can induce blood clots. They appear to stabilize plaque. About 5% of people, most with a specific allele of SLCO1B1, have muscle aches, and in some blood sugar increases. Statins inhibit HMG-CoA reductase which produces cholesterol in the liver.
and blood pressure reducing hydrochlorothiazide. The result
was great blood pressure and cholesterol readings. But the
treatment pushes out too much potassium into the urine forcing
compensating regular consumption of bananas and coconut water.
Owl RL drinks four cups to black tea a day, three cups of coffee and
numerous glasses of water.
Switching to a regular breakfast of oatmeal, bananas and organic
blue berries provides Owl RL with slow release carbohydrates that
constrains hunger, limits
pesticide residues and keeps glucose release rates low.
His old breakfast of raw oats, dried fruit and milk was delivering
far too much glucose too quickly for the liver is an emergent cellular system providing metabolic: Dietary compound metabolism and signalling: After gorging on sugar-rich foods the liver releases FGF21 hormone to dampen further eating activity; Detoxification, Regulation of glucose through glycogen storage (asprosin signalling from white adipose tissue); clotting, immune, exocrine and endocrine functions. It is supplied with oxygen-rich blood via the hepatic artery and blood rich in semi-processed foodstuffs from the intestines & spleen via the hepatic portal vein. It is constructed from: Hepatocytes which swim in the blood to process it, BECs, Stromal cells, Hepatic stellate cells, Kupffer cells, and blood vessels. The embryonic endoderm cells invade the mesoderm to form the liver bud. Subsequently the liver bud vascularizes and is colonized by hematopoietic cells. The liver operates on a daily cycle (Aug 2018) allowing it time to recover from the stress of processing toxic substances. In a healthy adult liver cells do not divide significantly. But in a damaged liver, the liver cells shift back to a neonatal state to re-enter the cell cycle and rebuild the liver. There are over 100 disorders of the liver. Obesity and diabetes are associated with increased prevalence of these liver disorders worldwide. to metabolize -
with the possibility of skinny pre is a condition where the subject's blood sugar levels are higher than normal but they are not yet suffering from irreversible type 2 diabetes. In 2016 the CDC estimates 86 million adults, including at least 22 million people 65 or older, are pre-diabetic increasing their risk of heart disease, stroke and diabetes. Doctors test for pre-diabetes with a blood test: FPG, OGTT, A1C; with fasting required in the first two. Pre-diabetes is treatable but only about 10 percent with the condition are aware they have it. Left untreated, up to one-third of people with pre-diabetes will develop diabetes within five years. The YMCA developed a pre-diabetes treatment program. People can use a test devised by the CDC to assess their risk of pre-diabetes. -type-2-diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
.
Owl RL's lunch is almost always a little chicken curry with four
ounces of brown basmati rice followed by a cup of coffee.
Owl RL's dinner varies but is followed by a small cognac with the
evening cup of coffee.
With little revenue coming in, stress is a multi-faceted condition reflecting high cortisol levels. Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight. As these actions occur the levels of cortisol return to the baseline rate. A stressor is anything that disrupts the regular homeostatic balance. The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis. - The short term response to the stressor
- activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response. The brain's acuity and cognition are stimulated. The immune system is stimulated with beta-endorphin and repair activities curtail. In order for the body to destroy bacteria in wounds, pro-inflammatory cytokines increase blood flow to the area. The induced inflammation signals the brain to activate the insula and through it the ACC. But when the stressor is
- long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues. Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in. Sustained stress provides an evolved amplifier of a position of dominance and status. It is a strategy in female aggression used to limit reproductive competition. Sustained stress:
- Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment!
- Activates the integration between the thalamus and amygdala.
- Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful.
- BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning.
- Makes it easier to learn a fear association and to consolidate it into long-term memory. Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala. And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces. Accuracy of assessing emotions from faces suffers. A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand. The activation of the amygdala seems to determine how the hippocampus responds.
- Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression.
- Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive. It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.
- Increases the risk of autoimmune disease (Jan 2017)
- During depression, stress inhibits dopamine signalling.
- Strategies for stress reduction include: Mindfulness.
and its negative
effects as described by Robert Sapolsky (Nov
2004), should be a significant problem. But for Owl RL
the advice of Dale Carnegie in "How
to Stop Worrying and Start Living" has undermined 'learned
helplessness' that kept many former colleagues awake at
night. Mindfulness is an active meditative state of non-doing, attentively seeking each 'present moment' with one's body and mind 'being' at rest and so cultivating awareness, according to Jon Kabat-Zinn. Some traditions define it as observing when the mind wanders. Others use it to refer to the floating awareness that witnesses whatever happens in our experience without judging or otherwise reacting, explain Goleman & Davidson. The thinking mind usually spends a lot of time relating to the future and past which Kabat-Zinn argues limits its ability to become fully aware of the present. In times of stress those thoughts are so overpowering that they crowd out awareness and appreciation of the present. Mindfulness shifts attention to calming internal feelings. It allows review and prioritization of thoughts as they are recognized. Major attitude based pillars of successful mindfulness are: impartial to judging, patience, a beginner's mind, trust, non-striving, acceptance of seeing things the way they are and letting go. An awareness of the body's state can be built with tools including: inquiry, naming; from Yogi's attention to: - Breathing - which is a proxy for the environmental situation and through its rhythms is a model of our emotional state. Attention to breathing reminds people to feel their bodies too. Belly breathing is particularly relaxing.
- Sitting - erect with head, neck and back aligned vertically. Then attend to breathing moving back to it each time you observe the mind has wandered. When the body becomes uncomfortable, direct attention to the discomfort, observe and welcome it.
- Experience our body - rather than model, judge or hate it relative to an ideal - with a body scan.
- Hatha yoga - very slow stretching and strengthening exercises with moment-to-moment awareness supports being in your body.
- Walking meditation - Intentionally attend to the immediate experience of walking.
may also help. And Owl RLs dog's companionship and hour long
daily walks undoubtedly does help.
As Owl RL nears sixty the signs of aging, described by Atul Gawande
in Being Mortal, are ever present:
Owl RL and Heradity
Owl RL's father developed:
- 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).
of the
salivery gland from smoking
- Heart attack is an AMI. It can induce cardiac arrest. Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI. Risk factors include: taking NSAID pain killers (May 2017). There is uncertainty about why AMI occur. Alternative hypotheses include:
- Plaques started to gather in the coronary arteries and grew until no blood flow was possible. If this is true it makes sense to preventatively treat the buildup with angioplasty.
- Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot. If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors.
from smoking, and lack of exercise.
- Possible signs of dementia is a classification of memory impairment, constrained feelings and enfeebled or extinct intellect. The most common form for people under 60 is FTD. Dementia has multiple causes including: vascular disease (inducing VCI) including strokes, head trauma, syphilis and mercury poisoning for treating syphilis, alcoholism, B12 deficiency (Sep 2016), privation, Androgen deprivation therapy (Oct 2016), stress, Parkinson's disease, Alzheimer's disease, and prion infections such as CJD and kuru. The condition is typically chronic and treatment long term (Laguna Honda ward) and is predicted by Stanley Prusiner to become a major burden on the health system. It may be possible to constrain the development some forms of dementia by: physical activity, hypertension management, and ongoing cognitive training. Dementia appears to develop faster in women than men. .
Owl RL's mother developed:
Owl RL's sister has developed:
Owl RL and hospital
processes
These are still disconnected from the arriving patient and
family. Roads large enough to cope with hospital traffic flows
do not exist so the jams are hugely problematic. Valet parking
helps with the difficulty of finding spots. Auxillaries are
friendly and help with directions to the second floor where the ORs
and waiting rooms are. But the waiting would be so much easier
if you could see the process you are a part of. Instead
activity buzzes around your bed or waiting area. Everyone is
clearly busy.
The hospital has a heli-pad
that can move patients to Stanford Hospital
when necessary.
Willow Glen
Mercenary HD
Living life on the edge in South American jungle requires
willingness for risk taking. But tropical infections can be
powerful and so are the treatments. HD developed
jaundice. He got a parasitic infection in one arm and had to
insist it was not amputated.
Hard physical work left scars on the body. Some were internal
and became viewed by HD's immune system as foreign. That was
just another reason for HD's doctors to leverage chemo therapies to
suppress them.
But in the middle of these powerful treatments HD felt a powerful
chest pain emerged as a mental experience, Damasio asserts, constructed by the mind using mapping structures and events provided by nervous systems. But feeling pain is supported by older biological functions that support homeostasis. These capabilities reflect the organism's underlying emotive processes that respond to wounds: antibacterial and analgesic chemical deployment, flinching and evading actions; that occur in organisms without nervous systems. Later in evolution, after organisms with nervous systems were able to map non-neural events, the components of this complex response were 'imageable'. Today, a wound induced by an internal disease is reported by old, unmyelinated C nerve fibers. A wound created by an external cut is signalled by evolutionarily recent myelinated fibers that result in a sharp well-localized report, that initially flows to the dorsal root ganglia, then to the spinal cord, where the signals are mixed within the dorsal and ventral horns, and then are transmitted to the brain stem nuclei, thalamus and cerebral cortex. The pain of a cut is located, but it is also felt through an emotive response that stops us in our tracks. Pain amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so. Fear of pain is a significant contributor to female anxiety. Pain is the main reason people visit the ED in the US. Pain is mediated by the thalamus and nucleus accumbens, unless undermined by sleep deprivation. while
motorcycling. The AMI is acute myocardial infarction which means that some of the heart muscle has died from a blocked blood supply. AMI is hard to measure. Nanosensors offer a possibility (May 2016).
was treated with a stent is a small wire cage that can be inserted into an artery to prop it open. They were introduced as an alternative to bypass surgery in the 1990s. Stents are expensive. Medicare payments vary depending on what kind of stent is used and how many, but are generally in the range $10,000 to $17,000 in 2015. Double blind trials show that stents have no effect on chest pain relief (Nov 2017) ,
diet, aspirin (acetylsalicylic acid) is a pain, fever and inflammation medicine. It is a platelet aggregation inhibitor. While its NNT is 2000 for cardiovascular disease prophylaxis, it is so cheap that this strategy is still important. It has been found beneficial in limiting esophageal cancer. , 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.
pills and statins are serum cholesterol lowering drugs established as safe and effective at reducing the risk of heart-attacks, hemorrhagic & Ischemic strokes and deaths from atherosclerotic heart disease. They also reduce inflammation that can induce blood clots. They appear to stabilize plaque. About 5% of people, most with a specific allele of SLCO1B1, have muscle aches, and in some blood sugar increases. Statins inhibit HMG-CoA reductase which produces cholesterol in the liver. .
Double pneumonia required an 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.
stay and Cefaprime cathetered is a thin tube that can be inserted into the body.
to the heart; when your immune system has been suppressed! A heart attack is an AMI. It can induce cardiac arrest. Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI. Risk factors include: taking NSAID pain killers (May 2017). There is uncertainty about why AMI occur. Alternative hypotheses include: - Plaques started to gather in the coronary arteries and grew until no blood flow was possible. If this is true it makes sense to preventatively treat the buildup with angioplasty.
- Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot. If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors.
during this treatment was handled fast with another stent.
But:
And why does the hospital never have a record of Mercenary HD's advance
directive specify patients decisions about how they wish to be cared for as they die. , setup by a lawyer, accessible electronically and
previously provided to the provider.
Parkinson's and
UCSF cardiology patient/caregiver empowerment
Bret Parker, who has Parkinson's
disease corresponds to the breakdown of certain interneurons in the brain. It is not fully understood why this occurs. Dopamine system neuron breakdown generates the classical symptoms of tremors and rigidity. In some instances an uncommon LRRK2 gene mutation confers a high risk of Parkinson's disease. In rare cases Italian and Greek families are impacted in their early forties and fifties resulting from a single letter mutation in alpha-synuclein which alters the alpha-synuclein protein causing degeneration in the substantia nigra, after a build up of Lewy bodies in the neurons. But poisoning from MPTP has also been shown to destroy dopamine system neurons. DeLong showed that MPTP poisoning results in overactivity in the subthalamic nucleus. People who have an appendectomy in their 20s are at lower risk of developing Parkinson's disease. The Alpha-synuclein protein is known to build up in the appendix in association with changes in the gut microbiome. This buildup may support the 'flow' of alpha-synuclein from the gut along neurons that route to the brain. Paraquat has also been linked to Parkinson's disease. Parkinson's disease does not directly kill many sufferers. But it impacts swallowing which encourages development of pneumonia through inhaling or aspirating food. And it undermines balance which can increase the possibility of falls. Dememtia can also develop. Treatment with deep-brain stimulation, after surgical implantation of electrodes in the subthalamic nucleus removes the symptoms of Parkinson's disease in some patients. , argues that tools like Fitbit and Apple Watch
(medical) may help collect data which Parker needs to understand if
his diet, or medication are correlated with some issue with his
symptoms. UCSF's Health
eHeart study aims to use big data encompasses the IT systems and processes necessary to do population based data collection, management and analysis. The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass. Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms: Precision medicine, Protein folding modeling (Feb 2019) assumes coevolutionary methods can be applied to identify contact points in a protein's tertiary structure. Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure: - Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Complex data models must include clinical aspects of the patient specific data, including disease state population wide.
