Strategic thought summaries

Summary

Introduction

Contents of published ideas

• Transformed health care
  
• Model organizations 
• Models of effective state health care
• Singapore
  

Title of probably relevent published idea

• 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. 
  : Aledade, Carena, Donna Medical Group, Iora Health, VillageMD;
• ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems.  Advocate health illustrates the idea.  Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize.  But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business.  The ACA regulates qualification to be a Medicare ACO.  Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS.  But the ACO is eligible for shared savings.  Within the shared savings program the CMS innovation center has setup advanced payment ACOs.  As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment.  CMS has established quality measures for ACOs for Medicare.  The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. 
  
  • CMS initiated its Physician Group Practice Demonstration in 2005.  By 2008 the congressional budget office reported on Bonus-eligible organizations. 
    
  • CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
  • CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing. 
    
  • CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.  
  • Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.  
  : Rio Grande Valley;
  
• Hospital networks: Dean Clinic, Kaiser Mid-Atlantic, WESTMED;
• Specialty hospitals and VASC is value added surgical center, a treatment facility with an optimized business model and processes. 
  s: Hoag Orthopedic Institute;
  
• Palliative care aims to relieve and prevent the suffering (symptoms, pain and stress of serious illness) of patients what ever their prognosis.  : Aspire Health;
  
• Home care: Village@Home;
  

• Singapore has no resources and a small population, surrounded by huge neighbors.  This weakness has encouraged & maintained focus and coherence across the society to: sustain its independence, ensure its defense, build its 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. 
  , provide housing, & improve education. 
  
• For thirty years Singapore has planned and executed strategies requiring cooperation and coordination across most government ministries.  It is exceptional in maintaining the People's Action Party consistently in power which resulted in political stability.  This allowed unity and constancy of purpose focused by a vision of 'first world standards'.  A successful 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. 
  strategy allowed subsequent investment in health.  The leaders aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group.  John Adair developed a leadership methodology based on the three-circles model. 
  felt health would be affected by almost every aspect of urban life: housing, water supply, food supply, air quality, waste disposal, road traffic, parks, tree planting etc. so health goals were built into every aspect of urban planning.  Their early focus was on 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.  
  and housing.  But they also financed postgraduate medical education and opened public outpatient dispensaries and maternal and child health clinics close to where the people lived.  Citizen concerns are used to adapt in evolutionary biology is a trait that increased the number of surviving offspring in an organism's ancestral lineage.  Holland argues: complex adaptive systems (CAS) adapt due to the influence of schematic strings on agents.  Evolution indicates fitness when an organism survives and reproduces.  For his genetic algorithm, Holland separated the adaptive process into credit assignment and rule discovery.  He assigned a strength to each of the rules (alternate hypothesis) used by his artificial agents, by credit assignment - each accepted message being paid for by the recipient, increasing the sender agent's rule's strength (implicit modeling) and reducing the recipient's.  When an agent achieved an explicit goal they obtained a final reward.  Rule discovery used the genetic algorithm to select strong rule schemas from a pair of agents to be included in the next generation, with crossing over and mutation applied, and the resulting schematic strategies used to replace weaker schemas.  The crossing over genetic operator is unlikely to break up a short schematic sequence that provides a building block retained because of its 'fitness';  In Deacon's conception of evolution, an adaptation is the realization of a set of constraints on candidate mechanisms, and so long as these constraints are maintained, other features are arbitrary. 
  the plans over time. Its key 21st century goals are:
1. Become a healthy nation by promoting good health
2. Promote individual responsibility.
3. Ensure good and affordable basic medical services for all Singaporeans
4. Engage competition and market forces to improve service and raise efficiency. 
   
5. Intervene directly in the healthcare sector when necessary, where the market fails to keep healthcare costs down. 
   
• Singapore's successful economic strategy has ensured its citizens a high standard of living is the relative wealth, comfort, useable time, goods and necessities available to particular [classes of] people.  As illustrated for the US, it is affected by availability and quality of: employment, housing, tools for risk management, percentage of salary required to purchase essential items: food, clothing & its VDS; communications & entertainment, transportation, information and computerized network support, health care, leisure time, paid retirement and education; and the rate of inflation and GDP.  Gordon extends standard of living to include conditions of work inside and outside of homes.  .  And Singapore has provided infrastructure for supporting 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. 
    
