Power

Power analysis

Summary

The power analysis uses Porter's five forces framework to compare the power of participants: customers, local economy, suppliers, government, monopolists, new technologies; across the health care providers' value delivery system (VDS). 


Introduction

The health care industry has a complex VDS is value delivery system.   including cooperating and competing payers, providers and physicians.  The federal government is forcing the restructuring of the VDS and is shifting risk, is an assessment of the likelihood of an independent problem occurring.  It can be assigned an accurate probability since it is independent of other variables in the system.  As such it is different from uncertainty. 
and uncertainty is when a factor is hard to measure because it is dependent on many interconnected agents and may be affected by infrastructure and evolved amplifiers.  This is different from risk, although the two are deliberately conflated by ERISA.  Keynes argued that most aspects of the future are uncertain, at best represented by ordinal probabilities, and often only by capricious hope for future innovation, fear inducing expectations of limited confidence, which evolutionary psychology implies is based on the demands of our hunter gatherer past.  Deacon notes reduced uncertainty equates to information. 
onto it. 

Powerful agents participating in the network include:





 







2013 Aug Philadelphia uses medium term debt to underwrite short term funding of its schools
NYT reports Philadelphia is edging towards a financial precipice.  The troubles are centered on the cash-starved public schools system. 

The city agreed at the last minute to borrow $50 million just to be able to open schools on time.  Even with that money schools will open Sept. 9 with a minimum of staffing and sharply curtailed extracurricular activities and other programs. 

Superintendent William Hite has been threatening to delay opening schools if the city did not come through with the $50 million, which he said was necessary to provide the minimum staffing needed for the basic safety of the district's 136,000 students.  In June, the district closed 24 schools and laid off 3,783 employees, including 127 assistant principals, 646 teachers and more than 1,200 aides, leaving no one even to answer phones. 

For a number of years, Mayor Michael Nutter and the City Council have been working, with some success and a fair amount of taxpayer pain, to shore up the city's finances, which have been troubled by mounting debt, a shrinking tax base and unfunded pension and health care obligations to retirees.  But the school district, supported by the same weary municipal taxpayers, though under the control of a state reform commission for more than a decade, has been largely ignored. 

While the city's own bond rating has been raised, to its highest level in 30 years, the school district's credit has been downgraded to junk, with warnings that more downgrades may come. 

The unusual situation stems from a combination of politics and long-term structural problems.  Decades of dwindling population and resources had already greatly weakened the schools, but now the Republican controlled state government has drastically cut aid to the district.  This move struck some in the Democratic-controlled city as punitive, though Gov. Tom Corbett, a Republican, has said the state wide cuts in education had nothing to do with party politics but with the simple need to do something about the state's own poor finances.  Federal aid to the district has also been chopped. 

After half-century of urban decline and population exodus, in recent years, the migration away from Philadelphia has leveled off.  Young professionals and empty-nesters have lately been moving back, reinvigorating the downtown - but its a relatively tiny portion of the city.  Center City and the nearby neighborhoods are doing fine, but elsewhere people's ambition is still to leave the city when they can afford to do it, so they can count on a better education for the kids. 

As middle-class people have left Philadelphia, the tax base has withered, raising the overall poverty rate of those who remain,  Over the years, it has forced both the city and school district to impose more taxes on a population that is more needy of public services, yet less able to pay for them. 

The school district has an estimated $304 million deficit for the coming year -- at a time when it is already paying $280 million to service its existing debt each year. 

Mayor Nutter's announcement that he would take out general obligation bonds to come up with the $50 million for the schools risks the city's own hard-won credit rating by taking on medium-term debt to pay for day-to-day operations. 

To help close the district's deficit, school officials had asked for $180 million in emergency aid -- $120 million from the state and $60 million from the city.  Only $45 million has been approved by the state and Gov. Corbett is holding that until he is satisfied with school district reforms. 

All this is occurring as the old teacher's contract expires and a new one is being negotiated. 






 





  • The suppliers are also powerful players. 
Advances in genetic analysis have led to the development of a number of breakthrough drugs which are currently filling a drug pipeline.  Regulators approved 39 drugs in 2012, the most in 16 years. 


