awffw Strategy Analysis

(scisa1: draft v495)

Contents

Executive summary

Introduction



Summary of business situation analysis



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This AWF generic analysis of the US health care network, written from the perspective of a hospital system, and structured to leverage complex adaptive system (CAS) theory, is generated from the demo source provided with AWF.  The source data should be replaced by your enterprise's particular details, situation, models and their implications.  We hope our analysis will provide an open template source for you to customize and replace as you see fit, providing a useful shape to your analysis frame but with details that are soon replaced with your creative private alternatives. 

Our main conclusions are:

This leads to all health care providers having to solve a strategic dilemma.  Do they:
Because others will choose a strategy to follow and what not to do. 


The analysis:

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Integrating the analysis




Trends in the Environment




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Major US spending programs reflect the New Deal policies of FDR: SSA; and LBJ: Medicare and Medicaid; along with Defense.  Since the 1930s the US corporate elite have adopted long term strategies to undermine the New Deal while 'liberals' have worked to maintain this public spending.  From the 1980s both Democratic and Republican parties have converged on a globalized, financial services and high technology based strategy.  But the escalating cost of US health care and the retirement of the baby boomers demanded action. 



Since the Nixon presidency the USA has indirectly integrated its education, energy, food (the omnivore's dilemma), raw materials, public health, health care, financial services (abandoning Bretton Woods), real-estate, News/film/broadcasting, advertising (critical condition) and political strategies.  During the Reagan presidency a further shift in strategy was initiated that has over time removed many of the previous constraints on free flow throughout the global network of nation states centered on the US.  The strategy is supported by tax & budget amplifiers.  Gingrich & Clinton completed the process: NAFTA.  Global and US limits (Dodd-Frank) on this free flow of capital and resources have been added back in response to the 2008 recession (Apr 2016).  Private equity has been selected, by the Obama administration, for its financial strength and legal flexibility, to help rebuild collapsed areas of the housing market (Jun 2016).  The Trump administration's NAFTA renegotiation culminating in the USMCA, leveraged the TPP intellectual property framework, extending the patent protections on Biologics (Oct 2018). 

This system has unleashed powerful emergent forces including:
As such health care strategies are best evaluated within a broader inter-national system reflecting the influence of other nations and state and federal actors.  Internationally the disintermediation of the US system by China is increasing the significance of the US debt load.  This debt load through balanced budget requirements is impacting the states.  States have responded to offshoring of jobs by using health care as a local infrastructure for supporting job and wealth creation.  The federal government and states with interests in pharmaceuticals, biotechnology and medical devices must balance global business opportunities with the cost of indirect US health care subsidies to these industries.  Trade agreements and diverse corporate tax rates across the world structurally affect the situation

After many years when health care providers had little direct competition and could be successful by providing valued, profitable but costly treatment of variable quality to their local patient base, the introduction of new technological and political forces have undermined profitability and made the health care landscape more strategic and competitive.  In particular the ACA has supported: narrow networks, reduced Medicare & Medicaid reimbursement, constraints of FFS, Extending risk to hospitals through FFV incentives: ACO; limiting demand for treatment with copayments; resulting in consolidation of power in the largest health care payers, PBMs and health care networks. 

The Obama White House innovation strategy references a 2009 ITIF benchmark of international competitiveness. 

The USA is adapting to the loss of trillions of dollars in the 2008 financial crisis.  Among other impacts this undercut the wealth of the majority of Americans. 

The population of the US is also aging rapidly.  Health care provision for older people is best focused on the person rather than on the treatment facility as has been typical in the US system. 

The US federal structure promotes competition between states based on cost and value add.  This generates the environment within which health care niches form. 
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Public health and health care
Societies have to decide how much to invest in public health and safety net programs to improve the health of hot spot individuals relative to health care oriented strategies (Dallas Parkland Health's Mobile clinics may help hospitals manage these costs May 2016).  Current analysis suggests safety net programs are more efficient at limiting health care costs.  They also depend on effective prophylaxis in public health to control the risks of an increasingly connected world.  CDC's Ebola response to 2014 outbreak initiated in West Africa suggests significant short comings.  The 2016 US Budget, agreed in 2015, allocated money for antibiotic research to the previously budget constrained NIH and to BARDA.  Bubonic plague research (Jul 2015) suggests small genetic changes can change the fatality and infectiveness of bacteria. 

Howard Friedman and Leslie Martin argue that today's health care is far too transactional.  It does not look holistically at the mental and physical health of individuals or integrate life paths into the treatment process. 

The American poor's life expectancy is dropping especially in the central zone ravaged by drug taking related deaths, but certain cities including New York and Birmingham Alabama, are doing relatively well. (Apr 2016)
Poor Americans are suffering from more pain (Nov 2015).  Prescribing of pain killers has been rising since 1996 but crested in May 2016

Technology invasion
Technology is rapidly invading the health care space.  Sensors are becoming pervasive and far more capable.  Agent's routine rule based information processing and problem solving are now accessible to support.  Robots are able to automate processes with vastly reduced error rates.  Virtual reality has large backers like Facebook (Oculus) and Microsoft and is being experimented with in supporting robotic surgery and PTSD treatments

But as aging and technology integrate the health care system is being undermined by strategic traps: ICU process inducing more long-term acute care impacts families and Medicare

The health care pseudo market
Frustration with the inequity of a pseudo-market:
Single-payer scenario
The National Health Service, as used in the UK, removes the threat of financial ruin from the treatment transaction.  But single-payer forces the government, who pays the bills, to confront the problem of limiting the demands of the health care system.  The government consequently uses its power as the single purchaser to limit its risks introducing distortions into the rest of the health care system.  And to carry out this mandate the government must plan out the allocation of resources.  This central planning problem was discussed by Hayek in The Road To Serfdom.  It not only allocates resources unfairly but also undermines innovation as explained in The Innovator's Prescription.  Innovations tend to be introduced into the US health system much faster than in the cost constrained single-payer systems.  But Democrats, such as Michael Moore, advocate for state based insurance plans

Health care complex adaptive system scenario
Any alternative to central planning must confront an alternative dilemma.  Profits can be diverted from reinvestment in efficiency and effectiveness to profit or leadership reward maximization.  Treatment for a catastrophic condition will be required whenever it occurs (Kaiser).  It is likely to demand immediate access to infrastructure and skills.  A private solution to this dilemma requires a network of providers who will be paid for the treatment transaction (ED [reengineered], Stabilization,) by insurance, personal payment or government reimbursement.  This is the US system.  Currently it is a relatively poor performer: Wait times.  Toby Cosgrove CEO of Cleveland Clinic argues that transparent competition will work well by 2024 forcing disintermediation of hospitals and consolidation down to a few hospital systems with high leverage of transportation. 

The architecture of new hospitals must also adapt to support new trends: Bigger people (Aug 2015);


Key influences of the health care network

Legislation constrains this network, forcing the various agents to adapt (Sep 2015) to gain access and participate in the flows.  The ACA has expanded the number of people (Aug 2015, Mar 2016) who use the health care network increasing its cost base (Aug 2015) but it supports contractual limits on non-catastrophic access to the health care provider network.  This encourages
For providers transaction flows depend on being part of the contractual network (Swedish Medical Center) and being on the referral list of the anterior transaction in the network. 

Payers are locked in to a yearly contracted revenue and payment streamIntermountain has developed a novel approach that encourages long term contracting with its health plan SelectHealth (share).  But in general the yearly contract creates false, but very real and problematic constraints:
Local public health situation (Feb 2016, Apr 2016) and associated federal, state and local political strategies affect the risk to the hospital's patient base from:


Digital networks connecting patients to the health care network and each other.  Smart phones and appliances offering integration with cloud based applications allowing:

Inhibition of digital data flow by:

Genomic, proteomic and medical knowledge trends - expanding set of discoveries about cellular and system operations and pathology:

Device trends - leverage of Nano-scale and networked sensors (IEEE nano in medicine (May 2016)), computer controls, appliance based mobility and cloud based algorithms:  laboratory automation is being deployed in diagnosis by Theranos, potentially disrupting Quest and Lab Corp and transforming the medical workflow as outlined by UCSF MC and David Helfet's vision of rapid control of hospital acquired infections.  Theranos's patented vision of an arm patch: sensor, drug delivery system and tele-health connection; is popularized in Lanier's Who Owns The Future.  Google and J. & J. are partnering on robot surgery

Pharmaceutical trends - Slow expansion of targeted treatments for micro-segmented patient groups resulting in disruption of the block buster business systems (although the industry has flows and court support to sustain blockbuster model - Making Risperdal a block buster Sep 2015) of 'big pharma' results in key advances in:

Value and visibility in drug pricing is increasing (Feb 2016).  Oncologists and insurers are pushing for visibility of costs of cancer drugs. (Jun 2015)  More pressure to amend MMA to allow Medicare to negotiate prescription drug prices (2015).  Medpac recommends that Congress incent private insurers to constrain prescription drug price increases (Apr 2016). 