  : an inexpensive and affordable mass transit system, neighborhood fresh food markets with affordable fresh fruit and vegetables, island-wide park connectors, exercise stations, funded community centers;
  
• Singapore insists the population contribute directly to their health care costs, which maintains awareness of the benefits and costs.  Singapore developed a financing infrastructure which allowed it to redistribute national income and incent the behavior of its people.  It supports home buying and saving for health care payments and catastrophic health insurance cover.  The funds of the compulsory government saving scheme Medisave can only be used to purchase health insurance which includes both deductibles and copayments is a fixed payment for a covered service after any deductible has been met.  It is a key strategy of the ACA to make subscribers aware of the costs of treatment and to put pressure on high cost health services.  As such suppliers and providers are keen to undermine the copayment: value based health insurance, Paying the copayment (Oct 2015), Place on the USPSTF list of preventative services (Sep 2016);
  . 
  
• Singapore spends only four percent 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. 
    
  on healthcare while getting first world results. 
  
• Singapore's housing & social programs, long term stress is a multi-faceted condition reflecting high cortisol levels.  Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight.  As these actions occur the levels of cortisol return to the baseline rate.  A stressor is anything that disrupts the regular homeostatic balance.  The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis. 
  
  • The short term response to the stressor
    
  • activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response.  The brain's acuity and cognition are stimulated.  The immune system is stimulated with beta-endorphin and repair activities curtail.  In order for the body to destroy bacteria in wounds, pro-inflammatory cytokines increase blood flow to the area.  The induced inflammation signals the brain to activate the insula and through it the ACC.  But when the stressor is
    
  • long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues.  Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in.  Sustained stress provides an evolved amplifier of a position of dominance and status.  It is a strategy in female aggression used to limit reproductive competition.  Sustained stress:
    
  • Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment! 
    
  • Activates the integration between the thalamus and amygdala. 
    
  • Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful. 
    
  • BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning. 
    
  • Makes it easier to learn a fear association and to consolidate it into long-term memory.  Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala.  And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces.  Accuracy of assessing emotions from faces suffers.  A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand.  The activation of the amygdala seems to determine how the hippocampus responds. 
    
  • Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression. 
    
  • Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive.  It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.  
  • Increases the risk of autoimmune disease (Jan 2017) 
  • During depression, stress inhibits dopamine signalling.  
  • Strategies for stress reduction include: Mindfulness. 
    
  minimization, public health investments are major aspects of the population's wellbeing, limiting the direct investment that must be made in health care. 
  
• Singapore's health care provision Shewhart cycle has matched 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).   commitments to preconditions.  Most of the Government's spending comprises: subsidies allocated to the hospitals and clinics, spending on construction of health care facilities, and human resources.  It maintains rigorous cost controls by: wide-scale management of the market and regulations on how new technology is introduced to the public hospitals.  Singapore allows a free market in prescription drugs but they do use group procurement to limit costs.  Most citizens pay 65 percent of the cost of health care provision themselves.  Prices charged for health care provision are generally a quarter of those paid in the US.  Patients limit their consumption of health care because of the deductibles and copayments.  In comparison patients in other middle income countries in the region spend a lot on health care because their under developed public infrastructure and lack of trust in it which empowers the private providers who are able to increase prices substantially. 
  
• Singapore maintains a mix of public and private sector health care but insists the public sector be larger to limit private domination.  In the view of the Singapore government private sector dominance enables influence of the government and public policy to serve the sector's own ends. Sophisticated costly services are not subsidized.  Technology deployment in the public infrastructure is constrained, undermining any health technology infrastructure arms race.  Singapore is focused on adding EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
  • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
  • The EHR does not necessarily reflect the patient's situation accurately. 
    
  • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    
  • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    
  • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    
  and Tele-health is the use of remote health care.  It includes telepharmacy and clinical telehealth for stroke and psychiatry.  It also includes sessions between primary care providers and patients and assisted caregiving such as medication reminders and DME usage monitors. 
  .  The Deputy Prime Minister noted that Singapore intends to increase the priority of long term care over acute care.  He added "Most importantly, we must make it easier and more affordable for the elderly to stay at home, with access to quality care services when needed." 
  
