Government analysis

Government analysis

Summary

The overarching role of government in shaping health care is reviewed.  The analysis includes: Role of the US is the United States of America.   president & state governors, administration of federal & state regulation, government use of health care services, response of government to the shifting economics of the US, Impact of the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
  • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
    • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
    • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
    • Children, allowed to, stay on their parents insurance until 26 years of age. 
  • Medicare solvency improvements. 
  • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's 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. 
;


Introduction

The health care industry has a complex VDS is value delivery system.   linked tightly to the government. 
 


The US is the United States of America.   government's considerable influence on health care is analyzed.  The goals of the political party in power, impacts all the other aspects of government.  Legislation constrains the strategies available to providers, specialists, and PCP is a Primary Care Physician.  PCPs are viewed by legislators and regulators as central to the effective management of care.  When coordinated care had worked the PCP is a key participant.  In most successful cases they are central.  In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements.  Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. 
s; and their suppliers.  Trade agreements regulate the operation of importers and exporters.  Federal and state regulation shapes the US is the United States of America.   VDS is value delivery system.   with powerful effects induced by the controlling legislation.  The government also directly provides coverage for many of the health care network's patients: military, veterans, poor/infirm, and elderly.

The power dynamics between the different health care entities: hospitals, suppliers, doctors, government; etc. are analyzed separately. 

The major aspects of government influence include: 


The President's power to nominate judicial and administrative candidates for office shapes long term policy including for health care. 

The Presidential judicial nominations:
The Presidential administrative nominations:

The president's control of federal regulatory policies allows him broad influence of the flow of regulated goods and services:


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.  
is maintained by a mixture of federal and state structures.  The wellbeing indicates the state of an organism is within homeostatic balance.  It is described by Angus Deaton as all the things that are good for a person:
  • Material wellbeing includes income and wealth and its measures: GDP, personal income and consumption.  It can be traded for goods and services which recapture time.  Material wellbeing depends on investments in:
    • Infrastructure
      • Physical
      • Property rights, contracts and dispute resolution
    • People and their education
    • Capturing of basic knowledge via science.  
    • Engineering to turn science into goods and services and then continuously improve them. 
  • Physical and psychological wellbeing are represented by health and happiness; and education and the ability to participate in civil society through democracy and the rule of law.  University of Wisconsin's Ryff focuses on Aristotle's flourishing.  Life expectancy as a measure of population health, highly weights reductions in child mortality. 
of the citizens is supported by this complex network of agents. 

The subjugation of infectious disease in the US between 1870s and 1940s has supported the development the hospital infrastructure.  With the additional discovery and deployment of antibiotics, public health and hospitals became more effective

But this beneficial situation has now begun to unravel:

The SSA is the social securities act of 1935 was part of the second New Deal.  It attempted to limit risks of old age, poverty and unemployment.  It is funded through payroll taxes via FICA and SECA into the social security trust funds.  Title IV of the original SSA created what became the AFDC.  The Social Security Administration controls the OASI and DI trust funds.  The funds are administered by the trustees.  The SSA was amended in 1965 to include:
  • Title V is Maternal and child health services. 
  • Title XVIII is Medicare.  
defends against poverty:
Additionally children's health care is supported by CHIP is:
  • The Children's Health Insurance Program started in 1997 as part of the BBA as SCHIP.  It provides health insurance coverage for children in families with income below 200 percent of the poverty line.  The coverage is focused on care specialized for children including: developmental delays, chronic conditions including asthma and obesity.  CHIP's funding must be iteratively re-authorized by Congress.  CHIP is financed federally, but states must enroll eligible children.  In many states one agency administers CHIP and Medicaid.  CHIP is leveraged by families that have employer based insurance with costly premiums, so the families only cover the adults.  
  • Clonal Hematopoiesis of Indeterminate Potential, where stem cells develop a somatic mutation cluster pair often found in leukemia, which is expressed in white blood cells they produce.  The mutation clusters give these stem cells a competitive advantage and they accumulate over time.  The white blood cells form inflammatory plaques.  CHIP increases with age, increasing the risk of dying, of clot fragment induced heart attacks and stroke, over the subsequent 10 years by 54%
:

Bipartisan Congressional action can provide focus:

The longevity of Americans is supported by:

The constraints on health care provision encourage the federal and state executive to contract with low cost providers.  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. 
(title I 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. 
- C) insurance market places were developed by a variety of developers including the federal division of CGI.  The implementation was delayed and changed by the Obama administration to limit attacks from Republicans in Congress.  But that approach left the developers failing. 

The ACA is designed to support the poor, insure everyone and constrain overuse of health care.  However, its dependence on commercial insurance companies to capitalize the payment pool through yearly contracts results in a series of structural conflicts that may result in its repeal:
Democrat's Medicare for All (a single-payer is a healthcare architecture in which there is a single financing organization.  Significant aspects of single-payer include:
  • Strengths of single-payer:
    • Removes the extensive replication of payer organizations and their different interfaces to the other healthcare entities and subscribers. 
    • One payment organization, removing the need to allow subscribers the yearly choice to change payer, encouraging payers to help subscribers remain healthy
  • Single-payer instantiates a political monopoly on health insurance. 
  • Problematic implementation of single-payer in the US
    • Undermines the alignment of the healthcare network, threatening profits, power structures and financial rewards.  This limits the possibility of single-payer in the US: Lobbying juggernaut: Politicians, Providers, Doctors, Insurers; leveraging dislike of tax increases, The 9 out of 10 Americans who are employed or retired are satisfied with their situation, Current insurance costs are hidden from the insured: in lowered pay packages, spread over all tax payers reducing government revenues; Current private insurers would be forced to reduce costs;
    • Alters one sixth of the US economy: Commercial health insurance replaced, investors impacted by transformation of business models; a huge change of high uncertainty, something evolution works to avoid by including mechanisms to force small incremental changes. 
  • A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations.  Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016). 
vision) will require transitional strategies, which Republicans should strongly resist:

ACA 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 provides an alternative:
By 2018 Chronic care is being addressed:
In 2015 funding for Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
  • Benefits
    • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
    • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
    • Part C: Medicare Advantage 
    • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
  • Eligibility
    • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
    • Persons under 65 with disabilities who receive SSDI. 
    • Persons with specific medical conditions:
      • Have end stage renal disease or need a kidney transplant. 
      • They have ALS. 
    • Some beneficiaries are dual eligible. 
    • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
  • Sign-up
    • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
    • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
  • Premiums
    • Part A premium
    • Part B insurance premium
    • Part C & D premiums are set by the commercial insurer.  
and Social Security is the social securities act of 1935 was part of the second New Deal.  It attempted to limit risks of old age, poverty and unemployment.  It is funded through payroll taxes via FICA and SECA into the social security trust funds.  Title IV of the original SSA created what became the AFDC.  The Social Security Administration controls the OASI and DI trust funds.  The funds are administered by the trustees.  The SSA was amended in 1965 to include:
  • Title V is Maternal and child health services. 
  • Title XVIII is Medicare.  
account for 40 percent of all federal spending.  The trustees of Social Security reported (Aug 2015) that the disability trust fund is the disability insurance trust fund.   would be depleted in the last quarter of 2016.  While Republicans may see this as further evidence that Medicare and Social Security must be reworked - say into Paul Ryan's voucher system - Democrat's echo HHS is the U.S. Department of Health and Human Services.   secutary Burwell's point -- 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. 
has extended Medicare's trust fund. 