But compounding pharmacies have been leveraging a 2012 change of industry standards that allowed them to start billing for each ingredient in a prescription.  Pharmacy benefits managers have noticed increases in the number and cost of ingredients submitted per prescription. 
And controlled drug distribution channels, such as specialty pharmacies, allow pharmaceutical owners to bundle low price generic drugs as specialty medications with high prices, limited generic competition and profit amplification from the MMA (Sep 2015).  These channels have started to incent the patients of specialty medications (Hemophiliacs Jan 2016). 

Trial trends - CAS agents, Bayesian models, expanded informatics and targeted cellular markers make for faster, cheaper, smaller [and more questionable] (Aug 2015, Sep_2015) trials:
Limited support for integrating the trends into better practice - vision of EHR as the interface to enhanced planning, execution and learning:
Increasing sensing of patient populations:
Providing data for cloud based applications to analyze at the population level. 
Robots are getting more deployable, cheaper and more effective supporting better processes in:
Training is being supported by more sophisticated simulations.  Already movie methods including computing, 3D printing and new materials are delivering realistic mannequins.  Eventually VR may replace the use of real materials in training. 



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The tight integration of health care provision with the US elite ensures a complex adaptive response to the environmental trends.  It is to be expected that power will continue to be used to sustain the elite.  But as is typical in such situations the presence of contrary flows and constraints offers the possibility of transformational events that enable the emergence of new networks of agents. 


Scenarios for US HEALTH CARE

A negative scenario that follows logically from above is that the US will continue to allow hollowing out of its assets, and replacement of its workforce, and overtime will see its markets disrupted by developing world economies funded with US capital


A model of US Health CARE


The US system can be seen as a CAS with supporting ubiquitous labour, finance, world-wide supplies: a limited supply pool (PCP and Nurses) with a control function including:

In many ways the US health care IT situation appears to parallel the computing market during the 1970s. 

The potential for disruption of the network of companies centered around Epic will depend on the value and availability of amplifiers to distribute that value as it becomes of interest to the mainstream health care providers.  The shift to consumer oriented health care will allow leverage of new amplifiers: Amazon, Apple, Facebook, Google

Ideas




Strategic amplifiers in health care



Infrastructure amplifiers such as telehealth offer health care providers the opportunity for initial differentiation and once their network expands network effects


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Evolved amplifiers support high margins in US health care.  They promote the selection of expensive treatments, price opacity, and cost management constraints. 
The screening, diagnosis and treatment of colorectal cancer provide an illustrative case.  Patients with little impact from prices are encouraged to get screened. CMS reimbursement price controls, and lobbying by medical guilds, supported by the risk of litigation encourages the amplifying development of fat margins for overelaborate procedures that benefit all the participants financed from taxes and insurance fees. 
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Colorectal cancer screening amplifier


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The screening decision has become important to Americans and shaped by powerful actors: 
Price not a constraint: Screening process via colonoscopy enables high charges.  In approving the sedative Propofol the FDA advised it should only be administered by a trained anesthesiologist.  With lobbying from the American Society of Anesthesiologists the FDA has so far declined to rescind the advisory for low doses required for sedation.  In 2007 Aetna tried to disallow payments for anesthesiologists delivering Propofol for colonoscopy sedation but backed off after heavy criticism from anesthesiologists and endoscopy groups. 

Reimbursement:
Long term learning:

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Contents

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Stand alone clinics: Surgery, Imaging, Laboratories, Oncology; are problematic for general hospitals. 
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Private equity provides funding and strategic pressure to hospitals. 
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Aligned federal policy, and industry practice and rewards can generate powerful cascades:

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Tax and budget policy have setup a powerful evolutionary amplifier for health care.  It will strengthen strategies for health care cost control and or rationing. 

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Dialysis provides another powerful evolved amplifier for hospitals. 
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ED referral incentives are problematic for hospitals. 
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Patient advocates for drugs (Sep 2016) enable an evolved amplifier framed by Thomas Donahoe for USCC lobbying:
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Hedge funds, private equity & banks collaborate with lawyers and surgeons to enable an evolved amplifier in medical device litigation:


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Health care IT long view



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Contents of long view scenarios

<scenario contents list>


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Title of long view scenario


<Summary of scenario>


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Disruption



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Potential for disruption and its implications


<Disruption discussion>


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The deployment of elective, standalone VASC, Oncology, Imaging and laboratories introduces a classical disruptive threat to all general purpose hospital business models.  The standalone focused businesses:

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The deployment of minaturized technologies by diagnostics operations will transform how and where diagnosis can occur.  Direct interactions with consumers, redeployment from hospitals to point-of-care at retail clinics, PCP and specialists offices. 

Point-of-care diagnostics:
Direct to consumer diagnostics:



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Health care's patient segmentation analysis



Analysis includes patient:

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Patient segmentation analysis - Core uncertainty comes from: The aging of the patient base, the processed food parasite, the expanding divide of rich from poor and chronic stress.  

The increasing economic separation of rich from poor described by Piketty is reinforced by the pressure exerted by the criminal justice system ensuring that the patient population will economically bifurcate. 

Capital provider
Payment backed by:

Decision making processes
People prioritize urgent issues over chronic ones.  Notable examples include:
People's individual decisions may be influenced:

Responding to CAS signals
CAS theory indicates that people will respond to perceived and represented harsh environmental signals by removing themselves from the competition for resources needed by their offspring.  But chronic stress conditions can also result from 'our' move into an environment far more plentiful than evolutionary forces would have encountered. 

These two aspects interact to complicate the wellness of populations and the health care of chronically ill patients. 


Cultural support
The US now assumes its adult population can adapt and cope easily with changes in their: hierarchy, position in the hierarchy.  These expectations, delivered culturally to children and adolescents in the US, and required of adults are at odds with the evolved framework of the brain.  This generates harmful long term stress in the individuals. 

Culture varies across the states of the US: Southern honor.  This variation has an impact on health: Kentucky values smoking

Immigrants to US have better health while they sustain their cultural support activities.  Over time these dissipate as the immigrants adopt US food system and culture (Apr 2016).  Michael Pollan's Omnivore's Dilemma illustrates how snacking aligns with process food industry goals and correlates with western diseases first seen in Britain with the adoption of refined sugar and processed flour.  Health and Dental systems chose to align with processed food strategies generating problems to treat.  Similarly the stress of living and cultural shifts limit the time dedicated to effective parenting.  A.D.H.D. diagnosis is rising across the western network of states (Nov 2015).  

Places like Singapore integrate their urban planning with wellness.  Parks and calming situations are planned into the walks around the main city areas allowing stress reduction. 


Marriage
Marriage has a complex, but generally beneficial effect on health (Apr 2016) and longevity

Social support
A variety of US states and cities have deteriorating fiscal situations.  Puerto Rico is only the most problematic (May 2016): 
The expected impact will be to:


Diet
Diet and disease have traditionally limited height and I.Q.  The West broke out of these constraints and global health experts continue to use heights as an indicator of wellbeing.  Heights have declined in many countries including the US:


Problems with bad diet for US consumers.  American's are eating less calories but still 220 too many each day (Jul 2015), and obesity rates are still rising (Nov 2015).  What is happening?

The Mediterranean diet is associated with reduced risk of breast cancer (Sep 2015) and it or the associated lifestyle with reduced risk of: type 2 diabetes, Alzheimer's disease (Feb 2016) and Parkinson's disease (Nov 2015).  JAMA study shows continued strong evidence of the diet benefiting the heart, and cognitive function and raising issues with saturated fats (Nov 2016). 

Tea (Oct 2015) and coffee (Nov 2015) are found to improve health outcomes. 

The cocoa in chocolate, and nuts are associated with reduced risk of heart disease:

Foods containing chilli peppers significantly reduced rates of ischemic heart disease, respiratory disease and cancers and lowered the overall risk of death (Aug 2015). 

Cataracts inhibited by dietary vitamin C (Mar 2016).

Babies' rice cerial arsenic content will be limited by F.D.A. (Apr 2016). 

Potato consumption correlated with increased risk of hypertension (May 2016)

US Agriculture since 1945 shifted to monoculture croping, which required added herbicides and pesticides.  This central planned shift:

Education
Early reading to children builds educational success (Aug 2015). 
Education's cost in the US has a large negative impact on health (longevity).  The potential to reduce the cost is increasing: Salman Khan's educational framework
Poorly educated white Americans' death rates are increasing dramatically (Nov 2015). 

Steven Pinker argues that better framing of comments about a patient's illness that require an understanding of probability should help with effectiveness of the interactions. 


Salary
US has offered limited access to health care for its poorest citizens.  Income inequality policies are correlated with poor health (longevity) across the globe.  The US has declining life expectancy with age for poor women (Oct 2015)!  The structural asymmetry has been a driver of the US system since before the revolution.  Even as wealth induced innovation and trade provided more time to invest in the future or the present. 

HSAs have been growing (Sep 2015), especially among the higher paid and older. 


Age
Age based situations include:
Exercise and activity


Treatable conditions
US health care is problematic because of the financial and clinical risks of being treated and the life styles of the patient population.  Health insurance coverage has been limited with restrictions on catastrophic charges that remove the reason for taking it out and adding to the stress
While the ACA aims to address this the final execution is still to be seen. 


Conditions include:
Treatable conditions/Sex based:
Medical errors:
Damaging substance and activity dependencies include:

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Patient centered hospitals
What makes a hospital experience great?  The factors include:

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Patient value capture

Certain types of patient use health care treatments a lot.  They have access to payment mechanisms.  However, some payment streams collapse when the economy turns down.  That is a point of stress which often correlates with a need for additional treatment. 

Chronic disease treatment adherence is also low.  Clayton Christensen Institute argues that provider business models are generating treatment regimes with weak motivation to adhere. 

Different types of value capture scenarios include:


Key flows in the patients life network
The key plans (P), flows (F), signals (S), constraints (C), infrastructure amplifiers (IA) and evolved amplifiers (EA) that operate on people in the US:



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Health care provider segmentation analysis



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The health care provider analysis includes:

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Provider business analysis
US health care providers are increasingly affected by:
Driving hospital disintermediation:

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Customer segmentation analysis
Hospital agency can only be understood when viewed in terms of the political constraints on cost growth, generation of jobs, reimbursement and pricing forces that dominate US health care. 

The dramatic pressures on health care providers are altering how they are structured and make money. 

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Christensen argues that each business model can only be optimized once they are separated.  He sees diseases as typically intersecting more than one 'system' within the body.  Typical hospital organizations encourage specialists to focus on one of the 'systems' and deal with both diagnosis and treatment.  But studying the disease from the perspective of only one of those systems, therefore, can't develop an integrated solution consonant with the integrated nature of the disease.  Christensen notes that Texas Heart Institute, Cleveland Clinic Institutes, and Mayo Clinic have separated out solution shops.  For the un-optimized hospitals Christensen argues they will find wrong prescription drugs and devices that were the result of inaccurate, incomplete diagnoses by a stream of individually operating specialists.  Steele & Feinberg agree with this assessment.  24 by 7 Branded Urgent Care (1, 2) may ramp the disruption.  CVS and Wal-Mart intend to enter the health care provider market offering low cost alternatives to traditional PCP etc.  Personal experience suggests that the situation is even worse than Christensen describes: 
In line with Christensen skilled nursing facilities can be seen to be seperating into short stay rehab facilities and long term stay facilities

But the U.S. government and U.S. health care have been part of a single complex adaptive system (CAS) for many years and the recent legislation has solidified this integration.  The core schematic structures that shape the health care network are medical school education, US federal and state laws.  The health care providers are phenotypic instances of these schematic structures and the HIE, and interfaces, provide them with controlled ways to expose some state, and present signals for interactions with other CAS agents.  Fraud and billing errors are monitored within CMSMedicare's CPIC investigates fraud.  RAC recovery from billing errors is a significant issue to Hispitals in 2014

Hospitals can use their platform structure, position and power within this unusual network to their benefit.  For example the regulatory effects, increasing costs of drugs and hospitals scale and scope have driven independent oncologists to affiliate with them
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Just because there is one connected network does not limit the types of agents that operate the network.  Indeed the wide variety of environments across different states and rich and sparse regions allows different forms of agent to compete effectively.  But some trends like people getting larger has resulted in a general need for flexible rooms that accomodate all sizes (Aug 2015). 

Some providers, notably Geisinger, have been exploring their CAS structure.  Geisinger used a Boem quality process to introduce and leverage schematic structure allowing them to increase the robustness of clinical processes.  Geisinger are now using extended phenotypic alignment through their PNH (PCMH) and xG strategies to transform PCPs.  It does not seem too much of a stretch to expect them to support their Pennsylvania geographic cluster's revenue base developments and public health activities.  Currently their population base is older, poorer, sicker, more rural, and less transient than the national median.  Geisinger's integrated approach does not seem to be affecting that according to the Clayton Christensen Institute.  As of 2013 Philadelphia's economic troubles are impacting its school system.  In comparison Stanford Hospital clearly benefits from feedback such as environmental enhancements created by the radio cluster build out of Stanford University (Medical Center), Silicon Valley and biotech. 

Internally the representation of EHR and other state within proprietary data base applications constrains the ability of the health care network to instantiate new phenotypic combinations since some of the agents have incompatible infrastructure.  If such constraints become significant to the legislators and regulators they can adjust the schemata, or introduce constraints and flows to encourage the standardization of these representations.  But that is not a current focus of government. 

Externally the effective interaction of agents that make up the extended phenotypic network appears to have sufficient representation and signalling mechanisms (HIE analysis) available to support adaptive interactions. 




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There are differing ways the providers can be deployed: Cost leadership, For profit differentiation, Quality differentiation, Business model focusMedical innovation focus;   



Medical system quality differentiation strategies

Geisinger is an example of a differentiated superorganism integrated health plan and care delivery network.  Similar businesses include: Intermountain Healthcare, VA Health SystemMayo Clinic, Virginia Mason, and Cleveland Clinic  are alternative business structures that integrate the care delivery network but cooperate & compete with independent health plan businesses. 

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Notable events involving these hospital networks include: Porter describes the risks of differentiation:
Of course the unusual nature of health care transactions means that Porter's strategic mechanisms are obscured at best. 

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Geisinger demonstrates how Deming/JIT principles can be applied to the delivery of health care.  Geisinger's reengineering resulted in technology supported PCMH based ACO with All-or-nothing bundled offers.  The lack of success of 2012 pioneer ACO pilots can differentiate Geisinger's strategy if it is successful.  With its hiring of David Feinberg they are aiming to expand the value of their health plan

Geisinger funds two direct research organizations to ensure some germ-line 'mutation' medical processes are present. 

Mayo Clinic sold Mayo Clinic Health Solutions to Medica in 2017.  Cleveland clinic 2015 is reticent to offer a health plan but is reluctantly deploying an ACO. 

The costs of medical errors, increasingly focused by the ACA's pay-for-performance penalties, onto hospital's Medicare & Medicaid business, provide a significant opportunity for JIT based error removal as well as complexity management with integrated clinical teams supported by checklists.  With Geisinger's integration of physician and hospital staff this should be relatively simple to organize and execute.  For the majority of hospitals with MSO based power structures it may be more challenging. 


The PCMH integration (ProvenHealth Navigator (PHN) with xG) is particularly important because it provides a capture point for integrating the patient population.  Through differentiated reputation Geisinger can bring potential patients and better processes and infrastructure to PCPs who can offer referrals to Geisinger's treatment regimes.  Geisinger must resolve conflicts between its Epic investments and its xG strategy

Mayo Clinic has spun out Ambient Clinical Analytics

This is driving the organizations to seek more information about their patient population, and techniques to manage the patients approach to staying healthy (PHM) where Geisinger (or Kaiser) can apply their relatively large pool of talented resources to implement an effective vision. 
Tools that help incent the patient population to make healthy choices will become valuable.  But that will mean understanding what healthy choices are?  See How UPMC similarly and visibly focuses on IT and its health plan is using predictive health analytics.  Currently most extended networks do not integrate across the care continuum. 

The totally integrated 'blend' when viewed as a Porter generic strategy appears conflicted.  But superorganism shared schematic planning, signal based cooperation, differentiated forms (of clinical microsystems), and networked effects is highly competitive in a rich environment.  Geisinger's behavioral transformation processes focus on this.  The capitation based reimbursement allows the internal business models to be separated as at Cleveland Clinic and Mayo Clinic.  Multiple profit oriented businesses within the overall group structure can explore niches at the edge of chaos such as Cleveland's Lerner collage of medicine work with IBM's Watson, but it is a compromise compared to a VC plus startups system. These superorgamisms can leverage the low cost of transportation to optimize and compete widely with less efficiently organized providers as explained by Cleveland Clinic's Cosgrove and at UCLA Health (1, 2, 3).  While the idea of transporting patients to the optimal center seems important its ramifications must be understood:

Cleveland Clinic's "centers of excellence" network connect strategy is leveraged by employers aiming to provide high quality compeititive care with reference priced cost control (Aug 2016). 


The Vivity joint venture (Sep 2014) aims to build a regional HMO/ACO comparable to Geisinger's offerings. 






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Medical system cost leadership strategies

Kaiser is an example of 'cost leadership' superorganism business strategies that assume all the risk. 
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It formed as a series of regional operations and this is still reflected in its structures.  Like global telcos such as Vodafone the operations are power centers which resist doing anything company wide that might reduce their power.  Hence about the only IT infrastructure that is truly global across Kaiser is the Epic EHR branded HealthConnect by Kaiser. 


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Notable events involving these hospital networks include: Porter describes the risks in overall cost leadership:

Hence Kaiser must ensure it benefits from total integration (which is a challenge with its regional based power structure).  This focus allows Kaiser to invest in infrastructure amplifiers, including IT and salaried physicians; so that it can PDCA end-to-end processes, and identify best practices from amongst its operations. 
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They are still seeking to limit costs and treatments where they cannot influence patient performance.  Kaiser argues that healthcare must be practiced in far lower cost reengineered environments such as at home via Tele-health.  It seems likely that Kaiser will suffer from the centralized planning problem that will undermine its process oriented quality strategy. 

Sovaldi treatment pricing has highlighted that even Kaiser's Insurance policies with their yearly membership and premiums are misaligned with treatments that cure rapidly and benefit long term health of the patient and nation. 
Kaiser may also struggle to drive up quality in its nursing partnerships

If providers conclude they must sustain this approach It should be expected that provider's goals will be in conflict with those of the food, tobacco, farming and agro value delivery system. 





The ACO potentially allows a 'virtual' structure to create a Kaiser like superorganismPartners healthcare are a vanguard for much of the ACO logic.  Essence group gain quality credibility from their ACO framework.  However, it is hard to see how the effects of the organizational partitions can be removed contractually or operationally.  M. Blum questions the ACO structure.  Another illustrative example of an ACO business dilemma is expressed by a SNF and reinforced by a HHA.  The Medicare-certified ACO experiments have not demonstrated a likelihood of long term return on investment or sustainability.  The cost of necessary infrastructure was higher than the shared savings payments obtained!
Like Kaiser, ACO strategists will see home care and Tele-health, which is increasingly being deployed, as key ways to limit costs, support margins and control readmission penalties. 

If an ACO becomes the dominant health care organization in an area it should obtain better payer contracts and payment rates.  Geisinger has found structuring as an ACO to be valuable.  As an ACO gains PCPs and patients it will then be beneficial for other specialists to become part of the organization to benefit from the rates and access to patients obtained.  To enter the ACO on good contractual terms the specialists may have to organize as a super group or clinically integrated network.  This will also help with developing focus and thus specialty value-add that is likely to be necessary to obtain significant future rewards from the ACO and payers.  There is consequent need for information and control systems that can identify and highlight best practices to support networked clinical integration. 

When it is less certain that an ACO will be successful it is likely that specialists will aim to undermine Medicare ACOs to stop power shifting to the PCPs.  Spurred to organize they can contractually constrain: service level, payment guarantees, levels and risk, easy termination, beneficial dispute resolution, require access to audit trails, limit covenants and offset patient decisions to go to out of network specialists. 



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Hospital network power

Sutter Health is an example of a hospital strategy based on network effects


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Notable events involving these hospital networks include:

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Medical system Innovation focus strategies
UCSF, Johns Hopkins, Harvard affiliated Partners Healthcare, UCLA Health, and NYULMC are examples of a niche business AMC strategy focused on innovative medical science and technology.  The business alignment with innovation provides a 'do the right product' quality focus and a channel for leading edge drugs and devices to deploy through.  The research focus reduces the constraining fear of mistakenly killing a patient which otherwise forces doctors to carefully follow historic precedent.  


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Notable events involving these hospital networks include: Porter describes the risks of focus:
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Like Geisinger with its xG startup many of these hospital groups are looking to spinoff technologies and startups from their health care IT incubators and so gain access to HCIT revenues.  A value delivery system is forming with clusters of providers such as UHC, and health care technology incubators such as AVIA


UCLA describes how investment in research and EBM processes can be used to make treatments, such as People-Animal Connection, robust in the face of budget cuts.  At Laguna Honda equivalent therapy strategies (the barnyard, the greenhouse, and the aviary) were undermined by cost cutting and regulations aimed at cleanliness.  Without evidence of benefits the Laguna Honda programs were easily constrained. 

UCLA Health also focuses on JIT

UCLA Health show how an exceptional leader's differentiation strategy can build and leverage a great culture to achieve broad excellence.  This builds on itself in various ways:



The 26 hospitals in the National Comprehensive Cancer Network calls itself "the arbiter of high quality cancer care."  It creates widely used practice guidelines for cancer treatment. 
However, even at these elite centers current use lags best practice (intraperitoneal ovarian cancer treatment 2006 - 2015).  And the participants have still found themselves involved in an innovation, technology and marketing arms race (Dec 2015). 

Nanoparticle drug delivery is slowly moving towards a targeted metastatic cancer killer (Mar 2016).  Ligandal uses logically similar model for CRISPR deployment (Nano conference). 

And the testing statistical frameworks (Bayesian) and publishing methodology being used in science is undermining (Aug 2015) the leverage hospitals can obtain from a leading edge diagnosis and treatment based focus.  Often lack of validation allows powerful business models (stents to treat angina) to continue unchallenged. 
Conversely Memorial Sloan-Kettering cancer center was able to build focused genomic databases of patients which reduced misdiagnosis of minority populations (Aug 2016). 

North Shore's Lenox Hill HealthPlex is a funnel of profitable patients through its standalone EDs to the North Shore Hospitals.  Standalone EDs also undermine the positioning of low cost urgent care clinics which are trying to reengineer the ED.  NYULMC is using the same strategy at Long Island College Hospital

The pressure to integrate to combat narrow networks and the shift to population health management (PHM) to manage chronic disease makes data silos a big issue.  Any resulting Big Data strategy (UPMC) will encourage IT solutions to the silo issue.  SMART on FHIR is one Government initiated example. 


Johns Hopkins hospital at home program is reducing costs for chronic care. 



Partners Healthcare has used geographic concentration to build regional power based on customers wanting access to its lead hospitals.  The strategy limited insurance companies ability to demand lower prices since Partners required all or nothing integration with its network. 


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Hospital business model focus strategies
Both specialists and service line focused generalists can leverage this focus generic strategy. 

PCMH structured value delivery systems such as Lehigh valley's community care teams and AtlantiCare's special care center aim to use coordination to support efficient handoffs between specialists. 

Businesses can target the employer funded patient niche with added focus. 

A variety of hospitals aim to specialize on particular areas of complex care: Cardiovascular care specialists such as Texas Heart, Cancer centers such as MS-KCC


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Notable events involving these hospital networks include: At its core PCMH aims to focus attention on the patient, and ensure the PCP has the support to manage the care of a complex case.  It builds infrastructure to leverage:

There are some constraints and incoherencies in the PCMH:


The AtlantiCare special care center also reduces its billing costs by being paid a flat fee per 'hot spot' patient by the sponsoring health funds.  The goal of the center is to keep the patients healthy enough they do not need hospital and ER visits.  The individual transactions at the care center are designed to be low cost and highly flexible.  More transactions must occur.  The key to success is staffs that are focused on patient service.  Patients do not get charged to visit the center.  Regular health care incents and trains the opposite.  The key requirements are:
It is not clear how AtlantiCare becoming part of the Geisinger health system will affect these activities. 

Lehigh valley's coordination aims to support effective transfers through the hospital stay and after discharge effectively moving the patient to the most appropriate facility for their needs.  It leverages care coordinators and IT infrastructure including the EHR.  Can the use of coordination overcome the structural inefficiencies of not being deployed in a team structure?  It is also not clear how costs are managed and patients are incented to focus on wellness


Specialized focused providers such as the Hospital for Special Surgery in New York, and even Cleveland Clinic's focused Institutes can contract directly with employers such as Walmart, leveraging the transport infrastructure to bring patients to centers of excellence. 73% of AHA/ACHE CEO's said they would contract directly with employers.  This pressure should facilitate the consolidation and disruption of the profit hospital management companies.  24*7 Branded Urgent Care is another reengineered niche undermining the constrained hospital EDs, and PCP practices. 

Reengineering ED use
The high cost of ED makes it a major focus for improvements.  NYT Dec 2013 reports on Raleigh NC attempts to limit inappropriate ED use by the mentally ill.  And NYT Sep 2013 op-ed notes 40 percent of ED visits are more cost effectively handled with home visits.  Companies such as Carna are providing doctors and nurse practitioners supported by customer care software that uses algorithms to help differentiate between cases that are safe to handle at home and those that require the ED.  There is also for profit competition from urgent care clinics with Wall Street financing
But hospital systems focused on innovation are using standalone EDs to undermine this reengineering and capture more patients. 


Specialist intuitive job shops leverage low error rates to gain a competitive advantage

Specialists can avoid many of the complex costs associated with general hospitals:
Cancer centers: MS-KCC; build complex relationships with scientists, federal agencies and suppliers of specialist diagnostics and treatments. 


Focused general hospitals!
The use of service lines to tighten the focus of a general hospital: Mayo Clinic, Geisinger, El Camino Hospital; can never directly match the efficiency of a specialist: Standalone VASC (Aug 2016);  But it fills a key need of the community it serves.  Recognition of that need can provide the community general hospital with its own focused strategic advantages to add to the effective execution of the service lines.  The key requirements are:



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Government sustained, safety net focus
Safety net hospitals such as Grady Memorial, benefit from high volumes of acute patients, helping specialists build operational expertise. 

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Notable events involving these hospital networks include:



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Medical system for profit differentiation strategies
HCA, HMA + CYH, LPNT, UHS and Tenet (THC) strategy: These for profit hospital management companies have leveraged FFS into a powerful mechanism for capturing treatment revenue.  They can benefit from ACA driven reductions in uninsured but must develop new strategies to cope with meaningful use constraints, at least while the Administration and Senate are Democratic.  Counter cyclical revenue generation, growth from the aging population demographics, and cash generation from high priced services, along with consolidation is popular with shareholders including hedge funds: GlenviewCYH and Tenet both target major purchases in 2013.  CYH bid for HMA was accepted.  They have the opportunity during the shift from FFS to shared risk to push independent PCPs and specialists towards direct employment and profit oriented medical strategies but they may just increase the cost structure and undermine profitability.  More likely they will consolidate, and then disintermediate to sustain profits unless constrained by the F.T.C. (sep 2014). 

CYH has spun off its rural hospitals as Quorum Health (Aug 2015). 

Consolidation of IT infrastructure of merged provider networks is likely judged key to removing complexity and cost and improving flexibility and IT responsiveness to the businesses.  It is not clear that the hospital business executives will agree. 




Geographic niche hospital strategies
The traditional community hospitals: El Camino Health; provide a platform supporting:
But these hospital's business model may be undermined by other evolved amplifiers:
Notable events involving these hospital networks include:
The supportive local, state and federal regulatory environments limited the competitive forces on the independent doctors undermining the drive to enter additional niches and encouraging extended phenotypic alignment
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Long Island college hospital is an example of an urban hospital whose:
Rural hospitals are recipients of DOA Food, Nutrition & Consumer Services, low cost financing. 

Rural hospitals, such as Mercy Hospital Independence Kansas, are under huge pressure from an aging (more chronically ill and costly) shrinking population and ACA driven reductions in Medicare reimbursements with dozens shutting (Oct 2015). 


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Key flows in the health care provider network
The key plans (P), flows (F), signals (S), constraints (C), infrastructure amplifiers (IA) and evolved amplifiers (EA) through these hospital management companies are:




Low value isolated market segments encourage more cost effective competitors with limited payers, hospitals and provider organizations.  This allows small players to leverage the variety of connections to carve out niches. 

Community hospitals such as NMHC's Northwestern Lake Forest and McLeod use case management to control costs and manage complexity.  Faith based hospital groups have used various strategies: Shawnee (case management) and Saint Thomas (care management via Curaspan discharge) to limit penalties and improve flows. 

But poor urban communities and their general hospital networks are likely to collapse when their network interconnects with major hospital groups, or health care delivery based on for-profit medical malls reusing closed hospitals.  Poorly funded and managed community hospitals with poor uninsured populations may have few specialties, while being burdened with costly community service requirements and too much debt.  The situation will stop them attracting insured patients.  They need the protection of restrictions to support restructuring as low cost disruptive structures: Democratic and even local Republican politicians will have to choose between for-profit strategies and providing those constraints as with New York City Democrats and SUNY's Long Island College Hospital.  In contrast to the union and job retention focus of poor urban hospitals HCA promotes its flexible labor strategy. 






Long-term care hospital (LTCH) and rehabilitation service providers are focus specialists with thin margins and low cost structures.  They often use time and stories rather than EBM and efficiency.  And CMS does not provide incentives for development, certification and deployment of EHR technology to LTCH and rehabilitation providers.  These factors have kept acute care providers and enterprise EHR vendors out of this market segment.  Instead the providers and solution venders are best-of-breed specialists.  This may be an important place to deploy disruptive technology and business models although regulation may require a tailored form of EHR system. 
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The post-acute providers have become important to effectively integrate due to CMS requiring effective transfer of patients from acute care to these post-acute providers and no unplanned re-admittance.  Hence acute hospitals (such as UPMC) aim to: affiliate with standalone LTCH/rehab providers, by using reengineering based on care coordination strategies with support from an HIE to integrate their EHRs; or to partner with larger hospitals that still own these post-acute facilities and are deploying their enterprise EHR there.  The risk with such strategies is that if the business models are not truly coherent the differences will undermine the integration once one or other business comes under pressure to focus on its core competences and withdraws focus and the resources necessary to maintain the coordination. 






Managing returns
Costs, efficiencies, effectiveness and value add:  Hospitals are a cluster of medical operations.  Originally they serviced a local or regional population.  More recently transport efficiencies can allow specialists to service more global populations.  But large populations were needed to support the PDCA flows that built specialties.  Cities could thus enable specialization of a cluster of hospitals.  Geographic clustering of experts then supported the hospitals reputation growth.  The clustering process can be enhanced or impacted by geography, political strategies (e.g. not accepting Medicaid extension can hurt hospitals serving poor areas (May 2015)), having a medical school and undergraduate campus, or being close to a biotech business cluster can create a virtuous circle of: medical skills, reputation - exemplified by Geisinger, referrals, valuable patients, effective / creative management, good salaries and rewards to the key staff.  Hospitals are dependent on funding from customers, government and payers.  But with the US payment structure it has also been possible to leverage FFS to grow revenues.  Old age is particularly valuable but there are a number of other high demand operations which can be captured.  This strategy seems less dependent on reputation than on referrals and volume.  The leverage is due to infrastructure amplification by the number of beds available.  Freeing beds becomes necessary.  PAC providers offered a convenient outflow.  Where the hospital [group] has built a broad range of services and has a limited set of payers it has the power to raise fees. 


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Moved to busituation to share

Most providers have to move beyond the FFS 'shop' business model.  They can restructure from a focus on acute care hospital transactional services to leverage bundled payments, or by tightly integrating with a PAC network, or as a PCMH or an ACO.  The increased clinical and financial risk/uncertainty taken on in this series of organizations must be managed.  In the limit we reach the total capitation (with an alternative quality contract) blended integrated health systems.  The progress of the Vivity joint venture will demonstrate the opportunity and threat.  

The risk is hightened by the continuing increase in chronic illnesses with more than three interacting problems, described by Lehigh Valley health.  This growth in chronic problems could overwhelm the available number of bed and nurses and require particularly sophisticated treatment management to cope with the additional complexity.  Many hospitals are exploring how to counteract this trend in their patient base by improving wellness as described by Cleveland Clinic's CEO Toby Cosgrove. 

The merging of payers is likely to increase the pressure for health care providers to consolidate. 

The bundled payments restructuring allows hospitals to separate their 'diagnosis' oriented solution shop and value-added repair based businesses.  Cleveland clinic's Cosgrove envisions increased leverage of transportation to deliver patients to the appropriate optimized hub for treatment.  Interstate licensing may facilitate this vision.

A core interest of the hospital group in extending back to 'employ or link in' the PCP and similarly out to the specialists is to capture patient referrals while limiting financial risk

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 Health care payer segmentation analysis



Government control, commercial payers and private parties



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Goals of funding health care

Any health care network must balance the amount of health care provided/utilized against the cost of providing that health care to the population.  With: The increasing life spans of the US population, Its aging, The shift of capital from the public to private accounts, The increasing debt burden of the payers, The effects of the economic system on the population, The additional interventions that can be provided by the health care network; new strategies for success must be adopted. 

The government needs to directly or indirectly:

The ACA has three components to support Democrats' strategies to achieve these goals:
  1. FFV health care provided to patients by hospitals and doctors paid by insurers, employers, TRICARE, Medicare & Medicaid (CHIP) with support from subsidies for poor patients.  Hospital readmissions are financially penalizedHospital-acquired conditions are financially penalized.  The amount of care requested by patients is constrained by network reach, premium prices, deductibles & copayments.  
  2. Mandated health insurance coverage to provide a mostly healthy premium base to the insurance companies.  Subsidies to insurers that initially have a relatively unhealthy insurance pool.  
  3. Taxes gathered from the rich to fund the payments 

The MACRA is a bipartisan law that continues the payment based pressure to shift from FFS to FFV encouraging physicians to focus on appropriate, high quality & cost effective care and keeping subscribers well.  It reinforces the use of ACOs and bundled payments

In 2016 CMS announced a mandated bundled-payment initiative for CABGs & AMIs.  Along with MACRA the impact on cardiovascular services is significant. 
Payer types
Historically, the US health network had four distinct types of payer. The evolved payment structure encouraged hospitals to use the 'shop' business model

Now the ACA is pushing hospitals towards FFV.  Unfortunately the option to change insurer each year distorts the payer's incentives towards the short term.  However, Intermountain has developed a novel approach that encourages long term contracting with its health plan SelectHealth (share). 


The scale and scope of government based payers: Medicare and Medicaid; ensure they have considerable influence. 
The participation of states in Medicaid funding ensures a keen interest in cost containment.  States ensure diversity in the strategies used:

State & local government provide a promise of retirement to their major sets of employees: Teachers, Nurses, Police, Fire; a difficult guarantee to keep.  They often leverage a focused organization: CalPERS; to manage the funding stream to match the promise.  This stream has become increasingly stressed:

As the gap in pension funding has expanded, the states, insurance companies and pension managers have increasingly used leveraged finance based on investments by large private equity firms - who are investing in housing & infrastructure including hospitals:

The health insurers have been transformed by the ACA:

Employment related health insurance is problematic because less people will be covered during a major downturn's layoffs.  The large employers: Alphabet, GE, Honeywell, IBM, UPS, Wal-Mart; have succeeded in shifting health care costs to their employees, as they explore ways to improve the management of capital and efficiency and effectiveness of the health care services their employees use and lifestyles:

People without health insurance are mostly in a weak position when they have to pay for health care:

Payer goals
The payers must transform subscription revenue into:
The subscriptions are mainly based on yearly contracts in 2015.   That is a poor match to the long term: chronic problems and wellness strategies; of the subscriber pool that are increasingly important contriibutors to the payers cost base. 

Intermountain's SelectHealth Share replaces the problematic yearly contracts. 

UHG's strategy develops a new network structure that addresses these mismatches:
Anthem has similarly extended from insurance into integrated health care, with its ownership of CareMore

CMS's CMMI encourages experimental bundled payment structures to form between care operations, doctors and patients. 

Aetna's acquisition by CVS links the payer to community based sites of care

Population goals
The population needs:



The current US system performs poorly relative to these goals

Payers are a key part of the US health system. 

The ACA encourages them to associate effectively with providers and to help their health plan members to become more healthy.  The idea stems from the Dartmouth Institutes advocacy of Grand Junction, Colarado's risk oriented health care network organization (Dec 2015).  To have any hope of understanding how to manage risk, payers such as UPMC's Pittsburgh Health Plan are developing predictive health analytics models. 

The US health system supports screening, diagnosis and treatment processes.  Each activity must be paid for. 

Screening
Screening is an adaptive process which induces key amplifiers within the health care network. 
Diagnosis
Each health problem processed by the US system is diagnosed (Francis Collin's vision, Issues: Sep 2015, Oct 2015, Aug 2016), consequently being labelled with a diagnosis code (ICD).  After postponing the deadline twice for using ICD-10 it is now 1 Oct 2015

Treatment
Treatments are proposed based on the diagnosis.  Treatment transaction codes (CPT) and descriptive codes (SNOMED-CT) are associated. 
Treatment will typically be associated with a bill for payment. 
The government and insurance companies require that the diagnosis and treatment (services) are covered appropriately by a contract that agrees the fee for each service. 

Both insurers and the government agree with health care providers how much each service will cost.  

Brokers have acted as middlemen between small businesses and the health plans with offerings for their employees.  The ACA is impacting this area.  Startups such as Zenefits are also active aiming to leverage network effects and using the broker fees to fund the business. 




Competition between the government, health plans and private payers


Developing a health insurance business in a newly entered state is challenging (2014). The ACA provides opportunities for insurers to participate in muliple states which should help increase competition.  The key constraints on entry (Sep 2015) are financial and due to need to build network effects.  Insurers need to develop contracted networks of doctors and hospitals local to the consumer.  That takes time and leaves their offer weak while the network is limited.  And while the insurer lacks knowledge of the demographics they may need a capital cushion to handle losses from guessing wrong.  Some states have relatively young fit populations: Utah, Colorado.  But entering other states may imply large payouts in early years (Aug 2015).  The republican led congress had also reduced the budget for co-op startup by 60%.   The state insurance regulators have ensured orderly winding up of the failing co-ops (Nov 2015);

Hospitals are presented with a dilemma when they classify care.  Payers check the classifications and downcode or refuse to pay for certain care activities.  Regulation allows CMS to audit (RAC) and punish hospitals who mis-classify care. 

BCBS of massachusetts has developed an alternative quality contract to replace capitation and so encourage providers to accept FFV based care delivery. 

Consultants provide hospitals with advice on how to maximize the revenue from optimized classification and appeals of Medicare billing.  Large Insurers (UHC's Optum) have purchased their way in to this consulting area (OptumInsight purchased Executive Health Resources).  But UHC also provides private Medicare Advantage plans and argues that is provides quality care at a lower cost which introduces a conflict of interest with its work for HHS.  And Optum is a main HealthCare.gov contractor. 

Pressure for narrow networks

Insurers (Wellpoint for example) should benefit from narrow networks increasing their power with providers.  The implementation of the ACA drives consumers to join narrow networks. 

The ACA mandates Americans take out health insurance.  As of 2013 insurance policies on the web site are hard to compare or assess for cost and coverage failure risk.  The mandates have forced a major shift in strategy at Wellpoint.  Both Anthem (was called Wellpoint) and Aetna are increasing their power by merging with other large health plans in 2015.  HHS 2015 audit indicates that federal insurance cooperatives are losing money and may have difficulty repaying startup loans to the government. 
HHS research Jul 2015 found increased insurer competition on 'HealthCare.gov' reduced premiums.  California's health care exchange 'Covered California' announced 4% growth in insurance premiums for 2015.  This is far better than the 10-40% proposed by insurers participating in other exchanges.  Over the long term preventative savings may be illusionary (Aug 2015/May 2016).  The Obama administration is asking the states to limit the high premiums requested by insurers for 2016.  The five year trend from 2015 - 2015 in deductibles shows a major increase reducing the use of unnecessary care but probably also some necessary care. (Sep 2015)

The legislative drive to integrate the health care value delivery system into a continuum offers payers opportunities to push for lower cost strategies.  Potential cost of Medicaid for aging baby boomers drives states' strategic shift to managed long-term care.  During discharge planning FFS payers are incented to push for low cost PAC providers

Individual users of the government health insurance exchanges have unknown medical histories and they include relatively unhealthy individuals who were blocked from health care coverage by prior legislation replaced by the ACA.  Required coverage means the insurers offering plans on the exchanges are taking on significant risk, illustrated by Oscar (Jun 2016).  This is a key area of conflict between Democrats and Republicans. 

US public corporations have far less need to offer health care incentives to capture and maintain staff.  They are shifting to reduce health care commitments.  For example U.P.S. pushed coverage of employed spouses onto their employer.  This will increase the complexity of treatment for families and will require effective addmitance RCM and ED (AB1203, RAC) processes at hospitals.  While private payer premiums are growing more slowly (4-5%) in 2013 they are still growing faster than wages (3%).  The 40% excise tax on cadillac plans will encourage further reductions in employer provided benefits (Jul 2015). 

HDHPs and HSAs have been growing in use (Sep 2015), especially among the higher paid and older. 

Other key employers are initiating disruption of the general hospitalWal-Mart is shifting planned operations to centers of excellenceGeneral Electric is working directly with hospitals and physicians and encouraging the shift to PCMH

Drug price increases are having significant effects

Specialty drug prices have been growing rapidly (> 10% per annum).  Amgen's Blincyto continues the trend in 2015.  PBMs (Express scripts, CVS Caremark, etc.) have started to exclude costly drugs with alternatives from their formularies.  As the PBMs become integrated into retail drug distribution companies they have the ability to block access to consumers.  Consequently CVS, Walgreens, Rite-Aid etc. have been expanding their drug distribution channel control to limit ways for drugs to flow around their control points.  It seems to be working for diabetes drugs (Oct 14).  Everyone is watching to see if the strategy will undermine the price of Gilead's Sovaldi.  The structure did force Gilead into steeper discounts (Sep 2015).  Drug companies have responded by paying the copayments to undermine the ACA use of direct contributions to provide the population with a direct signal of the benefits and costs (Oct 2015). 

State governments are also interested in controlling the cost of Sovaldi.  Their yearly balanced budget requirement is threatened by Sovaldi's treatment model (just a few months) and pricing.  Congress is responding (Jul 2015). 

Drug price increases and regulatory changes have pushed independent oncologists to affiliate with hospitals.  Oncologists have responded by releasing a framework for evaluating cancer drugs on benefit and price (Jun 2015). 

Medication spending may only be 10% of health spending in the US but increases in drug prices have an outsize effect on patients because:


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Strategic influence of government


Government (Administration, Legislature and Courts) influence in health care is significant and due to strategic differences in the Republican and Democratic strategies is quite unpredictable.

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The US 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 PCPs; and their suppliers.  Trade agreements regulate the operation of importers and exporters.  Federal and state regulation shapes the US VDS 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 maintained by a mixture of federal and state structures.  The wellbeing 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 defends against poverty:
Additionally children's health care is supported by CHIP:

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 (title I - 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 vision) will require transitional strategies, which Republicans should strongly resist:

ACA Medicaid expansion provides an alternative:
By 2018 Chronic care is being addressed:
In 2015 funding for Medicare and Social Security account for 40 percent of all federal spending.  The trustees of Social Security reported (Aug 2015) that the disability 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 secutary Burwell's point -- ACA has extended Medicare's trust fund. 

Federal regulation is administered by:
State regulation is also significant:
Competing state level health strategies can induce innovation:
State governors and their influence

The government is also a major user of Medical Infrastructure:

The increase in the percentage of GDP dedicated to health care makes it a central focus of politics. 
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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 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 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 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 increases the numbers of people covered by insurance.  As South Carolina is concluding many of the poor will be found eligible for Medicaid 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.  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:

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.  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). 

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Contents of significant technology
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Title of significant technology

<Summary of influential technology>


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 Electronic Health Records



Regulations (standards), Implementation specifications, certification critieria, compliance, Technology architectures, Business goals and Emergence



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The federal government seems intent on acting both as a sensor and evolved amplifier for its health care infrastructure.  ONC is chartered to act as a path finder sponsoring radical architecture projects: such as eHealth exchange; and the direct project.  ONC then identifies best practices which can be driven through HIT into the mainstream health care provider networkEHR is a key example of the amplification process.  But ONC is concerned about business driven EHR silos (May 2015). 

The EHR regulators evolved a preexisting legislative and regulatory CAS.  This provides coherence to the legal and regulatory framework but makes the technical challenges of implementation and compliance truly complex. 

The Federal Government's agenda is summarized (from ONC 10 year IOP paper) as:
The stated strategies for achieving this agenda are to facilitate government and private sector to develop five building blocks of a IOP infrastructure:
  1. Core technical standards and functions (via a vision like the JASON architecture for a robust health data infrastructure)
    1. Methods to accurately match individuals, providers, and their information across data sources
    2. Directories of the technical and human readable end points for data sources for discovery
    3. Methods for authorizing users  when they want access
    4. Methods for authenticating users
    5. Methods for securing the data
    6. Methods to represent the data
    7. Methods for handling the data
  2. Certification to support adoption and optimization of health IT products and services
  3. Privacy and security protections for health information
  4. Supportive business, clinical, cultural, and regulatory environments - including:
  5. Rules of engagement and governance

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Hospitals have been encouraged to deploy conforming EHR systems through HITECH financial incentives and meaningful use requirements. 
The EHR systems help hospitals:

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MACRA encourages doctors offices to also deploy EHR systems. 

The EHR vendors, with ten to twenty year old products, encouraged the evolution, which pushed their systems firmly into the US hospital operations.  Now the system must continue to evolve itself with the equivalent of SAP upgrades (Cerner spaghetti) to perform in parallel.  It seems clear that integrating an EMR with clinical operations and evidence is difficult. Epic's strategy includes encouraging friendly startups (Moxie) to improve the integration. 

PHR systems may improve EHR access:

While the EHR has been criticised (legitimately Oct 2014, Dec 2015) for focusing the doctors and nurses on the workstation rather than the patient new approaches such as Augmedix leverage of Google Glass to interface to the EHR show that this issue may eventually be removed. 

The EHR records for a patient aim to reflect the diagnosis and medication records of the patient creating a history to consult.  However, it is noted (Laguna Honda admitting) that the nature of acute, ED and ICU treatments risks adding diagnosis and medications to solve immediate problems.  It can require considerable time to unpick the mis-diagnosis (Sep 2015, Oct 2015, Aug 2016) and treatments from the root causes and to correct the record.  Often a drive for efficiency (2) undermines that option. 

The focus of HCIT regulations, including the HITECH act, and CFR final rule (Federal Register 45 CFR Part 170) and the HIT SC, on supporting meaningful use via EHR technology has created a force that has driven investment and effort into the development, deployment and implementation of EHR systems in ambulatory and hospital inpatient environments.  The thrust of regulations creates barriers to entry, and ongoing costs which should improve the competitive position of the leading EHR vendors.  As additional leverage is made of the platform based on the EHR requirements CMS, agencies, hospitals, PCPs and leading EHR technology suppliers should become increasingly phenotypically aligned


If the key privacy requirement is to protect the identity of the patient, it would seem an alternative strategy to the current EHR direction would be to make the linkage between the identity (highly encrypted) and all other details - totally open in the repositories, would allow simpler mechanisms for research on architectures, and sharing of the non secure data.  That would allow for an IETF like infrastructure to be developed by computer scientists that would become deployed once the current strategy of proprietary database silos and gateways becomes unmanageable and counter productive. 