- A key aspect is providing clear signals about the nature of the data using data visualization.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
techniques to
help cardiology patients to see how every day activities are
affecting their health.
Iceland
Prostate cancer
deCode
genomic testing of SCO Gulcher
Jeffrey Gulcher decided to undergo deCode's 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). .
In apparently excellent health and aged 48 at that time his results
predicted a 1.9 increased risk of 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
.
Since his father had a history of prostate cancer at age 68 Gulcher
was advised to have a PSA
test is prostate specific antigen. It is assessed from a blood sample and high counts are indicators of prostate cancer. PSA increases with age any way. Typical levels for: 50 - 59 year old are 3 nanograms (ng) per millilitre (ml), 60 - 69 year old are 4 ng/ml and 70 - 79 year old are 5 ng/ml. The USPSTF recommended against routine PSA based screening in 2012. and 12 followup biopsies is taken with a rectal probe. It finds cancer in only 30 - 40% of men with abnormal PSAs. They can result in infections and can miss more aggressive cancers because they examine only tiny snippets of the prostate. Research and development of liquid biopsys aims to replace and enhance the traditional biopsy. MRI has also been found to enhance targeting of prostate problems. .
Three of the biopsies showed 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). with a middle
range Gleason score grades prostate cancers based on their aggressiveness, an indication of metastasis and early death, based on the appearance of cells from a biopsy. The score ranges from 1 (no apparent cancer) to 10 (aggressive). .
For a young man in Gulcher's condition there are studies that
suggest it is better to use radical prostatectomy than active
surveillance is an approach to early-stage prostate cancer which replaces treatment, such as surgery or radiation, with monitoring to ensure the cancers aren't growing rapidly. It started to be used in about 2000 and so will take time to build a predictive history of the success of the regimen (10 year longitudinal study results Sep 2016). Active surveillance treatements include: Oncotype DX, PSA, STHLM3;.
After the prostatectomy it was found some of the cancer was in the
high Gleason range. And happily is an emotion which functions to mobilize the mind to seek capabilities and resources that support Darwinian fitness. Today happiness is associated with Epicurean ideas that were rediscovered during the renaissance and promoted by Thomas Jefferson. But natural selection has 'designed' happiness to support hunter-gatherer fitness in the African savanna. It is assessed: Relative to other's situations, Based on small gains or losses relative to one's current situation; and so what makes us [un-]happy and our responses can seem a counter-productive treadmill. For Pleistocene hunter-gatherers in the savanna there were many ways for losses to undermine fitness and so losses still make us very unhappy. Smoking, drinking and excessive eating were not significant and so don't make us unhappy even though they impact longevity. Gulcher did
not suffer any of the troubling side effects of prostate biopsies is taken with a rectal probe. It finds cancer in only 30 - 40% of men with abnormal PSAs. They can result in infections and can miss more aggressive cancers because they examine only tiny snippets of the prostate. Research and development of liquid biopsys aims to replace and enhance the traditional biopsy. MRI has also been found to enhance targeting of prostate problems. .
Illinois
Oak Brook
Noraine Scarpelli
To help control costs, Advocate has
hired scores of workers to coordinate care aims to transfer information between the patient and each care participant as required and establish accountability by defining who is responsible for each care delivery activity, the extent of that responsibility and when that responsibility will be transferred to other care participants or the patient and family. Successful care coordination requires face-to-face interactions. It also requires aligned incentives (ACO, Bundled payments). AHRQ defines quality measures for care coordination. The situation is usually complex and adaptive due to the interactions of all the providers, settings, the patients' preferences, and the number of physical health problems, treatments, and the patients' social situation. The potentially exponential increase in complexity as the number of these factors present increases leads to patient hot spots requiring explicit proactive coordination of care. It is argued that care coordination must include six specific activities: - Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history. It needs to be updated periodically and after new diagnosis and other changes in health or functional status.
- Creation and updating of proactive plan of care
- Communication
- Facilitation of transitions: typical transition problems are detailed by Project Boost. A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff.
- Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness.
- Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.
and keep an eye on the highest-cost patients, like those who are
obese or have type
2 diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
. It started providing doctors' offices with
report cards on their performance. Dozens of quality-control
measures cover items as varied as blood pressure, re-hospitalizations 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.
for 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; attacks or
the use of expensive imaging
machines.
On a blustery spring morning, those changes were visible in Advocate
care centers across the metropolitan area. Sumera Khan, a
clinical pharmacy specialist, popped into the hospital room of
Noraine Scarpelli, an elderly woman with congestive heart failure is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands. There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). Treatments include: digoxin; ,
to check her prescription drug levels, an additional level of
scrutiny that can help prevent complications. In another
building, Dr. Karen O'Mara flicked between eight computer screens,
peering at intensive care patients miles away, ready to alert a
doctor if they looked in distress.
Kentucky
Louisville
Patients of Family Health Centers
Current patients of Family Health
Centers, include a lot with multiple chronic problems such as
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; , high 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. ,
diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
,
chronic depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult;
and CHF is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands. There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). Treatments include: digoxin; which all tend to
create additional problems. Governor Steven Beshear says
that health outcomes in Kentucky are currently 'horrendous'.
The state has some of the highest rates of smoking, obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). , and deaths due
to 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
diabetes. Aggravating this situation most of Family Health
Centers patient population cannot afford to attend the clinic, and
only come when the situation becomes dire. But then they can't
afford the hospital treatments and drug regimes that the doctors
propose. If they were ever able to leverage insurance this was
removed by the payers include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
,
prior to ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
, when they
were found to have significant costly issues. The diagnosis
and treatment of a major chronic problem would increase the premiums
significantly inducing the patient to terminate coverage at which
point they could be refused coverage for the pre-existing
condition.
This seems like a key opportunity for the ACA to improve the
situation for these uninsured over time, but NYT was highlighting
the limited understanding of its benefits and the fear of the
insurance payments that they would soon have to make. In fact
Kentucky has taken the decision to expand Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. so these
patients should gain access to very low cost coverage, and would
contribute to revenue when they attend the clinic. Community
clinics are being given $150 million across the country to help
patients sign up for insurance during October 2013.
Family Health Centers is working on becoming a PCMH (PCMH) The Patient-centered medical home - Describes a reorganization of the health care delivery system to focus on the patient and care giver supported by EHR infrastructure and some form of process management which will be necessary to coordinate interventions by each of the functional entities resources to treat the patients specific problems. The disadvantage of a PCMH is the administrative and technology cost needed to support its complex processes. The PCMH
- Was promoted as a way to incent more PCP which had been seen as a low reward role by medical students. HCI3 argues this use of PCMH is flawed. PCMH is driven by the medical home models of the ACA. In this model the PCMH is accountable for meeting the vast majority of each patients physical and mental health care needs including prevention and wellness, acute care, and chronic care. It is focused on treating the whole person. It is tasked with coordinating the care across all elements of the health care system, including transitions and building clear and open communications. It must ensure extended access and availability of its services and patients preferences about access. It must continuously improve quality by monitoring evidence-based medicine and clinical decision support tools (NCQA). Many argue that to be effective it must be connected to a 'medical neighborhood'. The PCMH brings together the specialized resources and infrastructure required to develop and iteratively maintain the care plans and population oriented system descriptions that are central to ACA care coordination.
.
They have a consultant advising them on how to achieve this
certification. He is promoting computerized scheduling and
records. He also advocates matching office hours to the
attendance patterns of the patient population. Many of the
patients dislike is an emotion which initiates and maintains an altruistic partnership. It is a willingness to offer someone a favor. It is directed to those who appear likely to return the favor. early
morning appointments. ACA allocates $11 billion over 5 years
to improve and expand community clinics across the US. Family
Health Centers is getting $5.4 million to renovate a clinic for the
homeless and move a downtown clinic to a much bigger building,
adding dental, X-Ray and Pharmacy departments. It aims to
serve 10,000 extra patients at that site alone. If the extra
people are able to pay the increased revenue would allow Family
Health Centers to increase salaries.
Maryland
Bethesda
Francis
Collins personalized genomic testing
Dr. Collins described personalized 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).
performed on samples he provided anonymously, by direct-to-consumer
genetic testing companies: 23andme, deCode and Navigenics
in his book
'The Language Of Life'. He has some problematic genetic
traits:
- Alpha
1-antitrypsin deficiency is a deficiency in the liver's production of A1AT and consequent failure to protect the connective tissue in the lungs from neutrophil elastase disruption resulting over time in emphysema.
- Coumadin is a brand name for warfarin.
metabolism issues.
- Type-2-diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include:
- Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
with two copies of the TCF7L2 is a gene coding for transcription factor 7 Like 2. It participates in G-protein coupled receptor signalling and transport to the Golgi bodies. It is associated with various diseases: type 2 diabetes, colorectal cancer;
gene. After gaining some weight this factor's presence has
induced him to follow a diabetes
prevention program style regime.
- Glaucoma is damage to the optic nerve from high pressure within the eye.
- Hemochromatosis is caused by the build up of excess iron within the body, extracted from the food we eat. It is often genetic in origin. There are multiple genes that can cause iron overload: HFE, HJV, HAMP, BCS1L. When untreated the iron can poison the liver leading to cirrhosis. Iron chelating drugs can provide treatment.
- AMD is age related macular degeneration which is the leading cause of vision loss and blindness among Americans over 65. It is associated with a damaging buildup of drusen pigments in the dry form and additionally, blood vessels in the wet form. It is associated with a variety of genetic mutations. Using HapMap data it was realized that two gene variations on separate chromosomes, both involved in inflammatory response carry high risk for this disease. These two genetic factors along with smoking and obesity infer 80 percent of the risk. Treatments can thus target the inflammatory response. Ranibizumab blocks the VEGF stimulated growth of blood vessels that occur in the wet form.
Massachusetts
Cambridge
Sound required for babies brain
development
In feb 2015 B&W
researchers demonstrated that severely
premature babies without the signals of a mothers' sounds and
heart beat had a significantly less developed auditory cortex.
They studied 40 babies born eight to 15 weeks prematurely.
These babies have to be confined to incubators. Using speakers
placed inside the incubators, half of the babies were exposed to the
sounds of their mothers' voices and heartbeats for three extra hours
every day. The other half received no additional exposure to
such sounds.
After 30 days, babies in the experimental group developed is a phase during the operation of a CAS agent. It allows for schematic strategies to be iteratively blended with environmental signals to solve the logistical issues of migrating newly built and transformed sub-agents. That is needed to achieve the adult configuration of the agent and optimize it for the proximate environment. Smiley includes examples of the developmental phase agents required in an emergent CAS. In situations where parents invest in the growth and memetic learning of their offspring the schematic grab bag can support optimizations to develop models, structures and actions to construct an adept adult. In humans, adolescence leverages neural plasticity, elder sibling advice and adult coaching to help prepare the deploying neuronal network and body to successfully compete.
significantly larger auditory cortex is part of the temporal lobe that processes auditory information. It is present in both brain hemispheres. Auditory sensations only reach consciousness once signalled by the auditory cortex. Final sound processing is performed by the parietal and frontal lobes in humans.
than the control group. Dr. Lahav said "This is part of the
biological recipe for how you cook a baby".
Fear
influences patient's decisions but affects patients
differently
Lisa Rosenbaum, a cardiologist is the diagnosis and treatment of: Congenital heart defects, CAD, Heart failure, Valvular heart disease; by cardiologists.
at Brigham
and Women's Hospital, in an opinion responding to the NYT
report on doubts about surgery for DCIS explained:
- One patient faced with feedback of more 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).
cells found
after lumpectomy for DCIS is ductal carcinoma in situ where abnormal cells have been found piled up confined to the lining of the milk ducts of the breast. They are detectable in a mammogram and can look like cancer cells to a pathologist. The cells could be spread along the whole of the milk duct suggesting a need for mastectomy rather than lumpectomy analogous to cervical cancer treatments after a Pap test. It is now known that the DCIS may disappear over time, or stop growing and remain stable. Most women diagnosed with early stage DCIS have surgical or chemotherapy treatment, which does not alter their life expectancy (Aug 2015). No data is available detailing a correlation with breast cancer. But it is now understood that metastatic cancers are different from localized cancers.
opted for full mastectomy to "get this all out". This fear is an emotion which prepares the body for time sensitive action: Blood is sent to the muscles from the gut and skin, Adrenalin is released stimulating: Fuel to be released from the liver, Blood is encouraged to clot, and Face is wide-eyed and fearful. The short-term high priority goal, experienced as a sense of urgency, is to flee, fight or deflect the danger. There are both 'innate' - really high priority learning - which are mediated by the central amygdala and learned fears which are mediated by the BLA which learns to fear a stimulus and then signals the central amygdala. Tara Brach notes we experience fear as a painfully constricted throat, chest and belly, and racing heart. The mind can build stories of the future which include fearful situations making us anxious about current ideas and actions that we associate with the potential future scenario. And it can associate traumatic events from early childhood with our being at fault. Consequent assumptions of our being unworthy can result in shame and fear of losing friendships. The mechanism for human fear was significantly evolved to protect us in the African savanna. This does not align perfectly with our needs in current environments: U.S. Grant was unusually un-afraid of the noise or risk of guns and trusted his horses' judgment, which mostly benefited his agency as a modern soldier. can't be ignored
in deciding on treatment strategies Rosenbaum stressed.