Federal regulation is administered by:
State regulation is also significant:
Competing state level health strategies can induce innovation is the economic realization of invention and combinatorial exaptation.  Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty.  Innovation operates across all CAS, being supported by genetic and cultural means.  Creativity provides the mutation and recombination genetic operators for the cultural process.  While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity.  This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy. 
:
State governors and their influence

The government is also a major user of Medical Infrastructure:

The increase in the percentage of GDP is:
  • Gross domestic product which measures the total of goods and services produced in a given year within the borders of a given country (output) according to Piketty.  Gordon argues to include products produced in the home & market-purchased goods and services, following Becker's theory of time use.  Gordon stresses innovation is the ultimate source of all growth in output per worker-hour.  GDP growth per person is equal to the growth in labor productivity + growth in hours worked per person.  GDP has many problems.  Gordon concludes that between 1870 and 1940 all available measures GDP is hugely understated because:
    • GDP is a poor measure of:
      • Value & wealth
      • Who gets what
      • Global supply chains
    • GDP excludes:
      • Reduction in infant mortality between 1890 (22%) and 1950 (1%)
      • Brightness & safety of electric light,
      • Increased variety of food including refrigeration transported fresh meat and processed food
      • Convenience and economies of scale of the department store and mail order catalog and resulting product price reductions
      • Services by house makers
        • Time & health gains from having flush toilets, integrated sewer networks; rather than having to physically remove effluent and cope with fecal-oral transmission
      • Leisure
      • Costs & benefits of different length work weeks
      • Speed and flexibility of motor vehicles - which were not included in the CPI until 1935, after the transformation had occurred.  And competition from improved foreign vehicles, while it provides purchaser/user with improved standard of living (less breakdowns, repairs, etc.) is measured as reduced domestic manufacture
      • Coercion and corruption to obtain resources 
      • Consumption impact of finite resources: coal, oil;
      • Destruction impact of loss of entire irreplaceable species
    • GDP includes items that should be excluded:
      • Cost of waste - cleaning up pollution (single use indestructible plastic bags), building prisons, commuting to work, and cars left parked most of the time; should be subtracted
  • Guanine-di-phosphate is a nucleotide base. 
dedicated to health care makes it a central focus of politics. 



In 2014 healthcare accounts for one-sixth of the engine that drives the US 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. 
.  For more than twenty years healthcare costs have grown consistently.  But 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. 
is designed to change that through two conflicting mechanisms:
  1. Expand health coverage to millions of Americans without insurance. 
  2. Make the healthcare system more efficient by forcing doctors and hospitals to deliver care in a more cost-effective way. 
Which of the two aspects has more economic effect is contentious.  While 2014 Q1 numbers include a surprise drop in healthcare spending (only the fourth quarterly decline in 80 quarters) government actuaries (Jul 2015, Aug 2015) predict a rise through 2024.  The spending increase will be encouraged by the 2016 US budget (Dec 2015). 

Congressional Democratic proposals aim to drive the health care agenda for 2020:

Legislative challenges from Republicans to 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. 
proceed:


The legal challenges from Republicans to 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. 
proceed:



The reduced wealth is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker.  It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche.    and aging of the US population, is forcing state politicians to look for effective ways to restrict Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
spending on the elderly.  Given the power of the nursing home lobby and other political risks they are leveraging funding of private long-term care alternatives (indirection) to mitigate financial 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. 
as 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. 
via global capitation is a global payment for all care for a patient during a specified time period.  It forces the provider of care to take a high risk.  Managing the risk implies successful population health management. 
(flexibility).  But the scenario is becoming analogous to the psychiatric hospital closures of the 70s and 80s where the lower cost community services promoted as replacements rapidly lost funding.  The mentally ill had been forced to self-medicate and many ended up in the prison system. 

Puerto Rico's situation is particularly difficult.  Its bilingual health care workers are leaving the depressed health care sector for higher paying US mainland jobs. 
The Obama administration proposes US Congress support Puerto Rico's Medicare flows which is 20% of Puerto Rico's cash flow but Congress is cool to the proposal. 



Aging ensures heart disease, obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  Brain images of drug-addicted people and obese people have found similar changes in the brain.  Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors.  Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so.  Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease.  It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016).  Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome.  Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). 
, type-2-diabetes is the leading cause of blindness, limb amputations and kidney failure.  It is a risk factor for Alzheimer's disease.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
  • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
  • Diet
  • Exercise
and 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). 
will complicate the health care of a significant percentage of the US population.  That presents opportunities (Mar 2016) and problems for chronic 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. 
new entrants such as Wal-Mart

Aging tends to increase the number of problems that each patient has but it should also alter the treatment strategies.  For example:

Waiting behind these diseases are the neuro-degenerative diseases: Alzheimer's is a dementia which correlates with deposition of amyloid plaques in the neurons.  As of 2015 there are 5 million Alzheimer's patients in the USA.  It was originally defined as starting in middle age which is rare, so it was a rare dementia.  But in 1980s it was redefined as any dementia without another known cause. Early indications include mood and behavioral changes (MBI) and declarative memory and thinking problems (MCI).  Specific cells within the hippocampal circuitry and its gateway, the entorhinal cortex, are damaged.  The amygdala, cerebelum and other areas supporting implicit memory are not impacted during the early stages of the disease.  Grid cell destruction results in a sense of being lost.  The default mode network is disrupted.  Variants include: late-onset sporadic; with risk factors - ApoE4 for late onset Alzheimer's, presenilin, androgen deprivation therapy (Dec 2015), type 2 diabetes.  There are multiple theories of the mechanism of Alzheimer's during aging: Allen Roses argues that it is due to gene alleles that limit the capacity of mitochondria to support neuron operation, Neurons of sporadic Alzheimer's sufferers show greater APP gene diversity due to somatic recombination; It may be initiated by: stress induced HHV-6a, HHV7 herpes activation (Jun 2018) and or an increasingly leaky blood-brain barrier; and a subsequent innate immune response to the infections (May 2016).  The Alzheimer's pathway follows:
  • Plaques form.  These are seen in fMRIs 10 to 15 years prior to detecting memory and thinking changes.  APP deployed in the cell membrane is cut into three parts.  The external part becomes amyloid-beta peptide which aggregates into Amyloid plaques, external to the neurons, if too much is generated or it is not removed fast enough. 
    • Solanezumab aimed to inhibit plaque formation but clinical trials failed (Nov 2016). 
    • Encouraging the garbage collection of amyloid and tau with gamma rhythms stimulation retards Alzheimer's in mice studies (Mar 2019)
    • BACE inhibitors block an enzyme needed to form amyloid. 
  • Mutation driven misfolded Tau proteins can form tangles within the cytoplasm of neurons.  The Tau tangles kill nerve cells.  LMTX is a drug treatment targeted at these tangles. 
  • The brain becomes inflamed resulting in the killing of many more nerve cells.  The hippocampus disintegrates and the brain loses critical functions and memory loss becomes noticeable. 
, Parkinson's corresponds to the breakdown of certain interneurons in the brain.  It is not fully understood why this occurs.  Dopamine system neuron breakdown generates the classical symptoms of tremors and rigidity.  In some instances an uncommon LRRK2 gene mutation confers a high risk of Parkinson's disease.  In rare cases Italian and Greek families are impacted in their early forties and fifties resulting from a single letter mutation in alpha-synuclein which alters the alpha-synuclein protein causing degeneration in the substantia nigra, after a build up of Lewy bodies in the neurons.  But poisoning from MPTP has also been shown to destroy dopamine system neurons.  DeLong showed that MPTP poisoning results in overactivity in the subthalamic nucleus.  People who have an appendectomy in their 20s are at lower risk of developing Parkinson's disease.  The Alpha-synuclein protein is known to build up in the appendix in association with changes in the gut microbiome.  This buildup may support the 'flow' of alpha-synuclein from the gut along neurons that route to the brain.  Paraquat has also been linked to Parkinson's disease.  Parkinson's disease does not directly kill many sufferers.  But it impacts swallowing which encourages development of pneumonia through inhaling or aspirating food.  And it undermines balance which can increase the possibility of falls.  Dememtia can also develop.  Treatment with deep-brain stimulation, after surgical implantation of electrodes in the subthalamic nucleus removes the symptoms of Parkinson's disease in some patients. 
; as discussed by Stanley Prusiner which, in 2014, have no treatments and an empty drug pipeline. 

Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
  • Benefits
    • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
    • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
    • Part C: Medicare Advantage 
    • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
  • Eligibility
    • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
    • Persons under 65 with disabilities who receive SSDI. 
    • Persons with specific medical conditions:
      • Have end stage renal disease or need a kidney transplant. 
      • They have ALS. 
    • Some beneficiaries are dual eligible. 
    • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
  • Sign-up
    • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
    • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
  • Premiums
    • Part A premium
    • Part B insurance premium
    • Part C & D premiums are set by the commercial insurer.  
's Jul 2015 decision to test a blend of hospice has the key goal of helping people with a fatal illness to have the fullest possible life right now.  There are major hospice chains focused on providing palliative care. 
care and medical treatment may improve end of life care and help manage costs. 
But hospices found to overbill 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.  
(Apr 2016)





In 2013 the growth in health care costs has trended down reducing the pressure to act.  And Elisabeth Rosenthal, of the New York Times, questions the political will to lower health care costs in Health Care's Road to Ruin (Dec 23 2013). 

She notes that the US health care system has a larger GDP than France!  And it has many hidden, and exorbitant prices for hospital treatements.  10,000 readers wrote in frustration and agreement with these issues.  She judges 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. 
a first step in limiting the costs at best.  Even with the ACA many models suggest nearly 25% of gross domestic product will be eaten up by health care in 20 years.  Hospitalization and end of life care are particularly costly to the government.  There are well known ideas for repairing the pricing issues.  Often they are already practiced by other counties:
She says that other countries dependence on direct government intervention, negotiation or rate-setting suggests why the US focus on indirect intervention in private health care markets limits cost management.  By depending on regulating and mandating insurance plans ACA opportunity to improve competition in these markets is undermined by lobbyists constraining regulation.  Medicare is not allowed to regulate drug prices and Americans are forbidden by law to reimport medicines made dometsically and sold more cheaply abroad. 

Aaron Chatterji, former senior 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. 
at the White House Council of Economic Advisors, argues that health care and education are viewed by politicians as generating jobs which cannot be outsourced and that will continue to grow, since the US has an aging population which will need more health care and a young population that must be trained for the high skill jobs that will be essential to world leadership.  This has led to society spending large sums both on public and private sector education for our students and caring for the health of our citizens.  But he warns that these growth assumptions are questionable:

Rural areas are of necessity (May 2015) removing long standing requirements for doctors to supervise nurses. 


Multiple forces make Democratic politicians support their local hospitals.  Especially as losses at major hospitals force more to close (May 2016).  Opportunities for patronage, jobs for union workers and altruism benefits another organism at a cost to the behaver.  It is differentiated from kin altruism, by Williams and Trivers, since it can apply between unrelated individuals.  It can be induced by natural selection when there is mutual survival benefit in group activities and cheating can be detected and discouraged.  Humans, leveraging the cognitive niche, can particularly easily, build an evolved amplifier, through sharing information at little cost and significant benefit.  But African savanna hunters similarly gain from sharing large game meat with other un-related altruistic group members since the meat would otherwise spoil before it could be eaten. 
are all present.  Even though poorly funded and operated NewYork City Democrats support maintiaining SUNY's Long Island College Hospital
Democratic politicians have also leveraged opportunities in supporting health care delivery based on for-profit medical malls reusing closed hospitals, and with 'well informed' investments in licensed care companies: Extended home care and Excellent home care; 
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. 
increases the numbers of people covered by insurance.  As South Carolina is concluding many of the poor will be found eligible for Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
and registered for it expanding use even without ACA's Medicaid expansion made optional by SCOTUS.  Alaska's Governer used an executive order to expand Medicaid coverage.  Florida refused to expand Medicaid coverage.  It will be impacted by curtailing of LIP is either the
  • Medicaid supplemental 'low-income pool' hospital funding program which reimburses hospitals for the cost of care for the uninsured.  LIP is being wound down as the ACA Medicaid expansion occurs.  Or it is the
  • Lateral intraparietal area is involved in saccades of the eyes.  Some neurons in the LIP code the location of visual and auditary targets in an eye-centered reference frame.  Others code the location of a sound in reference frame intermediate between head-centered and eye-centered.  For many cells the magnitude of response is 'gain' modulated by eye, head, body or initial hand position. 
.  The Obama administration has offered $1.6 billion of support for Florida's hospitals (May 2015).  And Democrats, such as Michael Moore, are keen to add public insurance options to the ACA. 
The ACA extends the Governments long term support for primary care clinics

Republican strategists also view health care as very important.  It:

Republican candidates for President have proposed replacing the ACA:
  • Before the 2016 primaries Jeb Bush offers details of and ACA replacement plan (Oct 2015)

Republican state legislators in Florida and Texas have leveraged the ACA SCOTUS judgement and rejected the ACA's expansion of Medicaid.  In 2015 the biggest gains in health insurance coverage occurred in households with incomes less than $50,000 a year.  Massachusetts has 3.3 percent of people uninsured.  Texas has 19 percent uninsured. (Sep 2015)

Republicans continue attempts to undermine 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. 
.  To limit signup to the exchanges they are constraining communications about the benefits of membership and how to signup.  Once 2 million people were going to signup they looked at ways to replace the ACA (Dec 2013, Jan 2014). 



Health and education as local growth drivers

Oct 2013 The bad news for local job markets

NYT op-ed Aaron K. Chatterji
Professor Chatterji argues that the slow growth shown by 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. 
reflects limits to the strategies adopted by local governments around the US.  He argues that many analysts are banking on job growth from two key sectors, education and health care. 

'Ed and meds' have already accounted for a significant share of employment growth over the past several years.  More important, these jobs are the only thing keeping many small and midsize American cities from sliding into deeper decline.  Several regions are consciously building around these services under the logic that they cannot be out-sourced, and local demand will continue to grow.  Unfortunately, both assumptions are wrong, and that could mean bad news for many local job markets around the country. 

Growth in education and health care may not meet expectations
Education and health care jobs are so attractive because unlike manufacturing jobs, which have steadily declined over the last 25 years, they are largely shielded from global competition.  As a society we continue to spend large sums of money, both in the public and private sector, on educating our students and caring for the health of our citizens. 

Since good jobs will increasingly require more education and our population is aging, the long-term outlook for these sectors looks positive.  Education and health care also create jobs across income distribution, providing work for home health aides as well as college professors. 

However, while the total number of jobs in these sectors could grow, it is not likely that all regions would benefit equally.  For example, one might take for granted that there will be growing demand for orthopedic is the treatment of the musculoskeletal system which supports multi-cell higher animals and allows them to move about: including correcting deformities, breaks, tears, compression, tendonitis, disc failures, misalignment, fusion to treat damaged discs. 
surgeons in Toledo, Ohio and educational administrators in Iowa City.  But the same forces that led other industries to cluster in specific regions (think technology in Silicon Valley or banking in New York) are now sweeping through education and health care

Consider the education market.  The rise in online education, specifically massive open online courses, is expanding the number of students a top university can educate.  The Wharton School of the University of Pennsylvania, one of the top business schools in the world, recently announced that it would offer four of its 'foundation' courses online for free through Coursera;  students can receive a certificate of verification for $49 for each course completed.  A certificate might not be as valuable as an M.B.A from your local university but it could be in 5 or 10 years. 

What will happen to enrollment at lower-ranked business schools when students have the opportunity to take courses a la carte at Wharton for less than the cost of their monthly cellphone bill?  The best schools will attract more and more students, while the middle- and lower-tier institutions will mostly struggle, leading to less local demand for college administrators, tutors and faculty. 

