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We are products of complexity, but our evolution has focused our
understanding on the situation of hunter gatherers on the
African savanna.
As humanity has become more powerful we can significantly impact
the systems we depend on. But we struggle to comprehend
them. So this web frame
explores significant real world complex
adaptive systems (CAS):
- Assumptions of randomness & equilibrium allowed the
wealthy & powerful to expand the size and leverage of
stock markets, by placing at risk the insurance and
retirement savings of the working class. The
assumptions are wrong but remain entrenched.
- The US nation was built
from two divergent political
views of: Jefferson and Hamilton. It also
reflects the development
of competing ancient ideas of Epicurus and
Cyril. But the collapse of Bretton Woods forced Wall
Street into a position of power, while the middle and
working class were abandoned by the elites. Housing
financed with cash from oil and derivative transactions
helped hide the shift.
- Most US health care is still
operating the way cars built in the 1940s did.
Geisinger is an example of better solution. But
transforming the whole network is a challenge. And
public health investment has proved far more
beneficial.
- Helping our children learn to be
effective adults is part of our humanity, but we have
created a robust but deeply flawed education system.
Better alternatives have emerged.
- Spoken language, reading and writing emerged allowing our
good ideas to
become a second genetic material.
- The emergence
of the global economy in the 1600s and its subsequent
development;
It explains how the examples relate to each other, why we all
have trouble effectively comprehending these systems and
explains how our inexperience with CAS can lead to catastrophe. It
outlines the items we see as key to the system and why.
Example systems frame |
Dietrich Dorner argues complex adaptive systems (CAS) are hard to understand and
manage. He provides examples of how this feature of these
systems can have disastrous consequences for their human
managers. Dorner suggests this is due to CAS properties
psychological impact on our otherwise successful mental
strategic toolkit. To prepare to more effectively manage
CAS, Dorner recommends use of:
- Effective iterative planning and
- Practice with complex scenario simulations; tools which he
reviews.
Complexity catastrophes |
E. O. Wilson reviews the effect of man on the natural world to
date and explains how the two systems can coexist most
effectively.
Adaptive ecology |
Barton Gellman details the strategies used by Vice President
Cheney to align the global system with his economics, defense, and
energy goals.
US vds alignment |
Kevin Kruse argues that from 1930 onwards the corporate elite
and the Republican party have developed and relentlessly
executed strategies to undermine Franklin Roosevelt and the New Deal. Their
successful strategy used the credibility of conservative
religious leaders to:
- Demonstrate religious issues
with the New Deal.
- Integrate the corporate
elite and evangelicals.
- Use the power of corporate
advertising and Hollywood to reeducate the American
people to view the US as historically religious and
the New Deal and liberalism as anti-religious
socialism.
- Focus the message through evangelicals including Vereide and Graham.
- Centralize the strategy through President Eisenhower.
- Add religious elements to
mainstream American symbols: money, pledge;
- Push for prayer in
public school
- Push Congress to promote prayer
- Make elections more
about religious positions.
Following our summary of his arguments RSS frames them from the
perspective of complex adaptive system (CAS) theory.
Strategy is the art of the possible. But it also depends
on persistence.
Inventing Christian America |
Charles Ferguson argues that the US power structure has become
highly corrupt.
Ferguson identifies key events which contributed to the
transformation:
- Junk bonds,
- Derivative
deregulation,
- CMOs,
ABS and analyst fraud,
- Financial network deregulation,
- Financial network consolidation,
- Short term incentives
Subsequently the George W. Bush administration used the
situation to build
a global bubble, which Wall Street
leveraged. The bursting of the
bubble: managed
by the Bush Administration and Bernanke Federal Reserve;
was advantageous to some.
Ferguson concludes that the restructured and deregulated
financial services industry is damaging to
the American economy. And it is supported by powerful, incentive aligned academics.
He sees the result being a rigged system.
Ferguson offers his proposals
for change and offers hope that a charismatic young FDR will appear.
Following our summary of his arguments, RSS comments on them framed by
complex adaptive system (CAS)
theory. Once the constraints are removed from CAS
amplifiers, it becomes advantageous to leverage the increased flows. And it is often
relatively damaging not to participate. Corruption and parasitism can become
entrenched.
Financial WMD |
Matt Taibbi describes the phenotypic
alignment of the American justice system. The result
he explains relentlessly grinds the poor and undocumented into
resources to be constrained, consumed and ejected. Even as
it supports and aligns the financial infrastructure into a
potent weapon capable of targeting any company or nation to
extract profits and leave the victim deflated.
Taibbi uses five scenarios to provide a broad picture of the:
activities, crimes, policing, prosecutions, court processes,
prisons and deportation network. The scenarios are:
Undocumented people's neighborhoods, Poor neighborhoods, Welfare
recipients, Credit card debtors and Financial institutions.
Following our summary of his arguments, RSS comments on them framed by
complex adaptive system (CAS) theory. The alignment of the
justice system reflects a set of long term strategies and
responses to a powerful global arms race that the US leadership intends to
win.
Aligned justice |
Jonathan Powell describes how the government of, the former UK Prime Minister, Tony Blair,
actually operated. Powell was Blair's only chief of
staff.
Mechanics of power |
H. A. Hayek compares and contrasts collectivism and
libertarianism.
Libertarianism |
John Doerr argues that company leaders and their
organizations, hugely benefit from Andy Grove's OKRs.
He promotes strategies
that help OKR success: Focus,
Align, Track, Stretch; replaces yearly performance
reviews, and provides illustrative success
stories.
Doerr stresses Dov Seidman's
view that employees are adaptive and will
respond to what they see being measured. He asserts culturally supported OKRs/CFR processes will be transformative.
Following our summary of his arguments, RSS comments on them
framed by complex adaptive system (CAS) theory. Doerr's architecture
is tailored for the startups KPCB
invests in. It is a subset of the general case of schematic plans, genetic operators and Shewhart cycles that drive all
CAS. Doerr's approach limits support of learning and deemphasizes the
association to planning.
Startup PDCA |
David Bodanis illustrates how disruptive effects can take
hold. While the French revolution had many driving forces
including famine and
oppression the emergence of a new philosophical vision ensured
that thoughtful leaders
were constrained and conflicted in their responses to the
crisis.
Voltaire's disruptive network |
An epistatic meme suppressed for a thousand years reemerges
during the enlightenment.