But in part it is based on our overestimating the risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. of disease
recurrence and metastatic spread and then feeling the
fear. The decision process is not logical. Assessing
over-diagnosis and 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.
are more abstract.
- A second patient in the same situation decided to live with
the risk.
- Each is certain they made the right choice.
- The treating physicians do not have a diagnostic that can tell
a patient that their DCIS will not progress.
- The study detailed in the NYT
article:
- Did not establish that it is safe to not get
treatment. There are some randomized control trials
underway that may clarify this in the future.
- Did not compare treatment to no treatment. Everyone was
treated.
- Indicated that mastectomy and lumpectomy resulted in the
same mortality rates. That could mean mastectomy is not
useful except the study did not check if there were additional
symptoms associated with the mastectomies.
Rosenbaum concluded "The medical community has a role not only in
alleviating unwarranted fears, but also in identifying rational
ones. Both are essential to making good decisions in the face
of uncertain trade-offs.
Behavioral hazard
NYT Aug 11 2013 Sendhil
Mullainathan's economic view on 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.
and copayments is a fixed payment for a covered service after any deductible has been met. It is a key strategy of the ACA to make subscribers aware of the costs of treatment and to put pressure on high cost health services. As such suppliers and providers are keen to undermine the copayment: value based health insurance, Paying the copayment (Oct 2015), Place on the USPSTF list of preventative services (Sep 2016); :
Brigham
& Women's Hospital and Harvard Medical
School's Niteesh Choudry studied 6000 patients who had
suffered a heart
attack is an AMI. It can induce cardiac arrest. Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI. Risk factors include: taking NSAID pain killers (May 2017). There is uncertainty about why AMI occur. Alternative hypotheses include: - Plaques started to gather in the coronary arteries and grew until no blood flow was possible. If this is true it makes sense to preventatively treat the buildup with angioplasty.
- Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot. If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors.
and were to be prescribed drugs known to reduce the
chance of another -- statins, beta-blockers,
angiotensin-converting-enzyme inhibitors or angiotensin-receptor
blockers.
Half had their copays for these drugs waived; the other half paid
the usual fee. As expected, more people in the zero copay
group took the drugs, and their health improved. Those in the
zero copay group were 31% less likely to have a 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). , 11% less likely
to have another major "vascular episode" and 16% less likely to have
a myocardial infarction or unstable angina.
None of the benefits came at a cost. The insurers did not
spend more in total. By some measures they spent
less.
The New
England Healthcare Institute estimates that $290 billion could
be saved each year if patients did not execute behavioral
hazard.
Since moral hazard involves responding to a generalized problem by rewarding those who caused the problem. - In health care it includes the over use of subsidized treatments and medicines.
- For the US economy it includes using tax revenue to underwrite the losses induced by the reckless behavior of financiers and the politicians and regulators who enabled them.
is reduced by constraining copayments Choudry argues a targeted
approach should be taken to reducing behavioral hazard. Take
drugs that are shown to be of very high benefit to some people, and
make those drugs free for them.
Additionally:
Michigan
Ann Arbor
UMHS
depression management project
Dr. Michael Klinkman of University
of Michigan Health System is the principal investigator on a depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult; management is transitioning to mean an aggregate of utilization management, case management, disease management, and independent review for populations. But it sometimes refers to geriatric care management which is the process of planning and coordinating long term care of the elderly. Such care managers have typically been trained in nursing, social work, and gerontology. They integrate health care and psychological care with other services such as housing, home care, nutrition, socialization, financial and legal planning.
project. It is based on the Wagner
Chronic Care Model is Ed. Wagner's framework for producing healthy communities. It has six major components: - The community - Resources and polities.
- The health system - organization and payment model.
- Self-management support - education, tools, motivational techniques, patient empowerment;
- Delivery system design
- Decision support - allowing evidence based guidelines to support care.
- Clinical information systems - EHR, decision support, reminders
. It is performed on a set of partner
primary care 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. practice
patients such as Allegiance
Health, Medical Practice Management Depression
Management Program patients.
Participants complete an initial screening along with one-, three-,
and six-month follow-up sessions, while maintaining normal care with
the primary care provider 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. .
A health coach, a licensed medical social worker, contacts
participants by telephone to complete follow-up, monitor core
clinical outcomes and provide one-on-one support. The coach
feeds all results back to the primary care physician.
Between office visits, patients participate in regular follow-up
calls with a coach, who monitors how well the patient is responding
to treatment and provides feedback to the patient's primary care
doctor. The coach answers the patient's questions and provides
support, education and self-management skills in areas such as diet,
exercise and sleep.
UMHS hopes to demonstrate the program can be successful outside of
the educational community. Patients are being surveyed
throughout the program, but UHMS has not begun to assess the
results.
UMHS DMP Personalized Care, Ready Access
Patient/coach interaction happens via email, patient portal provides web and or application based access to a patient's EHR based health care information and services. Specific portal services are mandated by meaningful use. They include at a minimum lab test results, problem list, medication list, and medication allergy list.
or phone. With depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult;,
this is an advantage. The stigma of having to deal with
behavioral health goes away. The coach makes contact at the
time and date that works best for the patient.
During a regular office visit, a clinician may not have enough time
to uncover the underlying reasons for non-adherence is focused on improving how effectively patients take their medicines. In the US in 2017 the problem is huge and costly (Apr 2017). Chronic diseases such as Malaria illustrate the complexity of the task. A coherent medical network with shared access to EHR should help. So do blister packs with the days of the week marked. M-health glow caps with a wireless transmitter that lights up if medication has not been taken as expected. An improved prescription label is less open to confusion. Codes on drugs can be scanned by smartphones to initiate download of an informational video. Smart pillboxes control when pills are dispensed. Measuring the contents of a medication bottle can alert for intervention if too much or too little is in the bottle. Drug manufacturers see ways to get closer to the patient: Sanofi Toujeo deployment; Pharmacies are implementing VDS to support medication adherence: Connected Care;
to a plan of care outline the patient's current and long-term needs and goals for care, identifies coordination needs, and addresses potential gaps. This is consistant with the biopsychosocial model. It also clarifies how the patient will reach the goals and who is responsible for implementing each part of the plan. HL7's FHIR has defined a CarePlan resource. .
Most patients with chronic
conditions tend to have underlying behavioral issues that
affect the condition itself, or erect barriers to following the
clinician's instructions. The coach can leverage time and the
skill set to discover the barriers. Patients often tell
physicians what they want to hear, but they are more likely to
confide in a social worker. Identifying and addressing the
barriers are simple but essential steps.
Minnesota
Rochester
Michael D. Jensen director of obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). treatment
research comments on obesity treatment. "It just takes most
people so long to make permanent changes in eating or activity
habits. There's always this search for the quick fix, and
usually you can find somebody who's willing to sell it to
you."
Dr. Jenson studied the effectiveness of weight-loss programs and
found that short-term treatments did not sustain weight-loss.
You must persist in a six month to year program for the results to
be sustained.
Dr. Jenson worries about the conflict of interest in diet-clinics that
sell medications for profit.
Mayo clinic profits from selling prescription weight-loss drugs like
phentermine as well as diet products.
Mississippi
Poorly paid people are dropping health insurance cover
Abby Goodnough reports people with low incomes and lots of
repayments abandon their 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.
subsidized health insurance contracts. House payments, car
payments and child care seem higher priority.
The ACA needs more people to sign up this year than last. That
means successfully targeting the 10.5 million Americans' that are
still uninsured. And keeping those already signed up this
year. While 11.7 million people enrolled before March 2015,
15% of them dropped out. There is no scientific study
explaining why theses dropouts occurred.
Goodnough suggests insurance may be unaffordable for poor people in
states without 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 such as Mississippi. Mississippi had the highest
rate of dropouts.
And Goodnough notes there is a lot of confusion caused by difficult
wording of e-mails and health exchange websites.
Mississippi health insurance commissioner suggested some of the
attrition may be due to disenchantment with the low cost Magnolia Health
policies. He is trying to ensure that Magnolia respond
to calls for help and that their provider networks are
sufficient.
New Jersey
Camden
Camden has 42 percent of its population living in poverty.
They are mostly Hispanic or African-American. Heart attack is an AMI. It can induce cardiac arrest. Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI. Risk factors include: taking NSAID pain killers (May 2017). There is uncertainty about why AMI occur. Alternative hypotheses include: - Plaques started to gather in the coronary arteries and grew until no blood flow was possible. If this is true it makes sense to preventatively treat the buildup with angioplasty.
- Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot. If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors.
risk
is high. Type
2 diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
affects a high proportion of the population.
A patient having a heart attack had initially self-medicated and
then had gone to an urgent care
clinic 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. . A practitioner at the urgent care clinic did an
electrocardiogram and called an ambulance. But the clinic did
not alert the hospital that it had a heart attack patient or
transmit his electrocardiogram to Lourdes.
So the emergency department 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).
was not prepared for the patient on arrival.
Jeffrey Brenner mapped the ways patients flowed in an out of
Camden's hospitals. He made block-by-block maps of the city,
color-coded by the hospital costs of its residents, and looked for
the hot spots 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. .
The two most expensive city blocks were in North Camden, one that
had a large nursing home called Abigail House and one that had a
low-income housing tower called Northgate II. He found that
between January of 2002 and June of 2008 some nine hundred people in
the two buildings accounted for more than four thousand hospital
visits and about $200M in health care costs. The most
expensive patient cost insurers $3.5M.
He found that 1000 people accounted for 30% of the city's health
care costs. He offered doctors to take over these
'worst-of-the-worst' patients. They knew who the expensive
patients were and passed them along. An example problem
patient was suffering from severe congestive heart failure is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands. There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). Treatments include: digoxin; ,
chronic 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; ,
uncontrolled type
2 diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
, hypothyroidism is under production of thyroxine by the thyroid. ,
gout and a history of smoking and alcohol abuse. He weighed
560 pounds. He had spent half the previous 3 years in
hospital.
Brenner's treatment strategy was to visit the patient daily for an
hour trying to understand what made the patient 'tick'. He
showed the patient he was here for them and not just part of the
medical infrastructure. A toxic combination of poor health,
whiskey, cocaine left the hot spot patient with no consistent set of
doctors, job or housing. Brenner helped the patient: he stayed
close enough to recognize when serious problems were emerging.
He double-checked that the plans and prescriptions, the specialists
had made for the many problems actually worked together. When
they didn't Brenner called and got the conflicts resolved. He
teamed up with a nurse-practitioner who could make home visits to
check blood sugar levels and blood pressure, teach the patient about
what he could do to stay healthy, and make sure he was getting his
medications.
Brenner had to go beyond traditional primary care consists of providing accessible, comprehensive, longitudinal, and coordinated care in the context of families and community. Interpreting the meaning of many streams of information and working together with the patient to make decisions based on the fullest understanding of this information relative to the patient's values and preferences is key to PCP providing value. .
He got a social worker to help the patient apply for disability
insurance, so that he could leave the chaos of welfare motels, and
have access to a consistent set of physicians. The team pushed
the patient to find sources of stability and value: AA and the
Church for example. With a better regimen it is possible to
get the diabetes and congestive heart failure is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands. There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). Treatments include: digoxin; under
control. By losing 200 pounds in weight he can get up if he
falls rather than having to call an ambulance. Of course this
all takes time.
The clinic
is poorly funded and does not have space where they can see
patients. Instead the nurse practitioners and medical
assistants telephone or home visit. Over the phone they
inquire about emerging health issues, insurance or housing problems,
ask about unfilled prescriptions. All the patients get the
team's urgent-call number, which is covered by someone who can help
them through a crisis. If necessary they will make an
unplanned home visit. The patients would not call at all
except they know someone they know will answer (Brenner or Jackson
etc. ) "High utilizer work is about building relationships
with people who are in crisis." Brenner explains. "The ones
you build a relationship with, you can change behavior. Half
we can build a relationship with. Half we can't."
Typically it takes getting to know the patient in their home
environment to get an idea of what their core problems are - which
may be based on a chaotic environment. It allows the medical
staff to check the pill containers and food situation etc.