Wal-Mart strategy may dis-intermediate general hospitals

Health care jobs might seem very different at first glance.  Every city, large or small, will always need emergency room staff and obstetricians within a reasonable distance.  But this could be less true for orthopedic is the treatment of the musculoskeletal system which supports multi-cell higher animals and allows them to move about: including correcting deformities, breaks, tears, compression, tendonitis, disc failures, misalignment, fusion to treat damaged discs. 
surgeons and cardiologists is the diagnosis and treatment of: Congenital heart defects, CAD, Heart failure, Valvular heart disease; by cardiologists.  , who power the high-margin services that pump significant sums into the local economies 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. 
.  What will happen when more employers follow the example of Wal-Mart, which announced last fall that it would send employees in need of transplants or heart or spine surgery to one of six leading medical centers around the country, rather than to their local hospital? 

Wal-Mart is making this move because there is notorious variation across the country in health care costs.  If this trend accelerates, it will hurt local hospitals and leave them with fewer profitable service lines is a strategic focus and structuring by a general hospital to optimize for the most locally profitable areas of diagnosis and treatment such as: Cardiovascular, Neurology or Cancer; to respond to competition from specialist focused health care facilities such as the Texas heart institute and local low cost outpatient facilities.  It does not abandon other services which the community as a whole needs but limits the losses they generate.  A successful service line can: Diagnose and treat a high volume of service specific problems ensuring quality and efficiency, be profitable enough to gain additional investment and attract top physicians.  To be effective service line strategies require:
  • A clear view of the hospital's competitive environment. 
  • Visibility of the revenue, costs (activity based rather than top down) and benefits of particular procedures and bundles of care.  Cost estimates are often averaged by hospital accounting models. 
  • Effective management of PCP referrals to the hospital and its competitors. 
  • Changes to the: Organization structure, Incentive plans for doctors, Relationship with physicians (potentially including co-management) - who must own the problems of their service line, Business development, HCIT - which will need to capture all details of a service, HR who will need to support the employees during and after the transition. 
.  It will also certainly mean fewer jobs at these facilities. 

Thus while the number of education and health care jobs could indeed grow significantly in the coming years, that does not directly imply  job growth in small and midsize cities that spend on these sectors. 

In fact, the opposite situation could unfold for places that are not world leaders in providing education and health service.  This category includes most places outside major metro areas.  Toledo and Iowa City are quite typical in their heavy reliance on education and health care sectors.  Without job growth in these industries, there are few remaining employers in most places left to make up the difference. 

Instead, we might see the same dynamic of winners and losers observed in other industrial sectors, as top universities and hospitals become larger and absorb most of the increase in students and patients from across the nation.  While these shifts might increase economic efficiency and gross domestic product over all, they will leave even fewer opportunities for good jobs in the places that need them the most. 


Jul 2017 NYT The Private Equity Firm That Quietly Profits on Top-Selling Drugs

Randall Smith reports cashing in on rising drug prices often unleashes an outcry from consumers and politicians. 

Smith notes that Royalty Pharma has developed a $15 billion portfolio by buying the rights to 3 to 5% royalties on future drug sales.  It owns partial rights on seven of the top 30 selling drugs: Humira, Remicade, Lyrica, Januvia, Kalydeco, Rituxan; in the US is the United States of America.  
It uses low-cost debt financing to outbid competitors. 

Royalty Pharma's revenues have risen at an average 30% increase yearly: $161 million in 2005 to $2.47 billion in 2016. 

Royalty Pharma paid $700 million for a 3% royalty interest on Humira.  That allowed AstraZeneca to finance a $1.3 billion purchase of Cambridge Antibody Technology which originally developed Humira, in 2006. 

Royalty's business model has resulted in large payments to Universities and their researchers:
The developers who sell their potential royalty revenue stream to Royalty Pharma are taking a discount on the overall return to limit 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 gain access to capital is the sum total nonhuman assets that can be owned and exchanged on some market according to Piketty.  Capital includes: real property, financial capital and professional capital.  It is not immutable instead depending on the state of the society within which it exists.  It can be owned by governments (public capital) and private individuals (private capital).   upfront. 


Northwestern's Dr. Richard Sliverman worked on the nerve-pain emerged as a mental experience, Damasio asserts, constructed by the mind using mapping structures and events provided by nervous systems.  But feeling pain is supported by older biological functions that support homeostasis.  These capabilities reflect the organism's underlying emotive processes that respond to wounds: antibacterial and analgesic chemical deployment, flinching and evading actions; that occur in organisms without nervous systems.  Later in evolution, after organisms with nervous systems were able to map non-neural events, the components of this complex response were 'imageable'.  Today, a wound induced by an internal disease is reported by old, unmyelinated C nerve fibers.  A wound created by an external cut is signalled by evolutionarily recent myelinated fibers that result in a sharp well-localized report, that initially flows to the dorsal root ganglia, then to the spinal cord, where the signals are mixed within the dorsal and ventral horns, and then are transmitted to the brain stem nuclei, thalamus and cerebral cortex.  The pain of a cut is located, but it is also felt through an emotive response that stops us in our tracks.  Pain amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so.  Fear of pain is a significant contributor to female anxiety.  Pain is the main reason people visit the ED in the US.  Pain is mediated by the thalamus and nucleus accumbens, unless undermined by sleep deprivation. 
drug Lyrica.  The Royalty Pharma payments helped fund a $100 million laboratory center at the university, as well as undergraduate financial aid, graduate fellowships and research. 





Apr 2016 NYT Bankruptcy of Ambulance Firm Poses Tough Questions for City

Jim Dwyer reports on the effects of the collapse of TransCare

TransCare provided Ambulance Service to large parts of the Bronx and some areas of Manhattan. 

During Major Guiliani's time in office in NYC the city made arrangements with private hospitals, such as St. Barnabas Hospital, that permitted them to operate their own ambulances within the city's 911 network.  Many chose to contract with private suppliers including TransCare. 

This saved expenses needed to support running a fleet of ambulances for the city.  Other private operators have failed but TransCare was large (81 tours and 200 medical workers) causing the city to have to call in other services from across the city for extended periods. 

There is an abundance of firefighters but they are not as trained medically and they can not transport patients.  But firefighters are much more popular, and powerful politically than ambulance workers. 


Jun 2016 NYT When you Dial 911 and Wall St. Answers

Danielle Ivory, Ben Protess and Kitty Bennett report squeezed for profit by private equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors.  Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges.  Private equity companies were initially corporate raiders. 
emergency services fail to deliver. 

There is a profound shift in financing of emergency services since the 2008 financial crisis.  With the additional regulation applied to banks, private equity has been able to move into previous bank 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. 
niches.  This attaches less systemic risk than Wall Street finance

Warburg Pinkus, KKR and other large private equity firms have purchased emergency services companies.  Recently twelve of these have been ambulance services


Three of the private equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors.  Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges.  Private equity companies were initially corporate raiders. 
owned EMS is emergency medical services providing ambulance and critical care transport. 
s filed for bankruptcy is a legal status for an entity that cannot repay its creditor's loans.  It holds creditor lawsuits in abeyance while the restructuring process proceeds to allow the entity to continue operations.  It also has legal tools for forcing holdout creditors to accept repayments that are lower than the bond sale initially promised. 
in 2013 - 2016:  Patriarch's TransCare, Warburg Pinkus's Rural/Metro and First Med



The EMS is emergency medical services providing ambulance and critical care transport. 
business requires costly investment in medical gear, and with limited free cash flow is at risk from slow downs inducing collapse. 
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. 
was expected to increase the size of the insured customer pool, but many EMS users were covered 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. 
which constrains the billing practices of EMS businesses. 
Instead many companies were forced to conserve working capital. 


Rural/Metro was sold by Warburg Pinkus to the bottom feeding hedge fund is an investment fund that accepts investments from a limited number of accredited individual or institutional investors.  Hedge funds are able to use investment methods that are not allowed for other types of fund. 
Oaktree capital and from there on to health care provider Envision Healthcare which started adding staff (paramedics and E.M.T. is emergency medical technician. 
) to improve response times. 
Patriarch's strategies similarly failed to turn Transcare around. 