It was a poem
encapsulating the ideas of Epicurus rediscovered by a
humanist book hunter.
Greenblatt describes the process of suppression and
reemergence. He argues that the rediscovery was the
foundation of the modern world.
Complex adaptive system (CAS) models of the memetic mechanisms
are discussed.
Constraining happiness |
Isaacson uses the historic development of the global cloud of
web services to explore Ada
Lovelace's ideas about thinking
machines and poetic
science. He highlights the value of computer
augmented human creativity and the need for liberal arts to
fulfill the process.
Complex adaptive system (CAS) models of agent networks and
collaboration are discussed.
Arts technology & intelligence |
Haikonen juxtaposes the philosophy and psychology of
consciousness with engineering practice to refine the debate on
the hard problem of consciousness. During the journey he
describes the architecture of a robot that highlights the
potential and challenges of associative neural
networks.
Complex adaptive system (CAS) theory is then used to illustrate the
additional requirements and constraints of self-assembling
evolved conscious animals. It will be seen that
Haikonen's neural
architecture, Smiley's Copycat
architecture and molecular biology's intracellular
architecture leverage the same associative properties.
Associatively integrated robots |
Good ideas are successful because they build upon prior
developments that have been successfully implemented.
Johnson demonstrates that they are phenotypic expressions of
memetic plans subject to the laws of complex adaptive systems (CAS).
Developing ideas |
A government sanctioned monopoly
supported the construction of a superorganism
American Telephone and Telegraph (AT&T). Within this
Bell Labs was at the center of three networks:
- The evolving global scientific
network.
- The Bell telephone network. And
- The military
industrial network deploying 'fire and missile
control' systems.
Bell Labs strategically leveraged each network to create an innovation
engine.
They monitored the opportunities to leverage the developing
ideas, reorganizing to replace incumbent
opposition and enable the creation and growth of new
ideas.
Once the monopoly was
dismantled, AT&T disrupted.
Complex adaptive system (CAS) models of the innovation mechanisms are
discussed.
Strategic innovation |
Roger Cohen's New York Times opinion about the implications of
BREXIT is summarized. His ideas are then framed by complex
adaptive system (CAS) theory and
reviewed.
BREXIT |
Scott Galloway argues that Apple, Amazon, Facebook and Google
are monopolists that
trade workers for technology. Monopolies that he argues
should be broken up to ensure the return of a middle
class.
Following our summary of his arguments, RSS comments on these arguments
assuming they relate to a complex adaptive system (CAS).
While Scott's issue is highly significant his analysis conflicts
with relevant CAS history and theory.
Monopoly job killers |
The IPO of Netscape is
defined as the key emergent event of
the New Economy by Michael Mandel. Following the summary
of Mandel's key points the complex adaptive system (CAS) aspects are highlighted.
New economy |
Ed Conway argues that Bretton Woods produced a unique set of
rules and infrastructure for supporting the global economy. It was
enabled by the experience of Keynes
and White during and after the First World War, their dislike of the Gold Standard,
the necessity of improving
the situation between the wars and the opportunity created
by the catastrophe of the Second
World War.
He describes how it was planned
and developed. How it
emerged from the summit.
And he shows how the opportunity inevitably allowed the US to replace the UK at the center of the global economy.
Like all plans there are
mistakes and Conway takes us through them and how the US recovered the situation as
best it could.
And then Conway describes the period after
Bretton Woods collapsed. He explains what followed
and also compares the relative performance of the various
periods before during and after Bretton Woods.
Following our summary of his arguments RSS comments from the
perspective of Complex Adaptive System (CAS)
theory. Conway's book illustrates the rule making and
infrastructure that together build an evolved amplifier.
He shows the strategies at play of agents that were for and
against the development
and deployment of the system. And The Summit provides a
key piece of the history of our global economic CAS.
Bretton woods |
A key agent in the 1990 - 2008
housing expansion Countrywide is linked into the residential
mortgage value delivery system (VDS)
by Paul Muolo and Mathew Padilla. But they show the VDS
was full of amplifiers and control points. With no one
incented to apply the brakes the bubble grew and burst.
Following the summary of Muolo and Padilla's key points the
complex adaptive system (CAS)
aspects are highlighted.
Housing amplifiers |
Satyajit Das uses an Indonesian company's derivative trades to
introduce us to the workings of the international derivatives
system. Das describes the components of the value delivery
system and the key
transactions. He demonstrates how the system
interacted with emerging economies
expanding them, extracting profits and then moving on as the
induced bubbles burst. Following Das's key points the
complex adaptive system (CAS)
aspects are highlighted.
Derivative systems |
Johnson & Kwak argue that expanding the national debt
provides a hedge against unforeseen future problems, as long as
creditors are willing to continue lending. They illustrate
different approaches to managing the debt within the US over its history and of the
eighteenth century administrations of England and France.
The US embodies two different political and economic systems which
approach the national debt differently:
- Taxes to support a sinking
fund to ensure credit to leverage fiscal power in:
Wars, Pandemics, Trade disputes, Hurricanes, Social
programs; Starting with Hamilton,
Lincoln & Chase,
Wilson, FDR;
- Low taxes, limited infrastructure, with risk assumed by
individuals: Advocated by President's Jefferson & Madison,
Reagan,
George W. Bush (Gingrich);
Johnson & Kwak develop a model of what the US
government does. They argue that the conflicting
sinking fund and low tax approaches leaves the nation 'stuck in
the middle' with a future problem.
And they offer their list of 'first principles' to help
assess the best approach for moving from 2012 into the
future.
They conclude the question is still political. They hope
it can be resolved with an awareness of their detailed
explanations. They ask who is willing to
push all the coming risk onto individuals.
Following our summary of their arguments RSS frames them from the
perspective of complex adaptive system (CAS) theory.
Historically developing within the global cotton value delivery
system, key CAS features are highlighted.
National debt |
Robert Gordon argues that the inventions of the second
industrial revolution were the foundation for
American economic growth. Gordon shows how flows of people
into difficult rural America built a population base
which then took the opportunity to move on to urban settings: Houses, Food in supermarkets,
Clothes in
department stores;
that supported increasing productivity and standard of living.
The deployment of nationwide networks: Rail, Road, Utilities;
terminating in the urban housing and work places allowing the workers to
leverage time saving goods and services, which helped grow
the economy.