Atlantic city
Most patients required no more
than a ten-second mention. Mr. Green didn't turn up for his
cardiac testing or return calls about it. "I know where his
wife works. I'll track her down," the receptionist
said. Ms. Blue is pregnant and on a high-blood-pressure
medication that is unsafe in pregnancy. "I'll change her
prescription right now her doctor said, and keyed it in. A
handful of patients required longer discussion. One
forty-five-year-old heart disease is cardiovascular disease which refers to:
- Conditions where narrowed and blocked blood vessels
result in angina, hypertension,
CHD and heart
attacks and hemorrhagic/ischemic strokes.
Mutations of the gene PCSK9 have
been implicated in cardiovascular disease. Rare
families with dominant inheritence of the mutations have
an overactive protein, very high levels of blood
cholesterol and cardiac disease. Other rare PCSK9
mutations result in an 88% reduced risk from heart disease.
Inflammation is associated with cardiovascular disease (Aug
2017).
patient had just had blood tests that morning that showed
worsening kidney provides multiple vital functions. It: Produces renin which supports negative feedback, Removes excess organic molecules from the blood, Regulates electrolytes in the blood, Maintains pH homeostasis, Regulates fluid balance, Regulates blood pressure, monitors blood oxygen concentration and signals erythropoiesis with EPO, Reabsorbs water, glucose (SGLT2) and amino acids. Kidney function is monitored with the GFR. Kidneys can fail acutely or chronically. Kidneys are affected by a variety of cancers including: advanced kidney cancer, von Hippel Landau; some of which are induced by PFAS. Multiple myeloma, type 2 diabetes, TB and drug treatments for MDR TB place a strain on the kidneys and can induce failure.
failure. The team decided to repeat the blood tests that
morning, organize a kidney ultrasound in the afternoon if the
tests confirmed the finding, and have him seen in the office at
the end of the day.
A staff member read out the
hospital census. Of the clinic's
twelve hundred chronically ill patients, just one was in the
hospital, and she was being discharged. The clinic's
patients had gone four days without a single E.R. 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). visit. On
hearing this news, staffers cheered and broke into applause.
Afterward, I met a patient, Vibha
Gandhi. She was fifty-seven years old and had joined the
clinic after suffering a third heart attack is an AMI. It can induce cardiac arrest. Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI. Risk factors include: taking NSAID pain killers (May 2017). There is uncertainty about why AMI occur. Alternative hypotheses include: - Plaques started to gather in the coronary arteries and grew until no blood flow was possible. If this is true it makes sense to preventatively treat the buildup with angioplasty.
- Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot. If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors.
.
She and her husband, Bharat, are Indian immigrants. He
cleans casino bathrooms for thirteen dollars an hour on the night
shift. Vibba has long had poor health, with type 2 diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
,
obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). , and congestive heart failure is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands. There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). Treatments include: digoxin; ,
but things got much worse in the summer of 2009. A heart
attack landed her in intensive
care 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. , and her CAD is coronary artery disease, also called heart disease or CHD. It reflects atherosclerosis of the coronary arteries.
proved so advanced as to be inoperable. She arrived in a
wheelchair for her first clinic visit. She could not walk
more than a few steps without losing her breath and getting a
viselike chest pain emerged as a mental experience, Damasio asserts, constructed by the mind using mapping structures and events provided by nervous systems. But feeling pain is supported by older biological functions that support homeostasis. These capabilities reflect the organism's underlying emotive processes that respond to wounds: antibacterial and analgesic chemical deployment, flinching and evading actions; that occur in organisms without nervous systems. Later in evolution, after organisms with nervous systems were able to map non-neural events, the components of this complex response were 'imageable'. Today, a wound induced by an internal disease is reported by old, unmyelinated C nerve fibers. A wound created by an external cut is signalled by evolutionarily recent myelinated fibers that result in a sharp well-localized report, that initially flows to the dorsal root ganglia, then to the spinal cord, where the signals are mixed within the dorsal and ventral horns, and then are transmitted to the brain stem nuclei, thalamus and cerebral cortex. The pain of a cut is located, but it is also felt through an emotive response that stops us in our tracks. Pain amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so. Fear of pain is a significant contributor to female anxiety. Pain is the main reason people visit the ED in the US. Pain is mediated by the thalamus and nucleus accumbens, unless undermined by sleep deprivation. .
The next step for such patients is often a heart transplant.
A year and a half later, she is
out of her wheelchair. She attends the clinic's Tuesday yoga
classes. With the help of a walker, she can go a quarter of
a mile without stopping. Although her condition is still
fragile--she takes a purse full of medications, and a bout of the
flu is a virus, normally hosted in birds, which jumps to humans causing pandemics of flu infection and deaths. There are various types including: H1N1, H3N2 which mutates more causing vaccination strategies to have problems, B/Victoria, B/Yamagata; strains. The "Spanish flu" epidemic of 1918-1919 killed between 50 and 100 million people. The 2017 winter flu killed 80,000 people in the US. 95% of US winter flu occurs in mid-December. The US has vaccines that target three and four types of flu at once. It also adds the adjuvant MF59 and increases the dose for people over 65. Vaccine effectiveness drops from 60% by 20% a month so November is the most effective month. Infection in people appears to depend on host genetics but no mechanism has been identified. Flu is spread by droplets in the air. Being within 3 to 6 feet of someone who is affected means likely breathing in their exhaled virus. In the initial one to four day phase of infection the virus latches onto the mucous membranes that line the back of the nose, throat, and bronchial tubes. The viruses then leverage the metabolic and replication systems of the epithelial cells that make up the mucous membranes. People typically don't know they are infected in this first phase. In the next phase the immune system mounts an attack on the virus which is concentrated in the respiratory tract: releasing interferon and cytokines generating the classic symptoms: aches, fever, dehydration; of flu. Drinking lots of fluids compensates for the dehydration and helps the immune system agents to circulate. The respiratory tract epithelial cells are typically inflamed and damaged and release their contents which are experienced as a runny nose and cough. Stay upright and get fresh air to support the coughing. Medications that suppress this are not helping with recovery. If enough cells in the bronchial tubes are destroyed to create holes then secondary bacterial infections can occur including pneumonia. would send her
back to intensive-care unit-- her daily life is far better than
she once imagined.
"I didn't think I would live this
long," Vibha said through Barat, who translated her Gujarati for
me. "I didn't want to live."
I asked her what had made her
better. The couple credited exercise, dietary changes,
medication adjustments, and strict monitoring of her type 2
diabetes.
But surely she had been encouraged
to do these things after her first two heart attacks. What
made the difference this time?
"Jayshree pushes her, and she
listens to her only and not to me," Bharat said.
"Why do you listen to Jayshree?" I
asked Vibha.
"Because she talks like my
mother," she said.
Fernandopulle carefully tracks the
statistics of those twelve hundred patients. After twelve
months in the program, he found, their emergency-room 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). [ED] visits
and hospital admissions were reduced by more than forty per
cent. Surgical procedures were down by a quarter. The
patients were also markedly healthier. Among five hundred
and three patients with high 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. ,
only two were in poor control. Patients with high
cholesterol had, on average, a fifty point drop in their
levels. A stunning sixty-three per cent of smokers with
heart and lung disease quit smoking. In surveys, service and
quality ratings were high.
But was the program saving
money? The team, after all, was more expensive than typical
primary care consists of providing accessible, comprehensive, longitudinal, and coordinated care in the context of families and community. Interpreting the meaning of many streams of information and working together with the patient to make decisions based on the fullest understanding of this information relative to the patient's values and preferences is key to PCP providing value. .
And certain costs shot up. Because patients took their
medications more consistently, drug costs were higher. The
doctors ordered more mammograms is an X-ray record of the breast used for screening and diagnosis of breast cancer. Mammograms have become progressively more sensitive allowing detection of smaller tumors. This has allowed aggressive treatment practices which may be counterproductive (Aug 2015). Mammography policies are defined by: ACOG, ACS, NCCN, USPSTF;
and diagnostic tests, and caught and treated more 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). and other
conditions. There's also the statistical phenomenon known as
"regression
to the mean is an artifact of limited sampling in a statistical study. In a short time period exceptional scores are possible. But as more samples are taken the results will shift back to the mean. Two illustrative examples are Kahneman's explanation of Israeli fighter pilot trail scores and Deming's paddle wheel. ": the super-high-cost patients may have been on
their way to getting better (and less costly) on their own.
So the union's health fund
enlisted an independent 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. to
evaluate the clinic's one-year results. According to the
data, these workers made up a third of the local union's costliest
ten per cent of members. To determine if the clinic was
really making a difference, the economist compared their costs
over twelve months with those of a similar group of Las Vegas
casino workers. The results, he cautioned, are still
preliminary. The sample was small. One patient
requiring heart transplant could wipe away and savings
overnight. Nonetheless, compared with the Las Vegas workers,
the Atlantic City workers in Fernandopulle's program experienced a
twenty-five-per-cent drop in costs.
And this was just the start.
The program, Fernandopulle told me, is still discovering new
tricks. His team just recently figured out, for instance,
that one reason some patients call 911 for problems the clinic
would handle better is that they don't have the clinic's
twenty-four-hour call number at hand with they need it. The
health coaches told the patients to program it into their
cell-phone speed dials, but many didn't know how to do that.
So the health coaches began doing it for them, and the number of
911 calls fell. High-cost habits are sticky; staff members
are still learning the subtleties of unsticking them.
New York
New York
Frail patients
Advocates for the frail elderly say a rush to cut costs has already
hurt some patients. The New York Legal Assistance Group sued
five agencies in 2011 including Excellent, but not Extended --
saying they had illegally tried to dump disabled patients who
suddenly became unprofitable when the FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment. system was
replaced. The agencies paid $50,000 each in a settlement and
promised to do better, without admitting wrong doing. Mr Levy,
Excellent's lawyer, said the shedding of high-needs clients was an
industry wide issue in 2011, caused by the cutbacks in state
payments, which also led to problems paying the subcontractors who
sent the aides into homes.
Brooklyn
Brooklyn's 3 public and 12 nonprofit is a tax strategy selected by many hospitals in the US. These hospitals, which include: Cleveland Clinic, Johns Hopkins, Massachusetts General, Mayo Clinic; are exempt from federal and local taxes because they provide a level of community benefit. They are considered charitable institutions and benefit from tax-free contributions from donors and tax-free bonds for capital projects, explains Bellevue Hospital's Dr. Danielle Ofri. Prior to 1969, community benefit had to include charity medical care, but then the tax code was altered to allow many expenses to qualify as community benefits including: Accepting Medicaid insurance at a hospital estimated loss; and charitable care became optional. The ACA encouraged hospital networks to consolidate and with this additional pricing power, revenue at the top seven nonprofits has increased 15%, while charitable care decreased 35%. hospitals
suffer from mismanagement, under allocation of federal funds and 2%
cuts in 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.
funding for an area that predominantly serves the poor. Rich
patients with insurance have been using hospitals outside of the
borough. 40% of Brooklyn's 2.5 million population is on
Medicaid. One quarter of the population live in poverty, and
15% are uninsured. The community hospitals have to compete
with large externally based hospital networks, including Mt. Sinai
which has merged with Continuum (Beth Israel), which
have just entered the richer Brooklyn heights and Kings Highway
areas where they can cherry pick patients further undermining the
community hospitals revenue base.
NYT Aug 2013
St. Lukes ED and price gouging for saline
St.
Lukes Cornwall participated in treatment of a day trippers
that got food poisoning.
A Chinese-American toddler from Brooklyn and her 56 year old
grandmother were treated and released within hours from the
emergency room [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). ].
They ran up charges of more than $4000 dollars and were billed
$1,400 -- the hospitals rate for the uninsured, -- even though the
family is covered by an HMO is a health maintenance organization. Originally HMOs were fashioned after Dr. Paul Ellwood's admiration for group practices such as: Kaiser Permanente, Mayo Clinic; which employed salaried physicians and charged fixed fees rather than FFS. Ellwood argued that this architecture helped keep subscribers healthy which he termed a health maintenance organization. President Nixon was convinced by Ellwood signing the HMO Act. But the legislated HMO did not have to conform to Ellwood's group practice architecture. Instead by 1997 for-profit commercial insurance companies operated two-thirds of the HMO business. The legislated HMO: - Provides or arranges managed care for:
- Health insurance
- Self-funded health care benefit plans
- Individuals
- Acts as a liaison with health care providers
- Covers care rendered by those doctors and others who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in return for access to patients. Treatment choices were often driven by insurance company rules. Financial incentives often based the contracted physician income on success in reducing expenses rather than health outcomes. There are a variety of contracts with physicians:
- Closed panel plan
- Open panel plan
- Network model plan
- Covers emergency care regardless of the providers contracted status.
HealthFirst, under 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. .