While cities and towns are required to provide an education to all residents, other 'essential services' are not similarly tied down.  Michelle Wilde Anderson of Stanford argues that this has resulted in new lows in the public safety practices since private equity firms are not philanthropic. 


Nov 2016 NYT Going to the E.R. Without Leaving Home

Paula Span reports community paramedics tend to the elderly without always taking them to the hospital

While old people often prefer living at home they can struggle due to:
In a report of Northwell Health's House Calls program published in the Journal of the American Geriatrics Society, looking at 1,602 ailing, elderly, homebound patients, when EMTs responded for: shortness of breath, neurological and psychiatric complaints, cardiac and blood pressure problems, or weakness; they could evaluate and treat 78% at home, over a 16 month study period. 


Paramedics working with Northwell Health can be contacted via the House Calls service.  They travel by S.U.V., rather than ambulance, and have had an additional 40hrs of training targeted at allowing them to treat most of the problems they meet directly. 
Northwell Internist/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. 
Dr. Karen Abrashkin explains "A lot of what's been done in the 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). 
can safely and effectively be done in the home.  The hospital is not always the safest place to be,"  for old frail people with health problems:
Dr. Abrashkin noted "Often, even our sickest patients don't want to go to the hospital."  And she noted "The teams were able to identify those patients sick enough to really need and want to go to the hospital." 

The paramedics were led remotely by doctors, over the phone, or on a secure video link.  They:
80% of patients taken to hospital were admitted. 




Medstar Mobile Healthcare adopted mobile integrated healthcare (community paramedicine) in 2009.   Now the strategy is widely used by EMS is emergency medical services providing ambulance and critical care transport. 
services. 

State regulations differ:
  • Texas based Medstar usually makes scheduled visits rather than responding to emergency calls.  It teaches patients how to manage their chronic problems. 
But the different state programs share:
  • Additional training
  • A team approach
  • Emphasis on preventing unnecessary transportation. 
An inhibitor is 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.  
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. 
only reimburse EMS for ferrying people to hospital.  Medstar is negotiating with Insurers to reimburse at-home services.  Currently it has to fund such services from:
  • Foundation grants
  • Referral payments
  • Hospital financed programs. 





Aug 2016 NYT With Room Service and More, Hospitals Borrow From Hotels

Julie Weed reports at the Henry Ford West Bloomfield Hospital outside Detroit, patients arrive to uniformed valets and professional greeters.  Wi-Fi is free and patient meals are served on demand 24 hours a day.  Members of the spa staff give in-room massages and other treatments. 

Weed explains that hospitals have many incentives to move toward hotel-inspired features, services and staff training. 

Medical researchers report:
And hospitals are interested in improved marketing:
  • Attracting patients with private insurance who have a choice in where they receive care.  This includes competing for international patients against hospitals in Singapore, Bangkok etc. 
  • Encouraging word-of-mouth recommendations. 


Stanford Health Care Senior Program Manager Zig Wu was an author of a Journal of Healthcare Management article on hospitality in the medical field. 
Wu commented "It's a way for hospitals to compete with each other."  There is so little reliable comparative data on hospitals' medical outcomes.  "Patients  look to the quality of the hospital's environment." 

Stanford's adoption of C-I-Care 'See-I-Care' is a UCLA health acronym (described in Prescription for Excellence) for:
  • Connect with the patient or family member using Mr./Ms. or their preffered name.
  • Introduce yourself and your role.  
  • Communicate what you are going to do, how it will affect the patient, and other needed information.  
  • Ask for and anticipate patient and/or family needs, questions, or concerns.  
  • Respond to patient and/or family questions and requests with immediacy.  
  • Exit, courteously explaining what will come next or when you will return. 
is also seen as building a loyal customer base. 




Henry Ford Health System's Robert Riney says the hospitality features help the patients feel a little more control over their environment and "focus on getting better."  24-hour room service at Bloomfield started in 2009.  "If someone is feeling poorly after a tough procedure or taking medication, they aren't going to eat just because it's meal time.  They won't get the nutrition they need.  Its much better for their recovery," to be able to eat when they feel able. 



Patients of over 50 Henry Ford Medical outpatient centers can choose the time and location of many tests, procedures and appointments using an online system modeled on an airline reservation portal.  When it was introduced in 2014, cancellation and no-show rates dropped immediately, Riney explained. 

Outside donors financed the Henry Ford West Bloomfield's new $1 million hydroponic greenhouse and education center. 

Federally mandated surveys show that the evolving features at Bloomfield have helped to improve customer satisfaction ratings and the number of word of mouth recommendations.  Length-of-stay and readmission rates at Bloomfield have decreased.  A Deloitte study found hospital profitability was associated with high customer satisfaction scores. 

New construction provides additional opportunities to use hotel design features:
  • Curved hallway walls
  • Sound proofing
  • More friendly gathering spaces
  • Cupboards to keep instruments out of sight. 






New York Presbyterian Hospital's Alan Lee noted "New amenities that increase the operating expenses of a hospital have little to do with insurance billing.  We absolutely rely on donor and grant funding."   


But there are tradeoffs.  On-site stores, spas and gathering places can attract more patients, but there must be medical resources, including ORs is operating room.  , to cope with the additional procedures. 


Dec 2018 NYT Why New York Lags So Far Behind on Natural Childbirth

Julie Satow reports Lisa Binderow had envisioned her labor a thousand times over.  She bought a birthing ball, hired a doula is a birth coach, a non-medical person who supports the mother and her family during childbirth and recovery. 
and even practiced hypnotherapy. 
Her plan was to deliver at the Mount Sinai West Birthing Center, an area of the hospital marked by pastel curtains, family-size beds and large birthing tubs.  Separated from the regular labor and delivery floor, it is for women who want a natural childbirth with minimal medical intervention. 

But Satow explains the service was not operating and Binderow had a terrible experience at the hospital. 

The demand from women for natural childbirth is strong and rising.  But New York hospitals:
And New York state regulations still require midwifes at birthing centers to be supervised by a doctor.  In all other states midwifes run the services. 

These limitations & constraints reduce the opportunity for natural births in New York state by:


Mount Sinai West plans to replace its birthing center with 13 NICU is neonatal ICU also called an intensive care nursery.   beds & 15 private postpartum beds ($900 a night per bed). 


New York Presbyterian is building the Alexandra Cohen Hospital for Women and Newborns with 75 postpartum rooms & 60 NICU beds and a proximate OR is operating room.   as a state-of-the-art maternity facility to compete for a hotel like experience (Aug 2016). 

In New York City:
Doulas and Midwifery practices have closed in response to high malpractice insurance and low reimbursements is the payment process for much of US health care.  Reimbursement is the centralizing mechanism in the US Health care network.  It associates reward flows with central planning requirements such as HITECH.  Different payment methods apportion risk differently between the payer and the provider.  The payment methods include:
  • Fee-for-service,
  • Per Diem,
  • Episode of Care Payment, 
  • Multi-provider bundled EPC,
  • Condition-specific capitation,
  • Full capitation.  


NYCHHC's Metropolitan bucks the trend, in partnership with Village Maternity.  It offers private postpartum rooms at no extra charge. 

New York has four remaining birthing centers at: New York Presbyterian, Brooklyn, Buffalo, and New York in Brooklyn.  New Jersey is a more accommodating state.  Texas has 70 birthing centers.  California has 44. 


Mar 2014 NYT Repurposing Closed Hospitals as For-Profit Medical Malls

New Jersey has lost 26 hospitals in the last 20 years.  New Jersey's hospitals are required to provide charity care, which is challenging for the urban hospitals with lots of uninsured patients.  They also lose fee paying custom to outpatient departments with insurers constraining use of high cost inpatient treatment.  And they must maintain on call specialists and nursing staff.  In recent years some former hospital buildings have been repurposed  with developers reopening them as private medical complexes that offer many of the services the hospitals once provided. 