Code of Federal Regulations (CFR)

45 CFR part 160 and 162 (HIPAA CFRs)
45 CFR Part 160 and 162 interim final rule Jul 8 2011, associates HIPPA operating rules with the ACA legal requirements to improve the utility (uniformity) and reduce the administrative cost of HIPAA compliant integration of the RCM software based: (1) Eligibility for a Health Plan and (2) Health Care Claim Status transactions; infrastructure between covered entities: health care providers, clearinghouses and health plans

Part 160 covers administrative data standards and related requirements
Part 162 covers administrative requirements.  Specifies that all HIPAA covered entities must transact using specified ASC X.12 parts and NCPDP telecommunication standard (See table 1) but it accepts that the flexibility in these standards leaves gaps:
The ACA was designed to include legislation to remove the gaps.  It requires these CFRs to define mandatory business rules and guidelines, validated, and checked for technical coherence and consensus, by the NCVHS.  Operating rule authorizing entities that support the NCVHS in this role include the CAQH's CORE and the NCPDP.  The NCPDP's Version D.0 standard for retail pharmacies was deemed complete without additional operating rules. 

The CFR includes studies that were used in assessing the impact and opportunity for change in the transaction system:

This regulatory application and constraint of selected formal standards with mandated guidelines appears at first inspection to be a beneficial activity.  But, unlike the risk and progress oriented IETF process, this approach encourages heavy weight implementations that favor incumbents with the capital to resource all the requirements and rework.  Indeed the incumbents can be expected to:
In 2014 the USHEI report noted:


45 CFR Part 170
45 CFR Part 170's final rule applies only to EHR systems and EHR modules and does not directly regulate the situation in which they operate.  However, other rules and regulations such as meaningful use provide these constraints in specific environments.  45 CFR Part 170's final rule in tandem with Medicare BPCI and Medicaid incentive programs result in EHR system purchasers focusing on deploying qualified EHR modules and systems that have achieved EHR certification for their targeted environments (such as ambulatory or hospital inpatient).  Such modules and systems have passed the certification criteria adopted by the Secretary of Health and Human Services.  Hence instead of network effects amplifying the deployment of useful emergent technologies defined by an IETF style process, EHR vendors primary focus must be to obtain certification and health care providers will deploy the certified technology to ensure reimbursement.  

The regulations have adopted consensus standards in line with NTTAA statute except for:

The regulations have adopted the strategy of specifying constraints as goals with measures and certification criteria.  The certification criteria are able to reflect particular environments such as hospital inpatient and ambulatory allowing development of focused complete EHR systems.  Examples of such constraints would be:
The 45 CFR Part 170 regulation's final rule aims to be coherent with other regulations requirements.  The rule both defines standards, implementation specifications and certification criteria for HITECH and leverages and aligns with other existing ones such as HIPAA and 70 FR 67579 rule for Medicare Part D e-prescribing.  Compliance of EHR or EHR modules with adopted standards is solely reflected in the certification criteria which state how to achieve the compliance in terms of including 'specified capabilities implemented in accordance with' the required standards, implementation specifications and certification criteria.  Contexts and circumstances are not specified in 45 CFR Part 170 because they will be inherited from prior regulations when these (such as HIPAA and Medicare) apply. 

45 CFR 164.308(a)(1) the security risk assessment final rule specifies access control requirements of EHR modules.  Audit trails and alerts on configured events are required, including deletion of data.  It must be possible to detect reading of classified data from audit logs.  Automatic logoff is assumed. 
68 FR 8355 HIPAA's security final rule considers emergency access a required part of access control. 

75 FR 36158 the temporary certification program final rule specifies security and privacy requirements of EHR modules

NIST (FIPS 140-2) approved encryption.  Message data is required to be able to be encrypted and signed to detect tampering.  The EHR technology must have the capability to encrypt the data. 

OCR must regulate a final rule prior to its adoption for EHR technology certification. 

It seems likely that EHR vendors will be highly constrained and will focus significant effort on discovery and adherence to the extended CAS rules and regulations.  For example the patient summary certification focuses on data such as problem and medication lists.  It seems clear from project Boost and hot spot strategies exemplified by the special care center of AtlantiCare Medical Center that what would be effective needs to take into account the specific situation of the patient.  But that is a much harder problem for technology to solve.  Instead resources will be used to lock in on the certification capabilities.  (Dallas Parkland Health's Mobile clinics may help hospitals manage these costs May 2016).  Just as when the Federal government helped the consolidation of AT&T and IBM it seems likely that the EHR vendors will gain fat profits and can be expected to consolidate the market using classic IBM strategies and tactics.  It is reported that Epic is avoiding HIE integration.  Does the HIE have an effective security architecture?  KLAS respondents weren't convinced. 

An equally difficult challenge is the representation of inaccurate data within the EHR.  Laguna Honda illustrates how medication and diagnosis notes can become invalid.  So EHR data quality is hard to ensure and sustain. 

The architecture of the certified EHR network is a highly distributed network of EHRs.  The effective coordination of workflows in such a distributed environment with shared state is typically quite challenging.  For example when a patient provides updates about their current status (insurance details, medication changes etc.) does the network aim to update all copies of the information? 

This suggests there is a significant risk that the federal government will suck capital, or momentum, out of progressive HCIT projects and starve the HCIT industry of emergent opportunities.  KLAS post-acute care perceptions 2013 confirms this worry

SMART on FHIR
The Federal government responded to this challenge by sponsoring an application development environment for developing applets that can operate on distributed sets of EHRs, HIEs and other HITs.  This has developed into SMART on FHIR




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 Health Information Exchanges



Regulations (standards), Implementation specifications, certification critieria, compliance, Technology architectures, Business goals and Emergence



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Health Information Exchanges (HIE) can be viewed as schematically generated phenotypic infrastructure for supporting the signal and sensor deployment necessary for the interaction of complex adaptive system (CAS) agents within the health care provider network
HIE Core Services:
The Markle Foundation has been a significant influence on the early approaches taken to HIE architecture and deployment. 

It is suggested that HIE automatic reporting will reduce labor costs. 

The current nature of the foundation's common framework signal generation mechanism seems remarkably indirect.  Markle's approach to external standards resulted in common framework based systems being complicated and acts as a barrier (due to high development costs and limited value of the initial emergent entities) to emergence of networks (NHIN) based on such systems.  As ONC funding in 2012-13 has dried up the various state HIEs have been collapsing. 

Some exchanges, such as Tennessee's have been terminated in favor of use of the Direct Project which they concluded is simpler.  KLAS sees rising dissatisfaction with the HIE approach.  Dissatisfaction has increased over time. 

Deployment of HIE has been slow.  This has been attributed to:
However, as providers have worked with HIE, failure to scale appears to be the major issue with HIE based solutions.  With the requirement to construct the query results each time and then resolve the associated data with networked gets this is no surprise.  (recall RPC - 'its like a procedure call only slower'!)  In comparison Epic Care Everywhere is viewed by the customer base very positively.  KLAS also promote athenaHealth's strategy as an attractive alternative. 

Providing filters which remove sensitive information is only a partial solution to the privacy and security constraints.  Medication information that is withheld may be important to know to effectively prescribe new treatments and medications. 

Can CAS architectures effectively represent individual agents (patients)?  Typically they use ubiquitous equivalence to support flows. 


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Business rule Management



Centralized control, change and business rule architecture



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Centralization of business rules in a repository ensures business process flows can apply an agent like use of sensors to leverage the 'executable' derivative of the plan to select how to proceed.  The use of audit, monitoring, lifecycles and business editing capabilities allows the PDCA to interactively improve the schematic plan

The application of a genetic algorithm to improve the viability of the rule set is offset by the centralized ability to alter key aspects of the rules.  Given the need to specialize the rules by facility, business relationship and environment which would seem to benefit from a GA and the goal of central control and architectural understanding which would seem to be undermined by a GA the real implementations are not surprisingly challenged. 

The products like FICO's Blaze Advisor that implement these complex rule sets are like computer programs written in primitive languages like BASIC without type checking, scope control, or memory management support.   Therefore they become brittle and difficult to manage. 



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Financial Analysis



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Financial Analysis

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Financial SCENarios

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Published ideas



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Contents of published ideas

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Title of probably relevent published idea


<Summary of published idea>

Ezekiel Emanuel's Prescription for the future identifies model transformed health care organizations:
Haseltine's assessment of Singapore healthcare, provides a model of an efficient & effective health care network:


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