The charges included 'IV therapy' billed at $787 for the grandmother
and $393 for the child.
NYT Aug 2013 White Plains ED and price gouging for saline
White Plains
Hospital participated in treatment of a day trippers that got
food poisoning.
A day tripper with private insurance from Aetna was charged $91 for
one unit of Hospira
Saline that cost the hospital 86 cents. A hospital spokeswoman
defended the markup as 'consistent with industry standards.'
She said it reflected 'not only the cost of the solution but a
variety of related services and processes,' like procurement,
biomedical handling and storage. Presumably these were not
included in the charge of $127 for administering the saline and $893
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). services.
The patient ended up paying $100 for the visit.
Leukemia
patients and stool-banking
The study on proactive stool-banking by Dr. Eric Pamer, a physician
and scientist at Memorial
Sloan-Kettering, mainly included patients' with 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. . Before
stem cell transplants, patients receive antibiotics and chemotherapy is the treatment of cancers by highly cytotoxic chemicals: Paclitaxel, Platinum, 6-mercaptopurine; assuming that cancer cells are unusually active and will be differentially poisoned. It has been successful in offering treatments when no other course was available, but non-specificity means that healthy cells also get poisoned resulting in side effects which increase with age: Permanent nerve damage, heart failure (4-5%) and leukemia (0.5-1%). ,
often destroying their microbiota, the trillions of bacteria and viruses that live inside higher animals' guts, on their skin etc. These bacteria and viruses seem to play a role in: immune responses, digesting food, making nutrients, controlling mental health and maintaining a healthy weight. The signals from the gut microbiota are relayed by major nerve fibers: vagus; to the central nervous system. The symbiotic relationship must be actively managed. Human armpits include glands which provide food favoring certain symbionts who build a defensive shield above the skin. In the human gut: Barriers are setup: Mucus secretions form a physical constraint and provide sites for bacteriophages to anchor and attack pathogenic bacteria; Symbiont tailored nourishment: Plant-heavy food creates opportunities for fibre specialists like Bacteroides thetaiotaomicron; is provided, Selective binding sites are provided, Poisons are deployed against the unwelcome, and Temperature, acidity and oxygenation are managed. High throughput sequencing allows the characterization of bacterial populations inside guts. Beginning at birth, as they pass down the birth canal infants are supplied with a microbiome from their mothers. If they are borne via cesarean they never receive some of the key bacteria: Bifidobaterium infantis which is also dependent on oligosaccharides in breast milk; from their mothers. A variety of diseases may be caused by changes in the microbiome: - Eczema can be related to changes in the skin microbiome.
- Obesity can be induced by changes to the gut microbiome.
- Chronic inflammation
- Allergies
- Type 1 diabetes
.
Dr. Pamer found that the diversity of the microbiota just after the
stem cell transplant predicts well-being and survival. After
excluding death from leukemia recurrence, those with the least
diverse microbiomes after surgery were 5 times less likely to remain
alive, three years later, compared with those with the most
diverse. Dr. Pamer said "We often wipe out the flora. It
should become a routine part of practice to restore the
flora." He argued it is very reasonable to apply this
routinely when using broad-spectrum antibiotics.
Out-of-network
participants generate high charges
Out-of-network assisting specialists generate high priced surgery
bills. Peter Drier's three hour surgery for herniated disks at
Lenox Hill
Hospital generated many bills:
- Lenox Hill Hospital bill $56,000
- Anesthetist is used to describe anesthesia providers without the qualification of physician. Often these are CRNAs.
$4,300
- Orthopedist is the treatment of the musculoskeletal system which supports multi-cell higher animals and allows them to move about: including correcting deformities, breaks, tears, compression, tendonitis, disc failures, misalignment, fusion to treat damaged discs.
$133,000 (Spine
work makes them one of the best paid type of Doctor.)
- Assistant surgeon $117,000 from a Queen's based neurosurgeon
from Jamaica
Hospital Medical Center Queens but with a private practice
NeuroAxis Neurosurgical Associates of Kew Gardens Queens who was
out-of-network and he had not met.
It is becoming more common for surgeries to include participants
that are not justified but drive up the fees charged. Patients
often don't realize they participated until the bills arrive.
The practice increases revenue at a time when insurers are cutting
down reimbursements is the payment process for much of US health care. Reimbursement is the centralizing mechanism in the US Health care network. It associates reward flows with central planning requirements such as HITECH. Different payment methods apportion risk differently between the payer and the provider. The payment methods include: - Fee-for-service,
- Per Diem,
- Episode of Care Payment,
- Multi-provider bundled EPC,
- Condition-specific capitation,
- Full capitation.
for many services. The surprise charges are significant
because when out-of-network they bill at 20 - 40* the usual local
rates and often collect close to the full amount.
Insurers say surprise charges have proliferated and they have filed
lawsuits challenging them. In New York State unexpected
out-of-network charges have become the top complaint to the New York
State agency that regulates insurance companies. Health care
provider backed lobbyists are pushing hard to retain the
practice. Insurers are not in ER 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). when the decision is made
so they find it hard to win the court cases. Aetna has litigated
on egregious cases.
On occasion the surgeon and assistant surgeon share
remuneration.
Doctor's offices often pursue patients for the payments if insurers
refuse to pay.
Charges are added for additional activities by experts after surgery
as well.
House
calls can provide high quality patient information but
re-hospitalization is still a more profitable strategy
Sandeep Jauhar notes that house calls provide invaluable data:
Doctors and hospitals:
Re-hospitalization 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.
is costly for the US medical network. It has increased 50%
over the last thirty years. One in five 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.
patients
discharged from hospital is re-hospitalized within a month.
And Sandeep notes it is traumatizing for the patient.
Unplanned readmissions cost $17 billion for Medicare. CMS is the centers for Medicare and Medicaid services. is punishing hospitals
with high readmission rates. In 2014 2,600 hospitals were
fined up to 3% of their total Medicare revenue ($420 million).
Sandeep writes the fines have surprisingly not changed hospital discharge - have costly handoff problems reviewed by project BOOST. When discharge takes too long it ties up acute bed space which can result in adding up to 30% more (unnecessary) capacity when improved discharge would translate into additional revenue. Various interventions aim to improve the execution of the process including: CTI, TCN and RED for discharge to outpatient; InterAct for discharge to SNFs and BPIP to HHAs. Discharge information can include: - Patient info
- Behavioral summary
- Treatment history
- Medical history
- Treatment objectives
- Insurance policy
- Discharge plans
behavior. Hospitals have found it more profitable to keep the
beds full with readmitted patients. The payment system is
still rewarding readmissions.
Ohio
Cincinnati
In Cincinnati, G.E.
took both a cheerleading and coordinating role. In early 2010,
Jeffrey R. Immelt addressed local business leaders now aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group. Pinker notes the evolved pressure of social rivalry associating power with leadership. Different evolved personality types reinforced during development provided hunter-gatherer bands with alternate adult capabilities for coping with the various challenges of the African savanna. As the situation changed different personalities would prove most helpful in leading the band. Big men, chiefs and leaders of early states leveraged their power over the flow of resources to capture and redistribute wealth to their supporters. As the environmental state changed and began threatening the polity's fitness, one leader would be abandoned, replaced by another who the group hoped might improve the situation for all. Sapolsky observes the disconnect that occurs between power hierarchies and wisdom in apes. In modern Anglo-American style corporations, which typically follow Malthus, and are disconnected from the superOrganism nest site, the goal of leadership has become detached from the needs of this broader polity, instead: seeking market and revenue growth, hiring and firing workers, and leveraging power to reduce these commitments further. Dorner notes that corporate executives show an appreciation of how to control a CAS. Robert Iger with personality types: Reformer, Achiever, Investigator; describes his time as Disney CEO, where he experienced a highly aligned environment, working to nurture the good and manage the bad. He notes something is always coming up. Leadership requires the ability to adapt to challenges while compartmentalizing. John Boyd: Achiever, Investigator, Challenger; could not align with the military hierarchy but developed an innovative systematic perspective which his supporters championed and politicians leveraged. John Adair developed a modern leadership methodology based on the three-circles model. and urged
them to think strategically and align their efforts to make more of
a difference. There were already significant efforts under way
to foster medical
homes (PCMH) The Patient-centered medical home - Describes a reorganization of the health care delivery system to focus on the patient and care giver supported by EHR infrastructure and some form of process management which will be necessary to coordinate interventions by each of the functional entities resources to treat the patients specific problems. The disadvantage of a PCMH is the administrative and technology cost needed to support its complex processes. The PCMH
- Was promoted as a way to incent more PCP which had been seen as a low reward role by medical students. HCI3 argues this use of PCMH is flawed. PCMH is driven by the medical home models of the ACA. In this model the PCMH is accountable for meeting the vast majority of each patients physical and mental health care needs including prevention and wellness, acute care, and chronic care. It is focused on treating the whole person. It is tasked with coordinating the care across all elements of the health care system, including transitions and building clear and open communications. It must ensure extended access and availability of its services and patients preferences about access. It must continuously improve quality by monitoring evidence-based medicine and clinical decision support tools (NCQA). Many argue that to be effective it must be connected to a 'medical neighborhood'. The PCMH brings together the specialized resources and infrastructure required to develop and iteratively maintain the care plans and population oriented system descriptions that are central to ACA care coordination.
, for example, and G.E. pushed to find more financing to
expand the concept to more medical practices and keep the focus on
that initiative.
"The ever-present vigilance of the employers help nudge things
along," said Craig Brammer, chief executive of three area health
care coalitions, including the Greater Cincinnati Health Council,
which is made up of the area's hospitals, health plans and
employers.
The city's health systems say they recognize that insurers and
employers are increasingly going to reward them for better tracking
their patients in and out of the hospital. "We are clearly
gearing up to change directions from FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment. to what I'll call
payment for value," said Will Groneman, an executive vice president
for TriHealth, one of the systems.
The medical
home (PCMH) The Patient-centered medical home - Describes a reorganization of the health care delivery system to focus on the patient and care giver supported by EHR infrastructure and some form of process management which will be necessary to coordinate interventions by each of the functional entities resources to treat the patients specific problems. The disadvantage of a PCMH is the administrative and technology cost needed to support its complex processes. The PCMH
- Was promoted as a way to incent more PCP which had been seen as a low reward role by medical students. HCI3 argues this use of PCMH is flawed. PCMH is driven by the medical home models of the ACA. In this model the PCMH is accountable for meeting the vast majority of each patients physical and mental health care needs including prevention and wellness, acute care, and chronic care. It is focused on treating the whole person. It is tasked with coordinating the care across all elements of the health care system, including transitions and building clear and open communications. It must ensure extended access and availability of its services and patients preferences about access. It must continuously improve quality by monitoring evidence-based medicine and clinical decision support tools (NCQA). Many argue that to be effective it must be connected to a 'medical neighborhood'. The PCMH brings together the specialized resources and infrastructure required to develop and iteratively maintain the care plans and population oriented system descriptions that are central to ACA care coordination.
also appears to resonate with employees. When Mary
Farris, a 44-year-old marketing executive for G.E, found herself
going to a local urgent care
center 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. because she could never get an appointment with her
physician, she switched to a practice that had become a medical
home.
What strikes Ms. Farris was how much time the doctor and medical
assistant spent gathering her medical history and making sure there
weren't additional medical issues. While she came in for a
spider bite, the focus was her well-being as a working mother whose
father was seriously ill at the time. "The picture was more on
all of me as opposed to one isolated incident," she said.
"Somebody was trying to connect the dots."
In Cincinnati, there are beginning to be grudging signs of
success. Early results are promissing: patients enrolled in
medical homes had 3.5 percent fewer visits to the emergency room (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). ) and 14 percent fewer
hospital admissions over the four years from 2008 through
2012. G.E. plans to ask an outside firm to do a more detailed
analysis.
Oregon
Portland
Jan 3 2014
NYT Emergency visits seen increasing with health law
Oregon 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. Test
at Hospitals found rise of 40 percent in use of 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). .
The study compared thousands of low-income people in the Portland
area who were randomly selected in a 2008 lottery to get Medicaid
coverage with those who participated in the lottery but remained
uninsured.
Those who obtained Medicaid coverage made 40 percent more visits to
the ED than the uninsured. 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. visits also
increased. Medicaid protected them from high out-of-pocket
costs. It reduced stress is a multi-faceted condition reflecting high cortisol levels. Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight. As these actions occur the levels of cortisol return to the baseline rate. A stressor is anything that disrupts the regular homeostatic balance. The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis. - The short term response to the stressor
- activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response. The brain's acuity and cognition are stimulated. The immune system is stimulated with beta-endorphin and repair activities curtail. In order for the body to destroy bacteria in wounds, pro-inflammatory cytokines increase blood flow to the area. The induced inflammation signals the brain to activate the insula and through it the ACC. But when the stressor is
- long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues. Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in. Sustained stress provides an evolved amplifier of a position of dominance and status. It is a strategy in female aggression used to limit reproductive competition. Sustained stress:
- Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment!
- Activates the integration between the thalamus and amygdala.
- Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful.
- BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning.
- Makes it easier to learn a fear association and to consolidate it into long-term memory. Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala. And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces. Accuracy of assessing emotions from faces suffers. A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand. The activation of the amygdala seems to determine how the hippocampus responds.
- Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression.
- Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive. It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.
- Increases the risk of autoimmune disease (Jan 2017)
- During depression, stress inhibits dopamine signalling.
- Strategies for stress reduction include: Mindfulness.
.
The pattern was so strong that it held true across most demographic
groups, times of day and types of visit including those better
treated by a 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. .
Does prevention save money? There are various aspects:
- A randomized control trial of uninsured low-income people in
Oregon where they were placed in a lottery (Jan
2014) allowing some access to 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.
health
insurance recently reported its findings. Researchers
tracked both groups. Those given access to Medicaid spent
more on healthcare.
- Giving people insurance enables them to use preventative
care. It is often argued that this saves money in the long
run. Research disagrees! because:
- The number of people taking preventative care (number needed
to treat) vastly outnumbers the people that get ill with the
disease being prevented. If the cost of the prevention
is significant there is an overall deficit. That seems
to be true for screening for diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections.
and mammography is an X-ray record of the breast used for screening and diagnosis of breast cancer. Mammograms have become progressively more sensitive allowing detection of smaller tumors. This has allowed aggressive treatment practices which may be counterproductive (Aug 2015). Mammography policies are defined by: ACOG, ACS, NCCN, USPSTF; .
- People who are prevented from getting one disease usually
die from another costly one. Patients that leverage
cholesterol treatment may develop cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
, Alzheimer's is a dementia which correlates with deposition of amyloid plaques in the neurons. As of 2015 there are 5 million Alzheimer's patients in the USA. It was originally defined as starting in middle age which is rare, so it was a rare dementia. But in 1980s it was redefined as any dementia without another known cause. Early indications include mood and behavioral changes (MBI) and declarative memory and thinking problems (MCI). Specific cells within the hippocampal circuitry and its gateway, the entorhinal cortex, are damaged. The amygdala, cerebelum and other areas supporting implicit memory are not impacted during the early stages of the disease. Grid cell destruction results in a sense of being lost. The default mode network is disrupted. Variants include: late-onset sporadic; with risk factors - ApoE4 for late onset Alzheimer's, presenilin, androgen deprivation therapy (Dec 2015), type 2 diabetes. There are multiple theories of the mechanism of Alzheimer's during aging: Allen Roses argues that it is due to gene alleles that limit the capacity of mitochondria to support neuron operation, Neurons of sporadic Alzheimer's sufferers show greater APP gene diversity due to somatic recombination; It may be initiated by: stress induced HHV-6a, HHV7 herpes activation (Jun 2018) and or an increasingly leaky blood-brain barrier; and a subsequent innate immune response to the infections (May 2016). The Alzheimer's pathway follows: - Plaques form. These are seen in fMRIs 10 to 15 years prior to detecting memory and thinking changes. APP deployed in the cell membrane is cut into three parts. The external part becomes amyloid-beta peptide which aggregates into Amyloid plaques, external to the neurons, if too much is generated or it is not removed fast enough.
- Solanezumab aimed to inhibit plaque formation but clinical trials failed (Nov 2016).
- Encouraging the garbage collection of amyloid and tau with gamma rhythms stimulation retards Alzheimer's in mice studies (Mar 2019)
- BACE inhibitors block an enzyme needed to form amyloid.
- Mutation driven misfolded Tau proteins can form tangles within the cytoplasm of neurons. The Tau tangles kill nerve cells. LMTX is a drug treatment targeted at these tangles.
- The brain becomes inflamed resulting in the killing of many more nerve cells. The hippocampus disintegrates and the brain loses critical functions and memory loss becomes noticeable.
etc.
- People with health coverage should have less stress is a multi-faceted condition reflecting high cortisol levels. Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight. As these actions occur the levels of cortisol return to the baseline rate. A stressor is anything that disrupts the regular homeostatic balance. The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis.
- The short term response to the stressor
- activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response. The brain's acuity and cognition are stimulated. The immune system is stimulated with beta-endorphin and repair activities curtail. In order for the body to destroy bacteria in wounds, pro-inflammatory cytokines increase blood flow to the area. The induced inflammation signals the brain to activate the insula and through it the ACC. But when the stressor is
- long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues. Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in. Sustained stress provides an evolved amplifier of a position of dominance and status. It is a strategy in female aggression used to limit reproductive competition. Sustained stress:
- Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment!
- Activates the integration between the thalamus and amygdala.
- Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful.
- BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning.
- Makes it easier to learn a fear association and to consolidate it into long-term memory. Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala. And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces. Accuracy of assessing emotions from faces suffers. A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand. The activation of the amygdala seems to determine how the hippocampus responds.
- Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression.
- Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive. It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.
- Increases the risk of autoimmune disease (Jan 2017)
- During depression, stress inhibits dopamine signalling.
- Strategies for stress reduction include: Mindfulness.
induced by
health cost fears.
- Some preventions do save money: Contraception counseling;
- There are more people with access to health care with the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
expansion of
coverage.
Pennsylvania
Shoppers in Pennsylvania who put kale into their carts were more
likely to head next to the ice-cream or beer section. This is
the licensing
effect describes the brain's unconscious operation of a balance of virtuous and less honorable actions. The key insight first described by Uzma Khan and Ravi Dhar is that our choices are contingent. We use a self-concept to adjust as we judge our actions to be swinging away from our reference image of how: good/bad, healthy/unhealthy, selfish/altruistic; we are. where a more "virtuous" product encourages the shopper
to succumb to purchase of a vice.
Research indicates the effect is deeply wired into us. And
advertisers know it. Having a healthy option on a menu
increases the chances of ordering the least healthy choice.
It's those with the greatest self-control is an emotion, the ability to trade current for future use of resources. Hunter-gatherers are likely to benefit from immediate use of resources, since they have little opportunity to store them. Otherwise the resources, including men & women to reproduce with, may be lost, stolen or degrade. Since the intense drive for men to breed with any available woman can lead to costly disputes and lack of focus on strategic activities, self-control is promoted by parents and other powerful group leaders. But the frontal cortex can promote willpower to increase self-control. Genes also allocate more resources early in the life-cycle to avoid compounding failure to leverage resources to reproduce, with agent accidents and deaths. who
are most influenced.
A Taiwanese study gave two groups a placebo pill to take. But
the experimental group was told it was a vitamin. That group
consistently chose less healthy options:
- They selected the shorter route to walk.
- They picked the all-you-can-eat buffet rather than organic
option.
- They expressed desire for hedonic activities like casual sex,
sun bathing and excessive drinking.
- They smoked twice as many cigarettes.
To offset the licensing effect:
- Focus on the process of living healthfully rather than the
goal of being healthy.
- Narrow the focus of the decision so that the pros and cons are
judged in isolation. This stops the decision being part of
a broader assessment of the current offset from the base line
self-image.
- Tune out the advertising signals and ignore silver
bullets.
Pittsburgh
Big Data encompasses the IT systems and processes necessary to do population based data collection, management and analysis. The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass. Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms: Precision medicine, Protein folding modeling (Feb 2019) assumes coevolutionary methods can be applied to identify contact points in a protein's tertiary structure. Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure: - Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Complex data models must include clinical aspects of the patient specific data, including disease state population wide.
- A key aspect is providing clear signals about the nature of the data using data visualization.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
analysis of Pittsburgh Health
Plan
It has identified a few unexpected correlations:
Puerto Rico
Health care crisis
There is a steady stream of doctors leaving Puerto Rico. More
than 3,000 doctors have left in five years for better paying US
mainland jobs.
Now Puerto Rico faces additional heavy 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 cuts (VI is ACA transparency and program integrity. - Subtitle A: Physician ownership and other transparency.
- Subtitle B: Nursing home transparency and improvement.
- Part I: Improving transparency of information.
- Part II: Targeting enforcement.
- Part III: Improving staff training.
- Subtitle C: Nationwide program for national and state background checks on direct patient access employees of long term care facilities and providers.
- Subtitle D: Patient-Centered outcomes research.
- Subtitle E: Medicare, Medicaid, and CHIP program integrity provisions.
- Subtitle F: Additional Medicaid program integrity provisions.
- Subtitle G: Additional program integrity provisions.
- Subtitle H: Elder justice act.
- Subtitle I: Sense of the senate regarding medical malpractice.
, IX is ACA revenue proposals. - Subtitle A: Revenue offset provisions.
- Subtitle B: Other provisions.
) to its Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
(11 percent
cut in 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.
which is three quarters of Puerto Rico's Medicare) and Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. (My Health)
programs, even as it struggles with a shortage of Medicaid
funds. Cuts will result in higher copays 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); for medication
and hospitalization.
Puerto Rico has among the highest rates of diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
and 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; in the United
States.
More than 60 percent of residents receive Medicare or Medicaid due
to Puerto Rico's poor and aging population. But Puerto Rico's
Federal funding is less than mainland US states contributing to $25
billion of Puerto Rico's $73 billion debt burden. The US
Congress placed a cap on Medical payments in the territories in
1968. So Puerto Rico has been using debt to finance its higher
share of the payments. For Medicaid this means Puerto Rico
gets $373 million a year from the federal government and picks up
the rest of the $2.5 billion bill. Puerto Rico's Medicare
reimbursements are 40% lower than on the mainland.
Puerto Rico is not allowed to use Healthcare.gov
and it chose not to provide its own exchange.
Managed care contracts together its subscribing patients with particular groups of doctors and hospitals who agree to provide contracted care for a particular price which the managed care organization reimburses. It was based on the group practice organizations: Kaiser, Mayo Clinic; operations. The initial HMOs, supported by the HMO act and PPOs has subsequently been joined by other forms of managed care. Original capitation based implementations were problematic with only Kaiser succeeding. Managed care is now enhanced by inclusion of upside measures as in alternative quality contracts.
companies have dropped several hundred doctors to cope with the
reductions in funding.
Tennessee
- Tenessee use of private long-term care ramps 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.
costs (Mar
2014)
- Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births.
access
restrictions have proved fatal: Tennessee; while
expansion has reduced mortality Chicago's
Baicker & Harvard's
Sommers & Epstein found (Jan
2018)
NYT Mar
2014 Pitfalls Seen in a State's Turn to Privately Run Long-Term
Care
26 states (including California, Florida, Illinois and New York) are
rolling out mandatory programs that put billions of public dollars
into privately managed long-term care plans, in hopes of keeping
people in their homes longer, and expanding alternatives to nursing
homes in a nuanced
attempt to restrain the ballooning 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. cost of
long-term care as people live longer and survive more disabling
conditions.
Long-term care plans are spending on advertising to capture share in
this large new market.
Tennessee argues that the shift is already working effectively with
the state serving a quarter more people with inexpensive home and
community services. But the NYT asserts there are hidden
pitfalls as the system of caring for the frail comes under the twin
pressures of cost
containment and profit seeking. In many cases the NYT
conclude care was denied after needs grew costlier -- including care
that people would have received under the old system. And they
warn Tennessee may be as good as any in terms of oversight and
financial regulation.
Avoiding the
nursing home lobby constraints to lowering the cost of long-term
care
Managed long-term care was originally seen as a way to break the
stranglehold of nursing home lobbies that opposed shifting more 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. money to home and
community-based care. But the very debilitated people who need
care the most are being denied it.
Constrained
state budgets limit access to long-term care services
The offer initially seems attractive - instead of having to move to
a nursing home with the bills paid 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. ($4,583 per
month), debilitated people could stay at home with daily help
($3,820 per month), and go to a nursing home later if needed.
This initially is a win for the debilitated, the government and the
insurers. But after the state adopted tighter rules to allow
more people to be served for the same overall cost, when it became
necessary to move to the nursing home the state and insurer have
denied the applications for nursing home placement and threatened to
remove the home assistance too.
In 2005, Tennessee shrank Medicaid from one of the most expansive to
one of the most restrictive eliminating coverage for more than
170,000 people.
It embraced 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. (TennCare Choices) with a governor who had been a managed
care executive. Officials say tight regulations helped keep
increases in the state's Medicaid budget to half the national trend
line.
Any long-term care program, reflects difficult policy decisions
including whether to provide an unlimited array of benefits to a
few, or a reasonable package of benefits sufficient to support the
many. Tennessee has chosen to be a as cost effective as
possible, allowing the state to eliminate waiting lists for
community-based services, serving 13,000 people while keeping
nursing home residencies flat at 19,200.
The state's new scoring sharply raised the disability threshold
required to get into a nursing home, or get equivalent care at
home. Such thresholds are state specific. In Tennessee
41 percent of 34,000 applications for care were denied over the 13
months since the scoring change, compared with under 10 percent
previously. Officials explain that with budget cuts this was
the only way to double the proportion of Medicaid recipients served
outside nursing homes to 40 percent.
Medicaid costs
are focused on the long-term care patients
The problem for the states is that 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. spends more
than five times as much on an aged or severely disabled person in
long-term care as it does on a poor child. Traditionally
long-term care cases were considered too vulnerable and politically
sensitive to be assigned to a 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.
company. But recession-starved budgets and looming costs of an
aging population have forced states to abandon the old model as
unsustainable.
About 4.2 million people receive long-term care services paid for by
Medicaid, representing only 6 percent of Medicaid beneficiaries, but
about $136 billion, or one-third of all Medicaid spending.
They include many formerly well-off people in nursing homes who have
"spent-down" their "countable" assets -- the primary home is the
major exclusion -- to less than $2000, the maximum for Medicaid
eligibility in many states.
Previously when the nursing homes billed Medicaid directly for
services provided they were incented to bill for expensive,
unnecessary and even fraudulent care. And little Medicaid
money was allocated to cheaper alternative care even when this would
be more appropriate. Nursing homes have lobbied to maintain
this allocation.
Managed care offers the state government more predictable,
controlled spending. For a fixed sum per employee, plans pay
networks of providers to deliver care. Plans benefit by
keeping costs lower and people healthier, as long as the expense of
customers who need more care is counterbalanced by those needing
less. But that isn't what's happening:
- New York, enrollment in the largest plan, VNSNY-Choice,
was suspended for several months last year over the
cherry-picking of able-bodied seniors. And plans
were turning down bed-bound seniors with dementia.
- Wisconsin, the price of expanding managed long-term care
increased 43percent in three years when more people signed up
than was predicted. Two of the nine Wisconsin plans went
broke. Other plans cut caregivers wages and hours pushing
the burden onto relatives of patients.
- Minnesota was criticized by congress for shifting Medicaid
costs to federal Medicare. A 2011 audit found Minnesota
had overpaid more than $207 million since 2003 to
insurers.
Texas, New York, Arizona, Michigan, Wisconsin, Minnesota and
Tennessee have large and growing Medicaid managed long-term care
programs.
How can the care plans reduce their risk? They have been
pushing patients to accept placement in an assisted living center
such as Elmcroft,
rather than a nursing home. This is a third of the cost but
such centers are not regulated or equipped for people with serious
impairments.
Memphis
African American outreach
To reach out to the large african-american community Methodist formed
the Congregational Health Network. Initially 12 area churches
by Dec 2013 it has 500. Through the network 18,000 people have
been told of screening, prevention and been given health
education.
The outreach has resulted in patients staying out of hospital four
months longer than non-network patients with a similar
diagnosis. They have programs to work with pastors and
congregants, spreading the word about early screening and acting as
a point of contact. It supports access to public health is the proactive planning, coordination and execution of strategies to improve and safeguard the wellbeing of the public. Its global situation is discussed in The Great Escape by Deaton. Public health in the US is coordinated by the PHS federally but is mainly executed at the state and local levels. Public health includes: - Awareness campaigns about health threatening activities including: Smoking, Over-eating, Alcohol consumption, Contamination with poisons: lead; Joint damage from over-exercise;
- Research, monitoring and control of: disease agents, reservoir and amplifier hosts, spillover and other processes, and vectors; by agencies including the CDC.
- Monitoring of the public's health by institutes including the NIH. This includes screening for cancer & heart disease.
- Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.
- Development, deployment and maintenance of vaccination strategies.
- Development, deployment and maintenance of fluoridation.
- Development, deployment and maintenance of family planning services.
- Regulation and constraint of foods, drugs and devices by agencies including the FDA.
programs and offers taxi vouchers so they can get to medical
appointments.
Education must be supported by finance. Insurance is needed to
pay for the health care.
Texas
Dallas
First Ebola
patient Thomas Eric Duncan
Thomas Eric Duncan, was the Liberian man who travelled to the US
while incubating Ebola is a viral disease discovered in 1976. It is an ancient virus branching 20 million years ago from other filoviruses. It mainly infects rodents and other mammals. It appears highly lethal when infecting Gorillas, and is also acute in humans, so we are not a reservoir for Ebola but a dead-end host. The death toll is very small compaired to influenza or Covid-19. A West African epidemic was probably reservoir hosted by forest dwelling bats and transferred to a boy. The 1976 northern Zaire (Yambuku) strain was able to spillover to humans with a case fatality rate of 88%. Sudan, Reston (Philippines), Bundibugyo (Uganda), and Tai Forest, Ebola like viruses have lower case fatality rates. The 1995 Zaire (Kikwit) outbreak was in a forest clearing close by a city of 200,000. A man who felled trees fell ill and died of hemorrhagic fever a week later. He had fatally infected three members of his family and ten of his friends. When it reached a local maternity hospital it infected a lab technician who was transferred to the general hospital where doctors, nurses and nuns were infected and the nuns and technician died. The CDC identified the pathogen as Ebola, which had killed 245 including 60 hospital staff members. The 2014 epidemic is seen as the result of a single infection. Evolutionary biologists consider it unlikely that natural selection will give the virus the ability to spread more easily. The size of the 2014 epidemic gives more potential for mutations but the current transmission mechanism is working for the virus so there is little obvious pressure for out-competition by a new transmission path. There are likely to be lots more viruses with similar infection model to Ebola. Typically an individual is not sick for three to five day after the onset of symptoms which can fool care givers. Then around day 5 to 7 they really crash. Their blood pressure goes down, they become stuporous to unresponsive, and they start to have renal and liver failure. This correlates with the enormous viral load (making it very contagious which is a significant risk to care givers), which is just attacking every organ in the body. Ebola patients lose enormous amounts of fluid from diarrhea and vomiting, as much as five to ten quarts a day during the worst phases of the illness which lasts about a week. Doctors struggle to rehydrate them, replace electrolytes and treat bleeding problems. Thomas Eric Duncan brought Ebola to Texas Health Presbyterian hospital, where the ED failed to identify his symptoms. .
He then developed typical symptoms. He went to the ED
at Texas Health Presbyterian on 25th September 2014. He
was sent home from the ED who did not initially recognize that he
had Ebola.
His condition got more extreeme and he went back to the ED where
they recognized their mistake, diagnosed Ebola and admitted Duncan
for treatment.
Thomas Duncan died from Ebola.
Nina Pham,
nurse treating Thomas Duncan contracts Ebola
Second Case of Ebola in the U.S. Nina Pham a nurse at Texas Health
Presbyterian treating Mr Duncan. Dr.
Frieden said that Ms. Pham's positive test for Ebola had
prompted the agency to "substantially" rethink how it approaches infection control works to prevent healthcare-associated infections. It monitors & supports associated hospital processes: Anti-microbial surfaces, Barrier clothing, Cleaning, Disinfection, Hand washing: North shore; Patient access during epidemics, Sterilization; to contain cross infection. The CDC provides support: Ebola process; and works closely with the primary biocontainment unit at Emory University Hospital.
for health officials. Dr. Frieden also appologized for the
wording of his comments a day earlier.
Ms. Pham felt a low-grade fever over night and dorve herself to the
ED at Presbyterian, where she was admitted 90 minutes later into
isolation.
NYT Oct
2014 Downfall for Hospital Where Virus Spread
The announcement that a second nurse, Amber Joy Vinson, from Texas
Health Presbyterian, who cared for Thomas Eric Duncan,
demonstrated the problems with US procedures for diagnosing and
treating the disease. It has also damaged the reputation of
the hospital:
- People are avoiding going there for treatment. Its
viewed as the epi-center of Ebola is a viral disease discovered in 1976. It is an ancient virus branching 20 million years ago from other filoviruses. It mainly infects rodents and other mammals. It appears highly lethal when infecting Gorillas, and is also acute in humans, so we are not a reservoir for Ebola but a dead-end host. The death toll is very small compaired to influenza or Covid-19. A West African epidemic was probably reservoir hosted by forest dwelling bats and transferred to a boy. The 1976 northern Zaire (Yambuku) strain was able to spillover to humans with a case fatality rate of 88%. Sudan, Reston (Philippines), Bundibugyo (Uganda), and Tai Forest, Ebola like viruses have lower case fatality rates. The 1995 Zaire (Kikwit) outbreak was in a forest clearing close by a city of 200,000. A man who felled trees fell ill and died of hemorrhagic fever a week later. He had fatally infected three members of his family and ten of his friends. When it reached a local maternity hospital it infected a lab technician who was transferred to the general hospital where doctors, nurses and nuns were infected and the nuns and technician died. The CDC identified the pathogen as Ebola, which had killed 245 including 60 hospital staff members. The 2014 epidemic is seen as the result of a single infection. Evolutionary biologists consider it unlikely that natural selection will give the virus the ability to spread more easily. The size of the 2014 epidemic gives more potential for mutations but the current transmission mechanism is working for the virus so there is little obvious pressure for out-competition by a new transmission path. There are likely to be lots more viruses with similar infection model to Ebola. Typically an individual is not sick for three to five day after the onset of symptoms which can fool care givers. Then around day 5 to 7 they really crash. Their blood pressure goes down, they become stuporous to unresponsive, and they start to have renal and liver failure. This correlates with the enormous viral load (making it very contagious which is a significant risk to care givers), which is just attacking every organ in the body. Ebola patients lose enormous amounts of fluid from diarrhea and vomiting, as much as five to ten quarts a day during the worst phases of the illness which lasts about a week. Doctors struggle to rehydrate them, replace electrolytes and treat bleeding problems. Thomas Eric Duncan brought Ebola to Texas Health Presbyterian hospital, where the ED failed to identify his symptoms. in the
US.
- Its viewed as bungling the care of Mr.
Duncan.
- Dr.
Frieden said the critical period at Presbyterian was the
first three days of Mr. Duncan's care at Presbyterian before he
was confirmed to have Ebola and before the C.D.C. team arrived
in Dallas -- Sep. 28, 29 and 30th. Both Ms. Pham and Ms.
Vinson had extensive contact with Mr. Duncan at that time, and
both had interacted with him while he was producing a large
amount of fluids from vomiting and diarrhea. It is
suspected that the nurses were using incorrect technique to
apply protective clothing which unfortunately hightened the risk
to them.
- Once Ms. Pham was diagosed the C.D.C. increased the risk
status of the rest of the group. But by that time Ms.
Vinson was in Ohio.
- Ms Vinson was moved to Emory
University Hospital rather than being treated at
Presbyterian. President Obama has met with the nurses at
Emory who treated the early Samaritan's
Purse staff with Ebola. He argued he felt safe with
them. "I want people to understand that the dangers of you
contracting Ebola, the dangers of a serious outbreak, are
extraordinarily low, but that we are taking this very seriously
at the highest levels of government," the President said.
He promised to find out how the two nurses became infected in
Texas.
- A nurses union National Nurses United releases a scathing
statement that it said was composed by nurses at Texas
Health Presbyterian. The statement told of:
NYT Oct
2014 Nurse Traveled on Airline Before Falling Ill
The reporting of the travel of the second nurse to catch Ebola is a viral disease discovered in 1976. It is an ancient virus branching 20 million years ago from other filoviruses. It mainly infects rodents and other mammals. It appears highly lethal when infecting Gorillas, and is also acute in humans, so we are not a reservoir for Ebola but a dead-end host. The death toll is very small compaired to influenza or Covid-19. A West African epidemic was probably reservoir hosted by forest dwelling bats and transferred to a boy. The 1976 northern Zaire (Yambuku) strain was able to spillover to humans with a case fatality rate of 88%. Sudan, Reston (Philippines), Bundibugyo (Uganda), and Tai Forest, Ebola like viruses have lower case fatality rates. The 1995 Zaire (Kikwit) outbreak was in a forest clearing close by a city of 200,000. A man who felled trees fell ill and died of hemorrhagic fever a week later. He had fatally infected three members of his family and ten of his friends. When it reached a local maternity hospital it infected a lab technician who was transferred to the general hospital where doctors, nurses and nuns were infected and the nuns and technician died. The CDC identified the pathogen as Ebola, which had killed 245 including 60 hospital staff members. The 2014 epidemic is seen as the result of a single infection. Evolutionary biologists consider it unlikely that natural selection will give the virus the ability to spread more easily. The size of the 2014 epidemic gives more potential for mutations but the current transmission mechanism is working for the virus so there is little obvious pressure for out-competition by a new transmission path. There are likely to be lots more viruses with similar infection model to Ebola. Typically an individual is not sick for three to five day after the onset of symptoms which can fool care givers. Then around day 5 to 7 they really crash. Their blood pressure goes down, they become stuporous to unresponsive, and they start to have renal and liver failure. This correlates with the enormous viral load (making it very contagious which is a significant risk to care givers), which is just attacking every organ in the body. Ebola patients lose enormous amounts of fluid from diarrhea and vomiting, as much as five to ten quarts a day during the worst phases of the illness which lasts about a week. Doctors struggle to rehydrate them, replace electrolytes and treat bleeding problems. Thomas Eric Duncan brought Ebola to Texas Health Presbyterian hospital, where the ED failed to identify his symptoms. from Texas
Health Presbyterian has highlighted the risks and process
problems of the US Ebola response.