Since 2008 developers in struggling cities in New Jersey such as Paterson, Hammonton and Trenton have been converting the buildings, which are often ideal structures for medical uses, into Medical Malls, such as Barnert medical arts complex, housing services such as:
Global life Enterprises is restructuring Trenton's former Mercer Hospital to make way for a $540 million state-of-the-art  facility in Hopewell.  They aim to develop a health and wellness is a health care oriented employer based strategy for reducing health care costs and encouraging wellbeing.  Wellbeing has traditionally been a focus of public health.   center, with plans for a hotel like lobby, a waterfall, an adutl medical day care facility, a spa and possibly a yoga center.  We aim to create a one stop health care mall explained Global life's co-founder Priti Pandya-Patel. 

Critics complain that these complexes are no substitute for the original hospitals.  Unlike a hospital, individual providers in the Mall are not required to provide charity care or serve the community's needs like a non-profit hospital. The medical malls do offer health care services, but not necessarily the same ones the prior hospital provided.  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. 
or pediatrician is a doctor who specializes in the treatment of infants, children and adolescents.  They are represented by the American Academy of Pediatrics. 
might not be prioritized relative to an oncologist, a cardiologist or a psychiatrist.  Often the services will be out of network translating to much higher out of pocket costs. 

Communities with a high mix of uninsured patients, find their remaining hospitals burdened with poor and uninsured patients while the paying customers are targeted by the medical malls.  David Knowlton, president of the New Jersey Health Care Quality Institute comments "You make it increasingly hard for the safety-net hospitals that remain to survive.  You could start a downward spiral." 


Jul 2014 NYT E.R., Not a Hospital, Is Set to Open at St. Vincent's Site

NYT reports a free standing ED is emergency department.  Pain is the main reason (75%) patients go to an E.D.  It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital.  The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals.  Unreimbursed care is supported from federal government funds.  E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing.  The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics.  Commercial nature of care requires walk-ins to register to gain access to care.  With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). 
, Lenox Hill HealthPlex, will open on an old St.Vincent's Hospital site in a trend driven by bottom line profits.  North Shore-Long Island Jewish Health System owns the new facility.  It argues that the ED is what the local community wants.  Since St. Vincents closure residents had to go across town to Bellvue Hospital Center, Mount Sinai Beth Isreal or NYU Langone.  Others argue that hospital groups intend to use high profile branded, stand alone EDs as competition for urgent care centers is an efficient and less costly 'alternative' to the ER.  There is no accepted standard.  Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls.  Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones.  Unlike an ER they can not admit patients to a hospital.  Some also offer services like pre-employment drug screening and summer camp physicals. 
.  ED's charge far higher prices but they usually treat anyone who visits. 

Similarly NYU Langone Medical Center will take over the ED of Long Island College Hospital Brooklyn. 

The hospital groups view standalone EDs as a high profit funnel to the parent hospitals since half their admissions come from the ED.  They are especially useful when they replace former hospitals removing competitors and extending the hospitals coverage area.  Many community hospitals have been undermined by their catchment areas going up market and have been forced to close.  Well regarded brands like NYU and North Shore can now gain access. 

Stand alone EDs are allowed to charge the same fees that hospitals charge with lower overheads. 

There are now four hundred standalone EDs.  Health analysts are worried by the trend since ED use has been one of the forces behind rising health care costs. 


Apr 2018 NYT An E.R. That Treats You Like a V.I.P.

Paul Sullivan reports at 3 a.m. on a recent Sunday, Herb Wilson's wife fell backward in the bathroom of their New York apartment and hit her head.  It was not her first fall.  She has Parkinson's disease corresponds to the breakdown of certain interneurons in the brain.  It is not fully understood why this occurs.  Dopamine system neuron breakdown generates the classical symptoms of tremors and rigidity.  In some instances an uncommon LRRK2 gene mutation confers a high risk of Parkinson's disease.  In rare cases Italian and Greek families are impacted in their early forties and fifties resulting from a single letter mutation in alpha-synuclein which alters the alpha-synuclein protein causing degeneration in the substantia nigra, after a build up of Lewy bodies in the neurons.  But poisoning from MPTP has also been shown to destroy dopamine system neurons.  DeLong showed that MPTP poisoning results in overactivity in the subthalamic nucleus.  People who have an appendectomy in their 20s are at lower risk of developing Parkinson's disease.  The Alpha-synuclein protein is known to build up in the appendix in association with changes in the gut microbiome.  This buildup may support the 'flow' of alpha-synuclein from the gut along neurons that route to the brain.  Paraquat has also been linked to Parkinson's disease.  Parkinson's disease does not directly kill many sufferers.  But it impacts swallowing which encourages development of pneumonia through inhaling or aspirating food.  And it undermines balance which can increase the possibility of falls.  Dememtia can also develop.  Treatment with deep-brain stimulation, after surgical implantation of electrodes in the subthalamic nucleus removes the symptoms of Parkinson's disease in some patients. 
and has fallen many times, causing him worry.  He leveraged having contracted with a concierge medical service: Priority Private Care

Hospitals are also providing concierge service:

Priority Private Care's business leverages a legal constraint 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). 
s: they must treat the sickest patients first by law.  You will wait if there are more high risk patients to be attended to.  And there are a lot of people visiting EDs, often for problems that don't need ED care.  In New York State average ED times before being sent home are three hours.  In New York City that can be five hours. 

In Texas, standalone ERs are allowed.  Coppell ER leverages this legal framework to offer concierge care. 


Jun 2017 NYT The Doctor Is In,  Co-Pay? $40,000. 

Nelson Schwartz reports when John Battelle's teenage son broke his leg at a suburban soccer game, naturally the first call his parents made was to 911.  The second was to Dr. Jordan Shlain, the concierge doctor here who treats Mr. Battelle and his family. 

Shlain's Private Medical ensured the treatment was carried out by a respected orthopedic is the treatment of the musculoskeletal system which supports multi-cell higher animals and allows them to move about: including correcting deformities, breaks, tears, compression, tendonitis, disc failures, misalignment, fusion to treat damaged discs. 
surgeon at the California Pacific Medical Center in San Francisco.  

Schwartz argues that just like in plane flights, cruise ships and amusement parks, money now buys access to faster, better health care in the US is the United States of America.  

As delays lengthen for gaining access to doctors, wealthy is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker.  It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche.    families are able to gain immediate access. 


MD Squared's Dr. Harlam Matles, an internist was seeing 20 to 25 patients a day while previously working at Stanford Hospital.  That allowed little time with each patient.  At MD Squared Dr. Matles says "I am able to give the time and energy each patient deserves.  I wish I could have offered this to everyone in my old practice, but it just wasn't feasible." 


Private Medical's Dr. Greene & Dr. Chiu are also motivated by the quality time they can dedicate to their patients. 

Schwartz notes that hospitals are also responding to the opportunity to serve the super-rich.  Stanford's new building will help it compete.  It also has a red blanket service for its major donors.  It's a signal to the staff of the importance of this patient. 


Lenox Hill Hospital hired Joe Leggio, previously from Louis Vuitton and Nordstrom to create an ambience like a luxury boutique hotel with five star services.  Its maternity ward's Park Avenue Suite costs $2,400 a night and attracted Beyonce, Chelsea Clinton and Simon Cowell's girlfriend.  The suite includes a separate sitting room, a kitchenette and full wardrobe closet, and has a view over Park Avenue. 





Jul 2014 NYT The Long Wait to See a Doctor

NYT editorial sites findings from a Merrit Hawkins 2013 survey that Americans are already experiencing long waits to get doctor's appointments.  They note the trend should get worse as 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. 
expands the number of people who are covered by insurance.  The findings of this survey showed little change across all specialities from surveys in 2009 and 2004. 