Gordon describes the concomitant transformation of:
- Communications
and advertising
- Credit
and finance
- Public
health and the health
care network
- Health insurance
- Education
- Social
and welfare services
Counter intuitively the constraints
introduced before and in the Great Depression and the demands of World War 2
provide the amplifiers that drive the inventions deeply and
fully into every aspect of the economy between 1940 and 1970
creating the exceptional growth and standard of living of post
war America.
Subsequently the
rate of growth was limited until the shift of women
into the workplace and the full networking of
voice and data supported the Internet and World Wide Web
completed the third industrial revolution, but the effects were
muted by the narrow reach of the technologies.
The development of Big Data, Robots,
and Artificial Intelligence may support additional growth,
but Gordon is unconvinced because of the collapse of
the middle class.
Following our summary of Gordon's book RSS frames his arguments from
the perspective of complex adaptive system (CAS) theory.
American growth |
Carl Menger argues that the market induced the emergence of
money based on the attractive features of precious metals.
He compares the potential for government edicts to create money
but sees them as lacking.
Following our summary of his arguments RSS frames his arguments from
the perspective of complex adaptive system (CAS) theory.
With two hundred years of additional knowledge we conclude that
precious metals are not as attractive as Menger asserts.
Government backed promissory notes are analogous to:
- Other evolved CAS forms of ubiquitous high energy
transaction intermediates and
- Schematic strategies that are proving optimal in
supporting survival and replication in the currently
accessible niches.
Emergence of money |
Eric Beinhocker sets out to answer a question Adam Smith
developed in the Wealth of Nations: what is wealth? To do
this he replaces traditional
economic theory, which is based on the assumption that an
economy is a system in
equilibrium, with complexity
economics in which the economy is modeled as a complex
adaptive system (CAS).
He introduces Sugerscape
to illustrate an economic CAS model in action. And then he
explains the major features of a CAS economy: Dynamics,
Agents, Networks, Emergence, and
Evolution.
Building on complexity economics Beinhocker reviews how evolution applies to
the economy to build wealth. He explains how design spaces
map strategies to instances of physical and
social
technologies. And he identifies the interactors and
selection mechanism of economic
evolution.
This allows Beinhocker to develop a new definition
of wealth.
In the rest of the book Beinhocker looks at the consequences of
adopting complexity economics for business and society: Strategy, Organization, Finance,
& Politics
& Policy.
Following our summary of his arguments, RSS explores his conclusions
and aligns Beinhocker's model of CAS with the CAS theory and evidence we
leverage.
Economic complexity |
Sven Beckert describes the historic transformation of the
growing, spinning, weaving, manufacture of cotton goods and
their trade over time. He describes the rise of a first global
commodity, its dependence on increasing: military power, returns for
the control points in the value delivery system(VDS), availability of land
and labor to work it including slaves.
He explains how cotton offered the opportunity for
industrialization further amplifying the productive capacity of
the VDS and the power of the control points. This VDS was quickly
copied. The increased capacity of the industrialized
cotton complex adaptive system (CAS) required more labor to
operate the machines. Beckert describes the innovative introduction of wages
and the ways found to
mobilize industrial labor.
Beckert describes the characteristics of the industrial cotton
CAS which made it flexible enough to become globally interconnected.
Slavery made the production system so cost effective that all
prior structures collapsed as they interconnected. So when
the US civil war
blocked access to the major production nodes in the
American Deep South the CAS began adapting.
Beckert describes the global
reconstruction that occurred and the resulting destruction of the traditional ways
of life in the global countryside. This colonial expansion
further enriched and empowered the 'western' nation
states. Beckert explains how other countries responded
by copying the colonial strategies and creating the
opportunities for future armed conflict among the original
colonialists and the new upstarts.
Completing the adaptive shifts Beckert describes the advocates
for industrialization
in the colonized global south and how over time they
joined the global cotton CAS disrupting the early western
manufacturing nodes and creating the current global CAS
dominated by merchants like Wal-Mart
pulling goods through a network of clothing manufacturers,
spinning and weaving factories, and growers competing with each
other on cost.
Following our summary of Beckert's book, RSS comments from the
perspective of CAS theory. The transformation of
disconnected peasant farmers, pastoral warriors and their lands
into a supply chain for a highly profitable industrial CAS
required the development over time: of military force, global
transportation and communication networks, perception and
representation control networks, capital stores and flows,
models, rules, standards and markets; along with the support at
key points of: barriers, disruption, and infrastructure and
evolved amplifiers. The emergent system demonstrates the
powerful constraining influence of extended phenotypic
alignment.
Globalization from cotton |
The structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
Health care |
Deaton describes the wellbeing
of people around the world today. He explains the powerful benefit of public
health strategies and the effect of growth in
material wellbeing but also the corrosive effects of
aid.
Following our summary of Deaton's arguments RSS comments from the
perspective of complex adaptive system (CAS)
theory. The situation he describes is complex including
powerful amplifiers, alignment and incentives that overlap
broadly with other RSS summaries of adaptations of: The
biosphere, Politics, Economics,
Philosophy and Health care.
Improving wellbeing |
Donald Barlett and James Steele write about their investigations
of the major problems afflicting US
health care as of 2006.
Problems of US health care |
Glenn Steele & David Feinberg review the development of the
modern Geisinger healthcare business after its near collapse
following the abandoned merger with Penn State AMC. After an overview of the
business, they describe how a calamity
unfolding around them supported building a vision of a
better US health care network. And they explain:
- How they planned
out the transformation,
- Leveraging an effective
governance structure,
- Using a strategy
to gain buy in,
- Enabling
reengineering at the clinician patient
interface.
- Implementing the reengineering for acute, chronic
& hot
spot care; to help the patients and help the
physicians.
- Geisinger's leverage of biologics.
- Reengineering healing with ProvenExperience.
- Where Geisinger is headed next.
Following our summary of their arguments RSS comments on them. We
frame their ideas with complex adaptive system (CAS)
theory.
E2E insured quality care |
Bad medical models |
US healthcare is ripe for
disruption. Christensen, Grossman and Hwang argue that
technologies are emerging which will support low cost business
models that will undermine the current network. Applying
complex adaptive system (CAS)
theory to these arguments suggests that the current power hierarchy can effectively resist
these progressive forces.