Analyzing DNA (DNA), a polymer composed of a chain of deoxy ribose sugars with purine or pyrimidine side chains.  DNA naturally forms into helical pairs with the side chains stacked in the center of the helix.  It is a natural form of schematic string.  The purines and pyrimidines couple so that AT and GC pairs make up the stackable items.  A code of triplets of base pairs (enabling 64 separate items to be named) has evolved which now redundantly represents each of the 20 amino-acids that are deployed into proteins, along with triplets representing the termination sequence.  Chemical modifications and histone binding (chromatin) allow cells to represent state directly on the DNA schema.  To cope with inconsistencies in the cell wide state second messenger and evolved amplification strategies are used.   structures behind specific kinds of cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure.  It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA.  In 2010 one third of Americans are likely to die of cancer.  Cell division rates did not predict likelihood of cancer.  Viral infections are associated.  Radiation and carcinogen exposure are associated.  Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016). 
and other diseases, has allowed companies to develop targeted medications:


Promising drugs are in the pipeline to treat many genetic diseases.  Six of the seven largest biotech companies are going through major product launches now or are expected to do so shortly. 

Immuno-oncology uses the immune system to treat cancer.  Cancer cells often have different molecules on their cell surface.  Studies have shown that genetic signatures of tumors can help predict which patients will benefit from treatment with PD-1 checkpoint inhibitors.  Checkpoint inhibitor based treatments aim to make the immune system target these antigens.  Clinical trial results indicate they are prolonging lives - even if only by a few months.  They have reduced side effects relative to generic chemo therapy.  There are three main strategies: cellular, antibody and cytokine.  
  • Antibody therapies target receptors including CD20, CD274, CD279 and CTLA-4.  These therapies include MABs: Alemtuzumab, Ofatumumab, Rituximab; and may induce checkpoint inhibition.
  • Cellular therapies have typically involved removing the immune cells from the blood or a tumor, activating, culturing and then returning them to the patient.  Trials of these CAR and TCR therapies are proceeding, with some significant problems (Jul 2016). 
  • Cytokine therapies enhance anti-tumor activity through the cytokine's regulation and coordination of the immune system. 
  • Vaccines, including Sipuleucel-T for prostate cancer and BCG, classically a vaccine for tuberculosis, which is used for treating bladder cancer. 
progress:

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. 
has been slow to gain F.D.A. Food and Drug Administration.   approved products:

HCIT is health care information technology.  The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets.  Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.; 
suppliers and SAAS is software as a service. 
providers support:

The clinical technologies business supply: ED is emergency department.  Pain is the main reason (75%) patients go to an E.D.  It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital.  The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals.  Unreimbursed care is supported from federal government funds.  E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing.  The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics.  Commercial nature of care requires walk-ins to register to gain access to care.  With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). 
s, 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. 
s, Laboratories, Radiology departments, Pre-operation rooms, OR is operating room.  s, Inpatient rooms, Rehabilitation centers, PAC providers is a Post-Acute Care provider.  A three-day hospital admission and discharge are prerequisite requirements to receiving Medicare PAC services.  Acute care hospitals become portals to the PAC business.  Referrals are key.  PAC includes different types of facility focused on different severity of illness (high to low):
  • Long term care Hospital (LTCH),
  • Inpatient rehabilitation facility (IRF),
  • Skilled nursing facility (SNF),
  • Home health agency (HHA) - most acute care hospitals and EMR providers have strategies for integration with home based care,
  • Outpatient rehabilitation.  SNF and HHA represent 80% of discharges and expenditures.  Assisted living is not part of federal Medicaid, but states often include it through a waiver. 
; with:

The food supply is now leveraging gene editing technologies. 

Investors have poored $5 billion into the biotech and healthcare sectors in 2013.  Investors have historically used the healthcare and biotech stocks as a destination to park money when the economy is a human SuperOrganism complex adaptive system (CAS) which operates and controls trade flows within a rich niche.  Economics models economies.  Robert Gordon has described the evolution of the American economy.  Like other CAS, economic flows are maintained far from equilibrium by: demand, financial flows and constraints, supply infrastructure constraints, political and military constraints; ensuring wealth, legislative control, legal contracts and power have significant leverage through evolved amplifiers. 
is down.  But in 2013 as the recovery continues the sectors are holding their investments.  Healthcare/biotech have outperformed all other sectors.  Many biotech investors favor giants like Amgen or Gilead Sciences (Apr 2016).  Janus Global Life Sciences also holds Aetna and Express Scripts

In contrast generic drug supplies suffer from structural problems that tend to encourage shortages

Counteracting the strong branded drug pipeline is the economics of healthcare: