General patient
Customer frame
General customer
Government constraints
General patient
Disease systems

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
Patients by geographic network

Patients by disease type or treatment:




The interplay of state regulation, insurance policy age, shifting provider structure and business model interactions limits patient satisfaction in long-term care. 


  • 2013 Patient Scenarios

Uncertainty with 2013 ACA insurance policies
Uncertainty with long-term care insurance policies
      • 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:
Aging populations

U.S. Health

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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
  • Diet
  • Exercise
 and 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, 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 a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease.  It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016).  Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome.  Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). 
is 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 a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease.  It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016).  Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome.  Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). 
, diabetes is the leading cause of blindness, limb amputations and kidney failure.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
  • Diet
  • Exercise
, 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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
  • Diet
  • Exercise
, 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:
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. 

LH - 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.  
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.  But poisoning from MPTP has also been shown to destroy dopamine system neurons.  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. 
, 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 memory and thinking problems (MCI).  Grid cell destruction results in a sense of being lost.  Variants include: late-onset sporadic; with risk factors - ApoE4, presenilin, androgen deprivation therapy (Dec 2015).  There are multiple theories of the mechanism of Alzheimer's during aging: Allen Roses argues that it is due to gene alleles that limit the capacity of mitochondria to support neuron operation; It may be initiated by: stress induced HHV-6a, HHV7 herpes activation (Jun 2018) and or an increasingly leaky blood-brain barrier; and a subsequent innate immune response to the infections (May 2016).  The Alzheimer's pathway follows:
  • Plaques form and set off the formation of tangled thread-like tau protein.
    • Solanezumab aimed to inhibit plaque formation but clinical trials failed (Nov 2016). 
    • 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. 
  • 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. 
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. 

LH - Medically complex
Such as ward E6, a men's ward:
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.  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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
  • Diet
  • Exercise
. 

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.  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 ones body and mind 'being' at rest and so cultivating awareness.  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 mindfullness 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 from 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 and 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:
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 amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so.  Pain is the main reason people visit the ED in the US.  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.  But poisoning from MPTP has also been shown to destroy dopamine system neurons.  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. 
, 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:
  1. 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. 
  2. Creation and updating of proactive plan of care
  3. Communication
  4. 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. 
  5. 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. 
  6. 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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
  • Diet
  • Exercise
.  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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
  • Diet
  • Exercise
, chronic depression is a debilitating state which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels; and an accumulation of traumatic events.  There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015).  The affected person will experience a pathological sense of loss of control, prolonged sadness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure.  Michael Pollan concludes depression is fear of the past.  It affects 12% of men and 20% of women.  It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016).  Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression.  Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease.   It has been associated with an aging related B12 deficiency (Sep 2016).  During depression, stress mediates inhibition of dopamine signalling.  There is an association between depression and particular brain regions: Hippocampal dendrite and spine number reductions, Dorsal raphe nucleus linked to loneliness, Abnormalities of the ACC.  Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable.  Treatments include: CBT, UMHS depression management.  As of 2010 drug treatments take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony.   Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult; 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 a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease.  It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016).  Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome.  Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). 
, 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:



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:
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 state which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels; and an accumulation of traumatic events.  There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015).  The affected person will experience a pathological sense of loss of control, prolonged sadness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure.  Michael Pollan concludes depression is fear of the past.  It affects 12% of men and 20% of women.  It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016).  Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression.  Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease.   It has been associated with an aging related B12 deficiency (Sep 2016).  During depression, stress mediates inhibition of dopamine signalling.  There is an association between depression and particular brain regions: Hippocampal dendrite and spine number reductions, Dorsal raphe nucleus linked to loneliness, Abnormalities of the ACC.  Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable.  Treatments include: CBT, UMHS depression management.  As of 2010 drug treatments take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony.   Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult; 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:
  1. The community - Resources and polities. 
  2. The health system - organization and payment model. 
  3. Self-management support - education, tools, motivational techniques, patient empowerment;
  4. Delivery system design
  5. Decision support - allowing evidence based guidelines to support care. 
  6. 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 state which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels; and an accumulation of traumatic events.  There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015).  The affected person will experience a pathological sense of loss of control, prolonged sadness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure.  Michael Pollan concludes depression is fear of the past.  It affects 12% of men and 20% of women.  It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016).  Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression.  Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease.   It has been associated with an aging related B12 deficiency (Sep 2016).  During depression, stress mediates inhibition of dopamine signalling.  There is an association between depression and particular brain regions: Hippocampal dendrite and spine number reductions, Dorsal raphe nucleus linked to loneliness, Abnormalities of the ACC.  Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable.  Treatments include: CBT, UMHS depression management.  As of 2010 drug treatments take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony.   Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult;, 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 a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease.  It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016).  Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome.  Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). 
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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
  • Diet
  • Exercise
 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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
  • Diet
  • Exercise
, 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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
  • Diet
  • Exercise
, obesity is a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease.  It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016).  Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome.  Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). 
, 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 amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so.  Pain is the main reason people visit the ED in the US.  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 non-profit 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:

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 aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group.  John Adair developed a leadership methodology based on the three-circles model. 
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.  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:


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.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
  • Diet
  • Exercise
 and 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



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, 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.  It mainly infects rodents and other mammals.  A West African epidemic was probably hosted by bats and transferred to a boy.  The 1976 strain was able to infect man.  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 outcompetition 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:
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.  It mainly infects rodents and other mammals.  A West African epidemic was probably hosted by bats and transferred to a boy.  The 1976 strain was able to infect man.  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 outcompetition 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 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 amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so.  Pain is the main reason people visit the ED in the US.  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 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 amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so.  Pain is the main reason people visit the ED in the US.  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 a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease.  It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016).  Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome.  Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). 
and diabetes is the leading cause of blindness, limb amputations and kidney failure.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
  • Diet
  • Exercise
.  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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