Disrupting health care |
Atul Gawande writes about the opportunity for a thirty per cent
improvement in quality in medicine by organizing
to deploy as agent based teams using shared schematic
plans and distributed signalling or as he puts it the use of checklists.
With vivid examples from a variety of situations including construction, air crew support and global health care Gawande illustrates
the effects of
complexity and how to organize to cope with it.
Following the short review RSS
additionally relates Gawande's arguments to its models of
complex adaptive systems (CAS) positioning his discussion within
the network of US health care,
contrasting our view of complexity, comparing the forces shaping
his various examples and reviewing facets of complex
failures.
Complexity checklists |
Friedman and Martin leverage the lifelong data collected on
1,528 bright individuals selected by Dr. Lewis Terman
starting in 1921, to understand what aspects of the subjects'
lives significantly affected their longevity. Looking
broadly across each subject's: Personality,
Education, Parental impacts,
Energy
levels, Partnering,
Careers, Religion,
Social networks,
Gender, Impact from war and
trauma; Friedman and Martin are able to develop a set of model pathways,
which each individual could be seen to select and travel
along. Some paths led to the traveler having a long
life. Others were problematic. The models imply that
the US approach to health and
wellness should focus
more on supporting
the development and selection of beneficial pathways.
Following our summary of their arguments RSS comments from the
perspective of CAS theory. The pathways are most
applicable to bright individuals with the resources and support
necessary to make and leverage choices they make. Striving
to enter and follow a beneficial pathway seems sensible but may
be impossible for individuals trapped in a collapsing network,
starved of resources.
Promoting longevity |
Gawande uses his personal experience, analytic skills and lots
of stories of innovators to demonstrate better ways of coping
with aging and death. He introduces the lack of focus on
aging and death in traditional medicine. And goes on to
show how technology has amplified
this stress point. He illustrates the traditional possibility of the
independent self, living fully while aging with the
support of the extended family. Central
planning responded to the technological and societal changes
with poorly designed infrastructure and funding. But
Gawande then contrasts the power of
bottom up innovations created by experts responding to
their own family situations and belief
systems.
Gawande then explores in depth the challenges
that unfold currently as we age and become infirm.
He notes that the world is following the US path. As such it will
have to understand the dilemma of
integrating medical treatment and hospice
strategies. He notes that all parties
involved need courage to cope.
He proposes medicine must aim to assure
well being. At that point all doctors will practice
palliative care.
Complex adaptive system (CAS) models of agency, death,
evolution, cooperation and adaptations
to new technologies are discussed.
Agent death |
Sonia Shah reviews the millennia old (500,000 years) malarial arms race between Humanity, Anopheles
mosquitoes and Plasmodium. 250 - 500 million people are
infected each year with malaria and one million die.
Malaria |
Peter Medawar writes about key historic events in the evolution
of medical science.
Medical science events |
Using John Holland's theory of adaptation in complex
systems Baldwin and Clark propose an evolutionary theory of
design. They show how this can limit the interdependencies
that generate complexity
within systems. They do this through a focus on
modularity.
Modular designed systems |
Lou Gerstner describes the challenges he faced and the
strategies he used to successfully restructure the computer
company IBM.
Compartmented systems |
Grady Booch advocates an object oriented approach to computer
software design.
Object based systems |
Bertrand Meyer develops arguments, principles and strategies for
creating modular software. He concludes that abstract data
types and inheritence make object orientation a superior
methodology for software construction. Complex adaptive
system (CAS) theory suggests agents provide an alternative strategy
to the use of objects.
Software construction |
Tools and the businesses that produce them have evolved
dramatically. W Brian Arthur shows how this occurred.
Tools |
Matt Ridley demonstrates the creative effect of man on the
World. He highlights:
- A list of
preconditions resulting in
- Additional niche
capture & more free time
- Building a network
to interconnect memes processes & tools which
- Enabling inter-generational
transfers
- Innovations
that help reduce environmental stress even as they leverage fossil
fuels
Memetic trading networks |
E O. Wilson argues that campfire gatherings on the savanna supported
the emergence of human creativity. This resulted in man
building cultures and
later exploring them, and their creator, through the humanities. Wilson
identifies the transformative events, but he notes many of these
are presently ignored by the humanities. So he calls for a
change of approach.
He:
- Explores creativity:
how it emerged from the benefits of becoming an omnivore hunter gatherer,
enabled by language & its catalysis of invention, through stories told in the
evening around the campfire. He notes the power of
fine art, but suggests music provides the most revealing
signature of aesthetic
surprise.
- Looks at the current limitations of the
humanities, as they have suffered through years of neglect.
- Reviews the evolutionary processes of heredity and
culture:
- Ultimate causes viewed
through art, & music
- The bedrock of:
- Ape senses and emotions,
- Creative arts, language, dance, song typically studied
by humanities,
&
- Exponential change in science and
technology.
- How the breakthrough from
our primate past occurred, powered by eating meat,
supporting: a bigger brain, expanded memory &
language.
- Accelerating changes now driven by genetic cultural coevolution.
- The impact on human nature.
- Considers our emotional attachment to the natural world: hunting, gardens; we are
destroying.
- Reviews our love of metaphor, archetypes,
exploration, irony, and
considers the potential for a third enlightenment,
supported by cooperative
action of humanities and science
Following our summary of his arguments RSS frames these from the
perspective of complex adaptive system (CAS) theory:
- The humanities are seen to be a functionalist framework
for representing the cultural CAS while
- Wilson's desire to integrate the humanities and science
gains support from viewing the endeavor as a network of
layered CAS.
Evening campfire rituals |
Brynjolfsson and McAfee explore the effects of Moore's law on the
economy. They argue it has generated exponential
growth. This has been due to innovation.
It has created a huge bounty of
additional wealth.
But the wealth is spread unevenly across
society. They look at the short and long term implications of
the innovation bounty and spread
and the possible future of
technology.
Following our summary of their arguments RSS comments from the
perspective of CAS theory.
Brilliant technologies |
Salman Khan argues that the evolved global education system is
inefficient and organized around constraining and corralling
students into accepting dubious ratings that lead to mundane
roles. He highlights a radical and already proven
alternative which offers effective self-paced deep learning
processes supported by technology and freed up attention of
teams of teachers. Building on his personal experience of
helping overcome the unjustified failing grade of a relative
Khan:
- Iteratively learns how to teach: Starting with Nadia, Leveraging
short videos focused on content,
Converging on mastery,
With the help of
neuroscience, and filling
in dependent gaps; resulting in a different approach
to the mainstream method.
- Assesses the broken US education system: Set in its ways, Designed for the 1800s,
Inducing holes that
are hidden by tests, Tests
which ignore creativity.
The resulting teaching process is so inefficient it needs to
be supplemented with homework.
Instead teachers were encouraging their pupils to use his tools at home so
they could mentor them while they attended school, an
inversion that significantly improves the economics.
- Enters the real world: Builds a scalable service,
Working with a
real classroom, Trying stealth
learning, At Khan Academy full time, In the curriculum at
Los Altos, Supporting life-long
learning.
- Develops The One World Schoolhouse: Back to the future with
a one
room school, a robust
teaching team, and creativity enabled;
so with some catalysis
even the poorest can
become educated and earn credentials
for current jobs.
- Wishes he could also correct: Summer holidays, Transcript based
assessments, College
education;
- Concludes it is now possible to provide the infrastructure
for creativity to
emerge and to support risk taking.
Following our summary of his arguments RSS frames them from the
perspective of complex adaptive system (CAS) theory. Disruption is a powerful force for
change but if its force is used to support the current teachers
to adopt new processes can it overcome the extended phenotypic alignment and evolutionary amplifiers sustaining the
current educational network?
Education versus guilds |
Amy Chua and Jed Rubenfeld's New York Times opinion based on The
Triple Package is summarized. Their ideas are then framed
by CAS theory and reviewed.
What drives success |
Peter Turchin describes how major pre-industrial empires
developed due to effects of geographic boundaries constraining
the empires and their neighbors' interactions. Turchin
shows how the asymmetries of breeding rates and resource growth
rates results in dynamic cycles within cycles. After the
summary of Turchin's book complex adaptive system (CAS) theory
is used to augment Turchins findings.
Warrior groups |
Through the operation of three different food chains Michael
Pollan explores their relative merits. The application of
complex adaptive system (CAS)
theory highlights the value of evolutionary
testing of the food chain.
Natural systems |
E. O. Wilson & Bert Holldobler illustrate how bundled cooperative strategies can
take hold. Various social insects have developed
strategies which have allowed them to capture the most valuable
available niches. Like humans they invest in
specialization and cooperate to subdue larger, well equipped
competitors.
Insect superorganisms |
Computational
theory of the mind and evolutionary
psychology provide Steven Pinker with a framework on which
to develop his psychological arguments about the mind and its
relationship to the brain. Humans captured a cognitive niche by
natural selection 'building out'
specialized aspects of their bodies and brains resulting in a system of mental organs
we call the mind.
He garnishes and defends the framework with findings from
psychology regarding: The visual
system - an example of natural
selections solutions to the sensory challenges
of inverse
modeling of our
environment; Intensions - where
he highlights the challenges of hunter gatherers - making sense
of the objects they
perceive and predicting what they imply and natural selections powerful solutions; Emotions - which Pinker argues are
essential to human prioritizing and decision making; Relationships - natural selection's
strategies for coping with the most dangerous competitors, other
people. He helps us understand marriage, friendships and war.
These conclusions allow him to understand the development and
maintenance of higher callings: Art, Music, Literature, Humor,
Religion, & Philosophy; and develop a position on the meaning of life.
Complex adaptive system (CAS) modeling allows RSS to frame Pinker's arguments
within humanity's current situation, induced by powerful evolved
amplifiers: Globalization,
Cliodynamics, The green revolution
and resource
bottlenecks; melding his powerful predictions of the
drivers of human behavior with system wide constraints.
The implications are discussed.
Computationally adapted mind |
The stages of development of the human female, including how her brain changes and the
impacts of this on her 'reality' across a full life span:
conception, infantile
puberty, girlhood,
juvenile pause, adolescence, dating years, motherhood, post-menopause; are
described. Brizendine notes the significant difference in
how emotions are processed
by women compared to men.
Complex adaptive system (CAS) theory associates the stages with
the evolutionary under-pinning, psychological implications and
behavioral CAS.
Evolved female brain |
The complexity of behavior is explored through Sapolsky
developing scenarios of our best and worst behaviors across time
spans, and scientific subjects including: anthropology,
psychology, neuroscience, sociology. The rich network of
adaptive flows he outlines provides insights and highlight
challenges for scientific research on behavior.
Complex adaptive system (CAS) theory builds on Sapolsky's
details highlighting the strategies that evolution has captured
to successfully enter niches we now occupy.
CAS behavior |
Carlo Rovelli resolves the paradox of time.
Rovelli initially explains that low level physics does not
include time:
- A present that is common throughout the universe does not exist
- Events are only partially ordered. The present is
localized
- The difference between past and future is not foundational.
It occurs because of state that through our blurring appears
particular to us
- Time passes at different speeds dependent on where we are and how fast we travel
- Time's rhythms are due to
the gravitational field
- Our quantized physics shows neither
space nor time, just processes transforming physical
variables.
- Fundamentally there is no time. The basic equations
evolve together with events, not things
Then he
explains how in a physical world without time its perception can
emerge:
- Our familiar time emerges
- Our interaction with the world is partial, blurred,
quantum indeterminate
- The ignorance determines the existence of thermal time
and entropy that quantifies our uncertainty
- Directionality of time is real
but perspectival. The entropy of the world in
relation to us increases with our thermal time. The
growth of entropy distinguishes past from future: resulting in
traces and memories
- Each human is a
unified being because: we reflect the world, we
formed an image of a unified entity by
interacting with our kind, and because of the perspective
of memory
- The variable time: is one
of the variables of the gravitational field.
With our scale we don't
register quantum fluctuations, making space-time
appear determined. At our speed we don't perceive
differences in time of different clocks, so we experience
a single time: universal, uniform, ordered; which is
helpful to our decisions
Emergence of time |
Consciousness has confounded philosophers and scientists for
centuries. Now it is finally being characterized
scientifically. That required a transformation of
approach.
Realizing that consciousness was ill-defined neuroscientist
Stanislas Dehaene and others characterized and focused on conscious access.
In the book he outlines the limitations of previous
psychological dogma. Instead his use of subjective
assessments opened the
window to contrast totally unconscious
brain activity with those
including consciousness.
He describes the research methods. He explains the
contribution of new sensors and probes that allowed the
psychological findings to be correlated, and causally related to
specific neural activity.
He describes the theory of the brain he uses, the 'global neuronal
workspace' to position all the experimental details into a
whole.
He reviews how both theory and practice support diagnosis and
treatment of real world mental illnesses.
The implications of Dehaene's findings for subsequent
consciousness research are outlined.
Complex adaptive system (CAS) models of the brain's development and
operation introduce constraints which are discussed.
Conscious access |
Reading and writing present a conundrum. The reader's
brain contains neural networks tuned to reading. With
imaging a written word can be followed as it progresses from the
retina through a functional chain that asks: Are these letters?
What do they look like? Are they a word? What does it sound
like? How is it pronounced? What does it mean? Dehaene
explains the importance of
education in tuning the brain's networks for reading as
well as good strategies for teaching reading and countering dyslexia. But
he notes the reading
networks developed far too recently to have directly evolved.
And Dehaene asks why humans are unique in developing
reading and culture.
He explains the cultural
engineering that shaped writing to human vision and the exaptations and neuronal structures that
enable and constrain reading and culture.
Dehaene's arguments show how cellular, whole animal and cultural
complex adaptive system (CAS) are
related. We review his explanations in CAS terms and use
his insights to link cultural CAS that emerged based on reading
and writing with other levels of CAS from which they emerge.
Evolved reading |
Read Montague explores how brains make decisions. In
particular he explains how:
- Evolution can create indirect abstract models, such as the dopamine system, that
allow
- Life changing real-time
decisions to be made, and how
- Schematic structures provide
encodings of computable control
structures which operate through and on incomputable,
schematically encoded, physically active structures and
operationally associated production
functions.
Receptor indirection |
Antonio Damasio argues
that ancient
& fundamental homeostatic processes,
built into
behaviors and updated by evolution
have resulted in the emergence
of nervous systems and feelings. These
feelings, representing the state of the viscera, and represented with general
systems supporting enteric
operation, are later ubiquitously
integrated into the 'images'
built by the minds of higher animals
including humans.
Damasio highlights the separate
development of the body frame in the building of
minds.
Damasio explains that this integration of feelings by minds
supports the development of subjectivity and consciousness. His chain of
emergence suggests the 'order of things.' He stresses the
end-to-end
integration of the organism which undermines dualism. And he reviews Chalmers
hard problem of consciousness.
Damasio reviews the emergence of cultures
and sees feelings, integrated with reason, as the judges of the
cultural creative process, linking culture to
homeostasis. He sees cultures as supporting the
development of tools
to improve our lives. But the results of the
creative process have added
stresses to our lives.
Following our summary of his arguments RSS frames his arguments from
the perspective of complex adaptive system (CAS) theory.
Each of the [super]organisms
discussed is a CAS reflecting the theory of such systems:
- Damasio's proposals about homeostasis routed signalling, aligns
well with CAS theory.
- Damasio's ideas on cultural stresses are elaborated by CAS
examples.
Emergence of feelings |
Alfred Nemeczek reveals the chaotic, stressful life of Vincent
van Gogh in Arles.
Nemeczek shows that Vincent was driven
to create, and successfully
invented new methods of representing feeling in paintings, and
especially portraits. Vincent
worked hard to allow artists like him-self
to innovate. But
Vincent failed in this goal, collapsing into psychosis.
Nemeczek also provides a brief history of
Vincent's life.
Following our summary of his main points, RSS frames the details from the
perspective of complex adaptive system (CAS) theory.
Vincent creates |
Richard Dawkin's explores how nature has created implementations
of designs, without any need for planning or design, through the
accumulation of small advantageous changes.
Accumulating small changes |
Russ Abbott explores the impact on science of epiphenomena and
the emergence of agents.
Autonomous emergence |
Terrence Deacon explores how constraints on dynamic flows can
induce emergent phenomena
which can do real work. He shows how these phenomena are
sustained. The mechanism enables
the development of Darwinian competition.
Constraint based phenomena |
|
|
Bad medical models
Summary
Robert Pearl explains the perspectives of a health care leader
and son who know that the current health care network interacts
with human behavior to induce a poorly performing system that
caused his father's death. But he is confident that these
problem perceptions can be changed. Once that occurs he
asserts the network will become more integrated, coordinated,
collaborative, better led, and empathetic to their
patients. The supporting technology infrastructure will be
made highly interoperable. All that will reduce medical
errors and make care more cost effective.
Following our summary of his arguments RSS is Rob's Strategy Studio comments on them. We
frame his ideas with complex adaptive system (CAS) theory
including synergistic examples of these systems in
operation. The health care network is built out of
emergent human agents. All agents must model the signals
they perceive to represent and respond to them. Pinker
explains how this occurs. Sapolsky explains why fear and
hierarchy are so significant. He includes details of Josh
Green's research on morality and death. Charles Ferguson
highlights the pernicious nature of financial incentives.
Mistreated
Why we think we're getting good health care--and why we're
usually wrong
In Robert
Pearl's book
'Mistreated' he:
- Celebrates his father's life and laments the failings of
the US is the United States of America.
The structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
health care network which induced
medical
errors that caused his death from sepsis is an infection triggered over-reaction by the immune system which causes general inflammation resulting in a cascade of problems: Blood clots, Leaky blood vessels; impeding blood flow to vital organs which can induce septic shock: Blood pressure drops, multiple organ failure, Heart damage and death. For every hour without antibiotics the probability of death increases 8%. Most cases start before people are hospitalized. People over 65, infants under 1 year, people with chronic diseases such as diabetes, or weakened immune systems and healthy people with incorrectly treated infections are most likely to contract sepsis. Most often the infections are of: lungs, urinary tract, skin, gut or intestines. Typically such infections were the result of a previous visit to a clinic or hospital. Symptoms of sepsis include: chills or fever, extreme pain or discomfort, clammy or sweaty skin, confusion or disorientation, shortness of breath and high heart rate. Dr. Diane Craig noted that sepsis had become the leading cause of death among hospitalized patients. Using patient matching on: age, symptoms, degree of illness; from the hospital system EHR, Craig identified the blood-lactate test as the key diagnostic that supported early, aggressive treatment of sepsis. She argued that whenever a patient had two symptoms of significant infection a lactate test be used along with EGDT treatment for patients with lactate counts as low as 2.5 millimoles/liter. This reduced sepsis mortality to 40% below the national average. But only half the hospitals in the US followed Craig's recommendations. Dr. Robert Pearl concludes this is because of the high risk of killing a patient with EGDT treatment, even though the protocol will reduce overall mortality by half. Doctors don't want to be responsible for killing patients so they opt not to order the lactate test. In 2017 sepsis is estimated to cost the US health care system more than $20 billion a year. The C.D.C. is concerned (Sep 2016) with antibiotic resistance generating more sepsis. . This
motivates Pearl to carefully analyze the network's problems
and the flawed perceptions that allowed them to develop and
persist. He aims to shift perceptions and gain
acceptance for alternate strategies that encourage high
quality low cost health care that his father would have
appreciated.
- Initially describes and analyses the problematic effects
of context on doctors,
patients and large health care
organizations. He identifies the resulting persistent but
incorrect ideas.
- Subsequently reviews
goals and strategies to transform the current network:
Goals of the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
, Pearl's four pillars of
transformation, and understanding our
health care wants and needs; so that doctors',
hospitals', insurers' and their suppliers' view of the
situation will increasingly highlight issues and so they
will respond by addressing them.
Pearl notes that doctors
are extensively trained, including years of rigorous practice,
so that they are competent to diagnose and treat medical
problems:
- Cutting open the body, inserting scopes, prescribing
powerful medications and removing damaged tissue to
eradicate disease.
- Leveraging modern technology to gain access to data and
diagnostic information and support of advanced scientific
discoveries including genomics combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes. ,
to radically enhance care.
- Total joint replacements are performed and the patients
are home in less than a day, instead of being kept in
hospital for at least a week as in the past.
- Children with life-threatening diseases: cystic fibrosis is a deadly, recessive genetic disease caused by a variety of single gene mutations in the CFTR gene, most commonly occurring in people of northern European background. Screening would work best if applied to couples prior to conception but this is not how carrier screening is organized as of 2015. Cystic fibrosis can result in: fibrous cysts in the pancreas; which does not secrete its normal digestive enzymes inducing serious malnutrition, intestinal blockages, infertility in males and lung damage due to accumulation of a thick, sticky secretion followed by recurrent infections. Symptoms vary among sufferers because:
- Modifier genes which vary between individuals.
- Environmental differences:
- Second hand smoke exposure is a significant contributor to cystic fibrosis effects
- Medical interventions such as: pancreatic enzyme capsules, chest physical therapy, antibiotics, aerosolized enzyme therapy, saltwater mists and double lung transplants; can reduce the effects
- Diet
,
leukemia is a group of cancers of blood forming tissues: bone marrow, lymphatic network; where abnormal white blood cells are generated. One type of leukemia is induced when TAD boundaries near the TAL1 gene fail allowing promotors from across the TAD border to distort the operation of the TAL transcription factor. Mutation clusters common in leukemia have been identified in CHIP. ; are now
treated and live longer and more normal lives.
- Heart disease is cardiovascular disease which refers to:
- Conditions where narrowed and blocked blood vessels
result in angina, hypertension,
CHD and heart
attacks and hemorrhagic/ischemic strokes.
Mutations of the gene PCSK9 have
been implicated in cardiovascular disease. Rare
families with dominant inheritence of the mutations have
an overactive protein, very high levels of blood
cholesterol and cardiac disease. Other rare PCSK9
mutations result in an 88% reduced risk from heart disease.
Inflammation is associated with cardiovascular disease (Aug
2017).
is no longer the leading cause of death in parts of the
world.
But Pearl
asserts that inside each doctor lurks a persistent sense of
terror: success in the role requires judgment, skill and
luck! Physicians fear making a
mistake that harms a patient. They agree to 'First, do no harm.'
But practice long enough and there will be a life-threatening
mistake: a problem diagnosis, causing a major infection, or
committing a technical error. He describes a set of system
problems:
- Avoiding testing for sepsis is an infection triggered over-reaction by the immune system which causes general inflammation resulting in a cascade of problems: Blood clots, Leaky blood vessels; impeding blood flow to vital organs which can induce septic shock: Blood pressure drops, multiple organ failure, Heart damage and death. For every hour without antibiotics the probability of death increases 8%. Most cases start before people are hospitalized. People over 65, infants under 1 year, people with chronic diseases such as diabetes, or weakened immune systems and healthy people with incorrectly treated infections are most likely to contract sepsis. Most often the infections are of: lungs, urinary tract, skin, gut or intestines. Typically such infections were the result of a previous visit to a clinic or hospital. Symptoms of sepsis include: chills or fever, extreme pain or discomfort, clammy or sweaty skin, confusion or disorientation, shortness of breath and high heart rate. Dr. Diane Craig noted that sepsis had become the leading cause of death among hospitalized patients. Using patient matching on: age, symptoms, degree of illness; from the hospital system EHR, Craig identified the blood-lactate test as the key diagnostic that supported early, aggressive treatment of sepsis. She argued that whenever a patient had two symptoms of significant infection a lactate test be used along with EGDT treatment for patients with lactate counts as low as 2.5 millimoles/liter. This reduced sepsis mortality to 40% below the national average. But only half the hospitals in the US followed Craig's recommendations. Dr. Robert Pearl concludes this is because of the high risk of killing a patient with EGDT treatment, even though the protocol will reduce overall mortality by half. Doctors don't want to be responsible for killing patients so they opt not to order the lactate test. In 2017 sepsis is estimated to cost the US health care system more than $20 billion a year. The C.D.C. is concerned (Sep 2016) with antibiotic resistance generating more sepsis.
so as not to damage or kill a patient with the dangerous,
but essential, EGDT is early goal directed therapy, Henry Ford Medical Center emergency and critical care physician Dr. Emmanuel Rivers's 2001 New England Journal of Medicine article recommending aggressive protocols for the early detection and treatment of sepsis. Dr. Robert Pearl explains this aggressive sepsis treatment is risky and potentially fatal. The steps include: - Puncture the patient's neck with a large needle, and deploy a central venous line down near the heart. This carries the risk of damaging the underlying lung.