The nurse, Amber Joy Vinson, flew to see her mother so they could go
shopping for her wedding clothes.
Vinson was among a group of workers who treated Thomas Duncan who
were being monitored by the CDC is the HHS's center for disease control and prevention based in Atlanta Georgia. .
Her temperature was elevated she had reported to the CDC at
99.5F. That is lower than the fever threshold of 100.4F.
CDC offered conflicting details:
- Dr.
Frieden said that workers had followed an evolving set of
protocols to protect themselves in the first days after Mr.
Duncan's hospitalization. Some, he said, donned three or
four layers of protective equipment and closed openings with
tape in the belief that it would afford greater safety.
"In fact, by putting on more layers of gloves or other
protective clothing, it becomes much harder to put them on, it
becomes much harder to take them off, and the risk of
contamination during the process of taking these gloves off is
much higher," he said.
- Dr Frieden announced that Amber Vinson would be flown to Emory
University Hospital.
- An official said Ms. Vinson had called federal health
officials before boarding the plane to report having a slightly
elevated temperature but was allowed to fly.
- Dr Frieden said "Because at that point shw was in a group of
individuals known to have exposure to Ebola, she shoul not have
traveled on a commercial airline. The C.D.C. guidance in
this setting outline the need for what is called 'controlled
movement.' That can include a charter plane or a car but
not include public transport.
- Hours after Frieden spoke a federal health official said that
because it was thought that Ms. Vinson's protective gear would
have kept her safe and because the temperature was only mildly
elevated, she fell into a catagory not covered by the C.D.C.
guidelines. "I don't think we actually said she could fly,
but they didn't tell her she couldn't fly," the official
said. He said the error was on the part of the C.D.C., not
the nurse. "She called us," he said. "I really think
this on is on us."
- Due to the closeness of the flight to Ms. Vinson developing a
full fever all 132 pasengers were asked to call a C.D.C.
hotline. Dr. Frieden stressed the passengers were in a low
risk group since Ms. Vinson did not have a fever, was not
vomiting etc.
The Frontier jet that carried Ms. Vinson made five flights after her
trip before it was pulled out of service. Frontier grounded
the plane as soon as it was notified at 1 a.m. Wednesday.
Vermont
Jan 2014 NYT
In Annual Speech, Vermont Governor Shifts Focus to Drug Abuse
Vermont Governor Peter Shumlin devoted his entire state of the state
message to 'a full blown heroin crisis'. 'In every corner of
our state, heroin and opiate drug addiction results from changes in the operation of the brain's reward network's regulatory regions, altering the anticipation of rewards. Addictive drugs mediate the receptors of the reward network, increasing dopamine in the pleasure centers of the cortex. The learned association of the situation with the reward makes addiction highly prone to relapse, when the situation is subsequently experienced. This makes addiction a chronic disease, where the sufferer must remain vigilant to avoid relapse inducing situations. Repeated exposure to the addictive drug alters the reward network. The neurons that produce dopamine are impaired, no longer sending dopamine to the reward target areas, reducing the feeling of pleasure. But the situational association remains strong driving the addict to repeat the addictive activity. Destroying the memory of the pleasure inducer may provide a treatment for addiction in the future. Addiction has a genetic component, which supports inheritance. Some other compulsive disorders: eating, gambling, sexual behavior; are similar to drug addiction. threatens
us,' he said.
Officials should be encouraged to respond to the addiction as a
chronic disease, with treatment and support, rather than only with
punishment and incarceration.
Last year nearly twice as many people died from heroin overdoses as
the year before in Vermont. Since 2000, Vermont has seen an
increase of more than 770% in treatment for opiate addictions, up to
4,300 people in 2012.
While the problem is acute in Vermont it is not isolated.
Addiction has surged in New England and across the US
generally. The CDC is the HHS's center for disease control and prevention based in Atlanta Georgia.
agrees that it's a growing national problem. The highest rates
of substance abuse are found in New England and the Northeast.
No one really knows why.
The governor made a plea for more money for treatment programs,
noting that incarcerating a person costs $1,120 a week whereas
treatment cost $123 a week. Currently Vermont has a waiting
list of greater than 500 for treatment.
The article did not note that Congress has started to restrict
access to prescription opiate pain emerged as a mental experience, Damasio asserts, constructed by the mind using mapping structures and events provided by nervous systems. But feeling pain is supported by older biological functions that support homeostasis. These capabilities reflect the organism's underlying emotive processes that respond to wounds: antibacterial and analgesic chemical deployment, flinching and evading actions; that occur in organisms without nervous systems. Later in evolution, after organisms with nervous systems were able to map non-neural events, the components of this complex response were 'imageable'. Today, a wound induced by an internal disease is reported by old, unmyelinated C nerve fibers. A wound created by an external cut is signalled by evolutionarily recent myelinated fibers that result in a sharp well-localized report, that initially flows to the dorsal root ganglia, then to the spinal cord, where the signals are mixed within the dorsal and ventral horns, and then are transmitted to the brain stem nuclei, thalamus and cerebral cortex. The pain of a cut is located, but it is also felt through an emotive response that stops us in our tracks. Pain amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so. Fear of pain is a significant contributor to female anxiety. Pain is the main reason people visit the ED in the US. Pain is mediated by the thalamus and nucleus accumbens, unless undermined by sleep deprivation. killers, after it was
recognized that these are now a major cause of death in the
US. It is suspected that many new heroin addicts were
previously prescribed prescription pain killers, had become
dependent and then responded to the Congressional constraint by
shifting to heroin.
Sep 2015
NYT OxyContin Is Not for Kids
Peter Shumlin, governor of Vermont writes that state politicians
have been concerned about the opiate and heroin crisis in Vermont
for a number of years. He laments that they have not been
winning the battle. So he was horrified that the F.D.A. Food and Drug Administration. issued a decision
(Aug 2015) to approve OxyContin for
use by children as young as 11 years old. He views this as a
very addictive results from changes in the operation of the brain's reward network's regulatory regions, altering the anticipation of rewards. Addictive drugs mediate the receptors of the reward network, increasing dopamine in the pleasure centers of the cortex. The learned association of the situation with the reward makes addiction highly prone to relapse, when the situation is subsequently experienced. This makes addiction a chronic disease, where the sufferer must remain vigilant to avoid relapse inducing situations. Repeated exposure to the addictive drug alters the reward network. The neurons that produce dopamine are impaired, no longer sending dopamine to the reward target areas, reducing the feeling of pleasure. But the situational association remains strong driving the addict to repeat the addictive activity. Destroying the memory of the pleasure inducer may provide a treatment for addiction in the future. Addiction has a genetic component, which supports inheritance. Some other compulsive disorders: eating, gambling, sexual behavior; are similar to drug addiction.
drug.
Shumlin notes in the last 18 months the state has invested millions
of dollars to limit opiate abuse. The state agreed that
addiction is primarily a health care issue and that users need
treatment, not prison cells. As such Vermont's:
- Doctors and hospitals are examining their prescription
practices to limit opiate distribution.
- Law enforcement and the families of addicts are carrying
Narcan, to reverse the effects of overdosing.
- Recovering addicts are visiting schools to tell their
stories.
- Treatment programs are expanding.
Other states have similar problems.
Shumlin advocates that the F.D.A. must play its part. He
argues it must reduce the availability of the drugs -- not expand
their use. He suggests the pharmaceutical industry and F.D.A.
helped ignite the crisis in the 1990s when the F.D.A. approved
OxyContin use. That set off a mass of prescriptions for pain emerged as a mental experience, Damasio asserts, constructed by the mind using mapping structures and events provided by nervous systems. But feeling pain is supported by older biological functions that support homeostasis. These capabilities reflect the organism's underlying emotive processes that respond to wounds: antibacterial and analgesic chemical deployment, flinching and evading actions; that occur in organisms without nervous systems. Later in evolution, after organisms with nervous systems were able to map non-neural events, the components of this complex response were 'imageable'. Today, a wound induced by an internal disease is reported by old, unmyelinated C nerve fibers. A wound created by an external cut is signalled by evolutionarily recent myelinated fibers that result in a sharp well-localized report, that initially flows to the dorsal root ganglia, then to the spinal cord, where the signals are mixed within the dorsal and ventral horns, and then are transmitted to the brain stem nuclei, thalamus and cerebral cortex. The pain of a cut is located, but it is also felt through an emotive response that stops us in our tracks. Pain amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so. Fear of pain is a significant contributor to female anxiety. Pain is the main reason people visit the ED in the US. Pain is mediated by the thalamus and nucleus accumbens, unless undermined by sleep deprivation. issues. The C.D.C. is the HHS's center for disease control and prevention based in Atlanta Georgia. shows that doctors
prescribed enough painkillers in 2010 to "medicate every American
adult around-the-clock for a month." They note heroin
addiction is surging across America. The strongest risk factor
for heroin abuse is "a prescription opioid use disorder".
Shumlin writes that many medical experts believe there is no reason
that powerful painkillers are so prevalent. But he suggests a
financial one: Opioids generated $11 billion in revenues for
pharmaceutical companies in 2010.
West Virginia
Jan 21 2014
NYT Law's expanded Medicaid coverage brings a surge in sign-ups
Sabrina Tavernise describes the relief chronicly sick and poor
people in West Virginia felt when the 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
started (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.
title II is ACA role of public programs. It includes: - Subtitle A: Improved access to Medicaid.
- Subtitle B: Enhanced support for children's health insurance program.
- Subtitle C: Medicaid and CHIP enrolment simplification.
- Subtitle D: Improvements to Medicaid services.
- Subtitle E: New options for states to provide long-term services and support.
- Subtitle F: Medicaid prescription drug coverage.
- Subtitle G: Medicaid disproportionate share hospital (DSH) payments.
- Subtitle H: Improved coordination for dual eligibles.
- Subtitle I: Improving the quality of Medicaid for patients and providers
- Subtitle J: Improvements to the Medicaid and CHIP payment and access commission (MACPAC)
- Subtitle K: Protections for American Indians and Alaska natives.
- Subtitle L: Maternal and child health services.
).
Enrollment in private insurance plans has been sluggish but signups
for Medicaid have surged in many states. West Virginia's
Democratic governer signed up for the Medicaid expansion and the
number of people in the state that were previously uninsured has
reduced by a third.
Tavernise notes that America ranks near the bottom of the developed
countries in health and longevity.
It is assumed that better coverage will improve that situation and
thus start to reduce health care costs. The newly covered poor
in West Virginia say their mental health is already much
improved. They are now protected from the punishing medical
bills that have punched holes in their family budgets.
While the people are happy is an emotion which functions to mobilize the mind to seek capabilities and resources that support Darwinian fitness. Today happiness is associated with Epicurean ideas that were rediscovered during the renaissance and promoted by Thomas Jefferson. But natural selection has 'designed' happiness to support hunter-gatherer fitness in the African savanna. It is assessed: Relative to other's situations, Based on small gains or losses relative to one's current situation; and so what makes us [un-]happy and our responses can seem a counter-productive treadmill. For Pleistocene hunter-gatherers in the savanna there were many ways for losses to undermine fitness and so losses still make us very unhappy. Smoking, drinking and excessive eating were not significant and so don't make us unhappy even though they impact longevity.
to get the coverage they do not like to talk about it. Many
see President Obama as the 'great satan'!! even as he is giving them
piece of mind.
Uninsured people tend to be sicker and die younger than those with
insurance. However, a key study suggests that 40% of the
reason for that is behavioral factors like smoking and eating
unhealthily, 50% is genetics and social and environmental
factors. Only 10% was lack of access to medical care.
Further an Oregon
study where people suddenly got Medicaid did not see rapid
change in problems like obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016).
and diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
.
Still mental health did improve drastically analogous to the
statements of the West Virginia enrollees.
Tavernise notes that the poor are still focused on getting access to
enough food to survive. Lack of 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. opportunity
and low levels of education significantly impact the
population. They are fatalistic with little interest in
prevention. The poor are unlikely to be consuming healthy food
since that costs more. And the poor of West Virginia are
already among the most unhealthy in America. Looking at a tiny
town of Welch in McDowell county which has a lot of logged timber
and coal mining life expectancy is lower than in Pakistan.
Rates of smoking and diabetes are nearly double the national
average. Half the men are obese.
But Medicaid expansion does mean that for those needing treatments
they do not have to offset eating against getting treated.
That should be a significant change. The line at the pharmacy
is long. Its filled with Medicaid patients starting to get
treatments they were ignoring previously.
.
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