The findings are consistent with an international 2013 survey of 11 industrialized countries by the Commonwealth Fund.  When American's got sick, 26 percent had to wait six days or longer for an appointment, better only than Canada and Norway but much worse than other countries with national health systems such as Britain and the Netherlands.  Patients in Britain and Switzerland also reported shorter waits to see a specialist than patients in the US. 

To reduce wait times the US can:
US problems with Veterans wait times may add political pressure in the US. 


Sep 2017 NYT For Many Medical Students, the Caribbean Was Warm and Welcoming.  Until Now. 

Anemona Harticollis & Amy Harmon report as Hurricane Maria roared over the island of Dominica on Tuesday, dozens of parents of students at Ross University School of Medicine posted anguished messages on the school's Facebook page, searching for their children and praying that they had survived unscathed. 


There are dozens of medical schools in the Caribbean.  Most are for-profit.  They may leverage their cash to reserve clinical training posts for their students. 

The target students of the Caribbean medical schools are people who did not gain access to the limited number of places at US medical schools.  They are willing to pay higher fees than the US schools charge to gain a qualification that will allow them to become US doctors.  They are typically focused by the schools on poor urban & rural 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. 
jobs that are not being supplied by the US universities.  The students usually also see the Caribbean as a tropical paradise but the current hurricane season has tampered that view.  If rebuilding delays the students' qualification dates, their huge loans will become more problematic. 
In 2004 St. George's responded to hurricane damage by moving its school to New York to ensure its students graduated on time. 


American medical schools responded negatively to the competitors from the Caribbean:
  • Arguing they provide inferior education
  • Limiting access to clinical rotations the Caribbean trained students need to graduate. 


Jan 2019 SJMN How Much Is That Aspirin At The Hospital?

John Woolfolk & Kaitlyn Bartley report Oakland's Highland Hospital lists its price for a single chest X-ray at $131, while over the Bay at [UCSF MC], they say it'll set you back $2,618. 

Woolfolk & Bartley compare prices at California's Bay Area hospitals:
The federal government is requiring hospitals to post their chargemaster is a hospital specific mapping of chargeable ICD procedure codes to the description and list price set by the hospital. 
prices on their web sites.  CMS is the centers for Medicare and Medicaid services.   assert it is a Trump administration priority.  California's payer bill or rights has required hospitals in the state to provide similar details, and average prices for common procedures, to the Office of Statewide Health Planning and Development.  Woolfolk & Bartley note finding the pages can be very difficult.  And because of insurance plan agreement discounts, deductibles and copayments these list prices do not correspond to most patients out of pocket costs.  

The wide variation in list prices, and no standardization of the chargemaster items, means consumer comparisons have little meaning. 

CMS is also requiring inpatient hospitals to post DRG is a diagnosis-related group.  It transformed the health care operating model, when 467 DRGs with standard payments were introduced by Medicare in the 1980s, enabling for-profit business strategies to seek ways to cut expenses and hence increase profits.  The DRG is a classification, designed by Yale's Robert Fetter and John Thompson, intended to define the products that a hospital provides.  It assumes patients within a grouping are clinically similar.  Grouping is based on ICDs adjusted for age, sex, discharge status and comorbidities.  For Medicare hospital inpatient claims the DRG is used to select the fee that will be reimbursed.   charges.  UCSF MC's vaginal delivery without complications DRG is $53,184.00!


May 2019 NYT Many Hospitals Charge Double or Even Triple What Medicare Would Pay

Reed Abelson reports in Indiana, a local hospital system is the owner of a set of hospitals and other owned infrastructure and employer of direct staff.  , Parkview Health, charged private insurance companies about four times what the federal 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.  
program paid for the same care, according to a study of hospital prices in 25 states released on Thursday by the nonprofit is a tax strategy selected by many hospitals in the US.  These hospitals, which include: Cleveland Clinic, Johns Hopkins, Massachusetts General, Mayo Clinic; are exempt from federal and local taxes because they provide a level of community benefit.  They are considered charitable institutions and benefit from tax-free contributions from donors and tax-free bonds for capital projects, explains Bellevue Hospital's Dr. Danielle Ofri.  Prior to 1969, community benefit had to include charity medical care, but then the tax code was altered to allow many expenses to qualify as community benefits including: Accepting Medicaid insurance at a hospital estimated loss; and charitable care became optional.  The ACA encouraged hospital networks to consolidate and with this additional pricing power, revenue at the top seven nonprofits has increased 15%, while charitable care decreased 35%. 
RAND Corp, with funding from RWJ Foundation

States paying the most are: Indiana, Wyoming, Maine, Wisconsin, Montana, Colorado, Texas, Georgia, Ohio, Washington;  while Michigan pays the least, potentially because its auto industry roots resulted in the unions pressuring the local Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments.  Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures.  The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment.  Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. 
plan to hold down prices (Michigan premiums are relatively high though). 

On average across the US is the United States of America.  , hospitals charge 2.4 * Medicare prices to the 181 million private health insurance patients.  Outpatient care was 3 * Medicare pricing; angering employers.  Some health economists assert that hospital mergers have increased their pricing power with employers (Nov 2018). 

Hospitals reviewed in the study include:

Employers say they must exert discipline on health care costs: will gather data on prices and quality to decide on the best strategy: single-payer is a healthcare architecture in which there is a single financing organization.  Significant aspects of single-payer include:
  • Strengths of single-payer:
    • Removes the extensive replication of payer organizations and their different interfaces to the other healthcare entities and subscribers. 
    • One payment organization, removing the need to allow subscribers the yearly choice to change payer, encouraging payers to help subscribers remain healthy
  • Single-payer instantiates a political monopoly on health insurance. 
  • Problematic implementation of single-payer in the US
    • Undermines the alignment of the healthcare network, threatening profits, power structures and financial rewards.  This limits the possibility of single-payer in the US: Lobbying juggernaut: Politicians, Providers, Doctors, Insurers; leveraging dislike of tax increases, The 9 out of 10 Americans who are employed or retired are satisfied with their situation, Current insurance costs are hidden from the insured: in lowered pay packages, spread over all tax payers reducing government revenues; Current private insurers would be forced to reduce costs;
    • Alters one sixth of the US economy: Commercial health insurance replaced, investors impacted by transformation of business models; a huge change of high uncertainty, something evolution works to avoid by including mechanisms to force small incremental changes. 
  • A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations.  Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016). 
, focus on best value hospitals;  Most businesses have no idea what their insurance companies are paying individual hospitals.  Colorado employers discovered they were paying 8 * Medicare prices 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). 
visits, X-ray scans and appointments with specialists. 

Insurers are not incented to keep prices down when working for self-insured companies - where insurers are spending the company's money and make more revenue when the company spends more. 

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

One-third of all healthcare spending goes to hospital care.  Hospitals are buying physician practices is physician practice management.  This consolidation of PCP practices was partly a response to Wall Street's capitalization of HMOs and hospitals in early 1990s.  As Wall Street switched to financing PPMs, enabling Medpartners's purchase of Mullikin Inc., hospitals responded by buying up the PPMs.  Most PPMs struggled to control costs in the capitated care framework of the 1990s.  Some of these PPMs shifted to become PBMs. 
and spending on new facilities.  Hospitals argue they lose money on 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. 
, so the comparison is biased.  AHA is the American_hospital association. 
commented "Medicare payment rates, which reimburse below the cost of care, should not be held as a standard benchmark for hospital prices.  Simply shifting to prices based on artificially low Medicare payment rates would strip vital resources from already strapped communities, seriously impeding access to care." 

Nov 2016 NYT First Came the Emergency.  Then Came the Surprise. 

Margot Sanger-Katz and Reed Abelson report Doug Moore was out of town at a Florida conference on information technology in October 2015 when he was struck with terrible abdominal pain emerged as a mental experience, Damasio asserts, constructed by the mind using mapping structures and events provided by nervous systems.  But feeling pain is supported by older biological functions that support homeostasis.  These capabilities reflect the organism's underlying emotive processes that respond to wounds: antibacterial and analgesic chemical deployment, flinching and evading actions; that occur in organisms without nervous systems.  Later in evolution, after organisms with nervous systems were able to map non-neural events, the components of this complex response were 'imageable'.  Today, a wound induced by an internal disease is reported by old, unmyelinated C nerve fibers.  A wound created by an external cut is signalled by evolutionarily recent myelinated fibers that result in a sharp well-localized report, that initially flows to the dorsal root ganglia, then to the spinal cord, where the signals are mixed within the dorsal and ventral horns, and then are transmitted to the brain stem nuclei, thalamus and cerebral cortex.  The pain of a cut is located, but it is also felt through an emotive response that stops us in our tracks.  Pain amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so.  Fear of pain is a significant contributor to female anxiety.  Pain is the main reason people visit the ED in the US.  Pain is mediated by the thalamus and nucleus accumbens, unless undermined by sleep deprivation. 
.  He tried to go to an 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. 
and called several local doctors.  No one could see him.  So he headed to the nearest 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). 
.  On the way, he called his insurance company to make sure the visit would be covered.  He was treated at Palms of Pasadena Hospital emergency room. 


But his bill for tests and some medications was $1,620 from an out-of-network doctor.  Doctors are often not employed by hospitals.  When the doctor has not contracted with the patient's insurer the treatments are billed at out-of-network rates. 


Research by Yale's Zack Cooper studying billing data from a national health insurer published in the New England Journal of Medicine found that more than one in five patients visiting the emergency room get a financial shock.  The research found:
  • Out-of-network bills cost on average $900 ranging up to $19,000. 
  • Wide variation across the country.  McAllen Texas surprise billing rate was 89% while Boulder, Colorado was near 0%. 
  • When people attend an ED they have little choice about who attends them. 


Zack Cooper commented on surprise billing is where a contracted service is used by a patient and the bill contains huge out-of-network charges from doctors who were consulting to the health care provider.  The opportunity to catalyze profits for: hospitals, physician staffing companies; while coping with rural E.D. staff shortages is encouraging this situation.  Examples include: E.D. billing (Nov 2016, Jul 2017)
.  "To put it in very, very blunt terms: This is the health equivalent of a carjacking."  Cooper argues the problem could be solved by Congress, who could make the visit a package including the hospital and doctor. 


Several states have passed legislation to control the problem: New York, Florida, California.  But the laws have issues.  They:
  • Only affect a fraction of insurance customers. 
  • Employer insured patients are covered by federal law. 
  • They work by setting up dispute resolution procedures, requiring patients to know they can go to state authorities to fight a big bill.  
CMS is the centers for Medicare and Medicaid services.   acting administrator sees constraining surprise bills as a policy priority.


The ACEP, representing 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). 
doctors, was critical of the Yale study.  They argued:




Insurers argue that hospitals have a responsibility to make sure the outside doctors they use to staff their 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 sign contracts with the same health plans they do.  AHIP's Kristine Grow said "This would go a long way to reduce and prevent consumers from receiving a big surprise is where a contracted service is used by a patient and the bill contains huge out-of-network charges from doctors who were consulting to the health care provider.  The opportunity to catalyze profits for: hospitals, physician staffing companies; while coping with rural E.D. staff shortages is encouraging this situation.  Examples include: E.D. billing (Nov 2016, Jul 2017)
balance bill. 


Doug Moore's insurer understood that he had gone to a contracted ED.  But they denied his claim. 


Jul 2017 NYT The Company Behind Many Surprise Emergency Room Bills

Julie Creswell, Reed Abelson & Margot Sanger-Katz report early last year, executives at a small hospital an hour north of Spokane, Wash., started using a company called EmCare to staff and run their emergency room. 


The hospital had been struggling to find doctors to work in its 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). 
, and turning to EmCare was something hundreds of other hospitals across the country had done. 


But assert Creswell, Abelson & Sanger-Katz that was the beginning of trouble at Newport Hospital and Health Services.  EmCare increased the use of complex expensive-billing-coded procedures from 6% of the time to 28% and expanded the use of surprise billing is where a contracted service is used by a patient and the bill contains huge out-of-network charges from doctors who were consulting to the health care provider.  The opportunity to catalyze profits for: hospitals, physician staffing companies; while coping with rural E.D. staff shortages is encouraging this situation.  Examples include: E.D. billing (Nov 2016, Jul 2017)



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


California recently passed a law setting a maximum amount an out-of-network doctor can charge patients.  Doctors lobbied hard to limit constraints on their bargaining position. 


While Newport hospital had negotiated rates for its fees with major health insurers, EmCare physicians weren't part of those insurance networks. 
When Newport was faced with angry patients' complaints the hospital took back control of its coding and billing. 




Yale's Zack Cooper & Fiona Scott Morton reported via the National Bureau 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. 
Research, that they found there was a pattern in the increased / surprise billing is where a contracted service is used by a patient and the bill contains huge out-of-network charges from doctors who were consulting to the health care provider.  The opportunity to catalyze profits for: hospitals, physician staffing companies; while coping with rural E.D. staff shortages is encouraging this situation.  Examples include: E.D. billing (Nov 2016, Jul 2017)


The researchers looked at Insurance data from one insurer for 9 million ED visits between 2011 and 2015. 

For customers of one large insurer when EmCare became part of the ED solution costly aspects increased
  • The rate of out-of-network doctor's billing
  • Rates of tests ordered
  • Rates of patients admitted from the E.R. to the hospital
  • The use of the highest billing codes
When ED doctors work for a company that isn't contracted with an insurer they can bill whatever they like.  A quarter of all ED doctors now work for a physician-staffing company. 

When EmCare entered 16 hospitals between 2011 and 2015 out-of-network billing rose quickly and precipitously at 8 of them.  The other 8 already had very high out-of-network billing.  Further the researchers looked at 194 hospitals where EmCare was employed with out-of-network billing rates of 62%. 

The researchers note that TeamHealth, a major competitor of EmCare, showed some increase but not as precipitously. 


EmCare said Cooper's study was flawed and dated.  However it was formerly named in the 2011 whistleblower lawsuit against HMA which claimed the two company's pressured E.R. doctors to increase admissions and tests and repeatedly terminated physicians and directors who pushed back. 


Sep 2018 NYT Blame Emergency Rooms for the Out-of-Control Cost of Health Care

USC public policy professor Glenn Melnick argues there are many reasons Americans pay more for health care than citizens of any other country.  But one of the most powerful forces driving cost increases is buried in a little-known set of regulations concerning [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). 
] care. 

Melick argues:
But Melick argues there is still a problem:


Jul 2014 NYT Race Is On to Profit From Rise of Urgent Care


24 by 7 365 days a year PhysicianOne Urgent Care treats insured, or self-pay, customers fast and immediately.  Private equity is the pooling of commitments from fund investors, to: buy assets that are not publicly traded: companies, real estate, and debt; improve their acquisition's value and sell them again, returning the sale cash to the fund investors.  Private equity companies gain competitive advantage from being lightly regulated, and wealth from the fees and special tax privileges.  Private equity companies were initially corporate raiders. 
is investing billions in Urgent Care is an efficient and less costly 'alternative' to the ER.  There is no accepted standard.  Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls.  Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones.  Unlike an ER they can not admit patients to a hospital.  Some also offer services like pre-employment drug screening and summer camp physicals. 
across the US.  It is not clear if the care is better or worse than alternatives.  PCP is a Primary Care Physician.  PCPs are viewed by legislators and regulators as central to the effective management of care.  When coordinated care had worked the PCP is a key participant.  In most successful cases they are central.  In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements.  Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. 
s argue that patients are trading quality for convenience. 

The urgent care chains are in a race to build out national consumer brands.  There are a number of forces driving the growth: 

It is not tightly defined what urgent care is.  In Illinois the authorities restrict the use of the word urgent, so clinics there are called 'immediate care' facilities.  Currently consumers seem impressed. 















































































































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