• Singapore maintains a transparent pricing system in the public sector which forces the private sector to maintain transparent pricing too.  The leaders aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group.  John Adair developed a leadership methodology based on the three-circles model. 
  assumed health care providers would have a powerful influence on the demand for services so pricing is transparent and public hospitals are influential enough to constrain prices. 
• Singapore is seeing increasing chronic disease including 11% obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016).  Brain images of drug-addicted people and obese people have found similar changes in the brain.  Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors.  Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so.  Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease.  It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016).  Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome.  Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016). 
  and 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
  (DM is diabetes mellitus or disease management in health care. 
  ).  Most DM sufferers don't keep the disease under control due to time constraints, distance to travel to medical appointments, no care givers and a lack of motivation.  Singapore has consequently adopted a cluster system of six regional hospitals leveraging EHRs to allow diabetes includes type 1 and type 2.  Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. 
  sufferers to migrate from acute care at the regional hospital to intermediate and long-term care facilities and local clinics to ensure easy access and utilization of the range of services they need.  
• Singapore's population is both aging and living longer.  Although Singapore families traditionally support their aging parents this new scenario adds additional pressures described by Atul Gawande for traditional families in India in Being Mortal.  Singapore is extending the working age and working to keep older people active and healthy.  Haseltine explains how Singapore has updated its central plans to cope:
• Ministerial Committee on Ageing to ensure awareness across the government. 
  
• Agency for Integrated Care - to develop and coordinate aims to transfer information between the patient and each care participant as required and establish accountability by defining who is responsible for each care delivery activity, the extent of that responsibility and when that responsibility will be transferred to other care participants or the patient and family.  Successful care coordination requires face-to-face interactions.  It also requires aligned incentives (ACO, Bundled payments).  AHRQ defines quality measures for care coordination.  The situation is usually complex and adaptive due to the interactions of all the providers, settings, the patients' preferences, and the number of physical health problems, treatments, and the patients' social situation.  The potentially exponential increase in complexity as the number of these factors present increases leads to patient hot spots requiring explicit proactive coordination of care.  It is argued that care coordination must include six specific activities:
  1. Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history.  It needs to be updated periodically and after new diagnosis and other changes in health or functional status. 
     
  2. Creation and updating of proactive plan of care
     
  3. Communication
  4. Facilitation of transitions: typical transition problems are detailed by Project Boost.  A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff. 
     
  5. Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness. 
     
  6. Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.  
  a continuum of care centered on the patient with improved discharge - have costly handoff problems reviewed by project BOOST.  When discharge takes too long it ties up acute bed space which can result in adding up to 30% more (unnecessary) capacity when improved discharge would translate into additional revenue.  Various interventions aim to improve the execution of the process including: CTI, TCN and RED for discharge to outpatient; InterAct for discharge to SNFs and BPIP to HHAs.  Discharge information can include:
  • Patient info
    
  • Behavioral summary
  • Treatment history
  • Medical history
  • Treatment objectives
  • Insurance policy
  • Discharge plans
  , transportation and follow-up.  
• Center for Enabled Living - to provide outreach for the elderly and disabled of: social care services to minimize institutionalization encourage compassion indicates an emotional state where resonance with someone else's distress leads one to help them.  The Dalai Lama stresses we must feel compassion for ourselves and others.  Tara Brach sees compassion as our capacity to relate in a tender and sympathetic way to what we perceive.  Meditation focused on feeling love for the suffering, strengthens compassion by activating the neuron networks for parental love for a child: ACC, insula, striatum, PAG, orbitofrontal cortex; and inducing a reduction in areas responsible for negative emotions. 
  and deliver health education. 
• Extend the provider infrastructure to push the whole continuum of care close to the elderly populous.  It is assumed that this will help the population manage any diseases effectively.  
• Focus elderly community care on the patient's home.  But citizens have pushed back against the politicians when long-term care facilities were deployed in their neighborhoods. 
  
• The capacity of the whole hospital system is being expanded.  And long term care facilities are being repositioned to be near the major residential towers.  
• The number of health care professionals and the scope of skills (adding speech therapists, dietitians, case managers, psychologists, dentists, optometrists and podiatrists) have been expanded in the budget.  And the government is encouraging the private 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 to expand preventative and monitoring services.