- Administer powerful antibiotics with large amounts of fluid. The fluid can flood the patient's lungs and overwhelm the heart's ability to pump, drowning the patient.
treatment protocol. Sepsis is a major killer of
hospital patients and aggressive treatment has been shown to
reduce deaths from sepsis by 40%. Pearl adds
- That sepsis is an infection triggered over-reaction by the immune system which causes general inflammation resulting in a cascade of problems: Blood clots, Leaky blood vessels; impeding blood flow to vital organs which can induce septic shock: Blood pressure drops, multiple organ failure, Heart damage and death. For every hour without antibiotics the probability of death increases 8%. Most cases start before people are hospitalized. People over 65, infants under 1 year, people with chronic diseases such as diabetes, or weakened immune systems and healthy people with incorrectly treated infections are most likely to contract sepsis. Most often the infections are of: lungs, urinary tract, skin, gut or intestines. Typically such infections were the result of a previous visit to a clinic or hospital. Symptoms of sepsis include: chills or fever, extreme pain or discomfort, clammy or sweaty skin, confusion or disorientation, shortness of breath and high heart rate. Dr. Diane Craig noted that sepsis had become the leading cause of death among hospitalized patients. Using patient matching on: age, symptoms, degree of illness; from the hospital system EHR, Craig identified the blood-lactate test as the key diagnostic that supported early, aggressive treatment of sepsis. She argued that whenever a patient had two symptoms of significant infection a lactate test be used along with EGDT treatment for patients with lactate counts as low as 2.5 millimoles/liter. This reduced sepsis mortality to 40% below the national average. But only half the hospitals in the US followed Craig's recommendations. Dr. Robert Pearl concludes this is because of the high risk of killing a patient with EGDT treatment, even though the protocol will reduce overall mortality by half. Doctors don't want to be responsible for killing patients so they opt not to order the lactate test. In 2017 sepsis is estimated to cost the US health care system more than $20 billion a year. The C.D.C. is concerned (Sep 2016) with antibiotic resistance generating more sepsis.
displays the
orphan disease problem. Sepsis can be caused by
multiple conditions and start in many different organs so
it is not owned by any particular medical specialty.
It is not the focus of a big fund raising advocacy
group.
- In
medicine failure has serious consequences for patients and
physicians. So both practice avoidance. Medical
schools discourage creativity in their
students. The goal is to learn "the right way" to
provide medical care without questioning it. The
most successful learn details rote and can answer
verbatim. And the training and residency teaches
that conforming to the "community standard" of care is the
best defense for criticism. To act otherwise is to
risk ones license and career. Pearl's point is that
when teachers and colleagues don't test for sepsis is an infection triggered over-reaction by the immune system which causes general inflammation resulting in a cascade of problems: Blood clots, Leaky blood vessels; impeding blood flow to vital organs which can induce septic shock: Blood pressure drops, multiple organ failure, Heart damage and death. For every hour without antibiotics the probability of death increases 8%. Most cases start before people are hospitalized. People over 65, infants under 1 year, people with chronic diseases such as diabetes, or weakened immune systems and healthy people with incorrectly treated infections are most likely to contract sepsis. Most often the infections are of: lungs, urinary tract, skin, gut or intestines. Typically such infections were the result of a previous visit to a clinic or hospital. Symptoms of sepsis include: chills or fever, extreme pain or discomfort, clammy or sweaty skin, confusion or disorientation, shortness of breath and high heart rate. Dr. Diane Craig noted that sepsis had become the leading cause of death among hospitalized patients. Using patient matching on: age, symptoms, degree of illness; from the hospital system EHR, Craig identified the blood-lactate test as the key diagnostic that supported early, aggressive treatment of sepsis. She argued that whenever a patient had two symptoms of significant infection a lactate test be used along with EGDT treatment for patients with lactate counts as low as 2.5 millimoles/liter. This reduced sepsis mortality to 40% below the national average. But only half the hospitals in the US followed Craig's recommendations. Dr. Robert Pearl concludes this is because of the high risk of killing a patient with EGDT treatment, even though the protocol will reduce overall mortality by half. Doctors don't want to be responsible for killing patients so they opt not to order the lactate test. In 2017 sepsis is estimated to cost the US health care system more than $20 billion a year. The C.D.C. is concerned (Sep 2016) with antibiotic resistance generating more sepsis.
when a patient
has a low-grade fever and slightly elevated pulse, this
doctor is likely not to either. Because if they do
order a blood-lactate test and follow through with EGDT is early goal directed therapy, Henry Ford Medical Center emergency and critical care physician Dr. Emmanuel Rivers's 2001 New England Journal of Medicine article recommending aggressive protocols for the early detection and treatment of sepsis. Dr. Robert Pearl explains this aggressive sepsis treatment is risky and potentially fatal. The steps include: - Puncture the patient's neck with a large needle, and deploy a central venous line down near the heart. This carries the risk of damaging the underlying lung.
- Administer powerful antibiotics with large amounts of fluid. The fluid can flood the patient's lungs and overwhelm the heart's ability to pump, drowning the patient.
treatment and then
damage the patient's lung inserting a central venous line,
no one will save them.
- Monthly "morbidity & mortality" conferences held by
community
hospitals and academic
programs allow the most senior physicians to judge
the mistakes and complications that arose during
treatment. Unacceptable explanations for major
errors can result in permanent damage to
reputations. Aggressive EGDT has been labeled
controversial even though results from leading hospitals:
Intermountain
Healthcare, New York State's fifty five hospital
sepsis pilot program; demonstrate the life saving
benefits.
- Society and traditional medical
training reinforce doctors sense of being near
the top of the hierarchy, discouraging self-doubt and
Walter Shewhart's iterative development process is found in many
complex adaptive systems (CAS).
The mechanism is reviewed and its value in coping with random
events is explained.
continuous improvement.
- Clinical practice is partly
art, partly science:
- Patients want "the best doctor for my problem." But
Pearl argues individual acumen and technical skill rarely
separate the best from the rest. The most important
determinants are:
- How well individual physicians are supported by
information technology
- How well their entire medical team works together
- How consistently the doctors on the team follow best
national guidelines
- How often the physician treats a particular problem or
does a particular procedure. The data shows that
these together reduce the likelihood of a patient dying
from a heart
attack is an AMI. It can induce cardiac arrest. Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI. Risk factors include: taking NSAID pain killers (May 2017). There is uncertainty about why AMI occur. Alternative hypotheses include:
- Plaques started to gather in the coronary arteries and grew until no blood flow was possible. If this is true it makes sense to preventatively treat the buildup with angioplasty.
- Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot. If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors.
or stroke is when brain cells are deprived of oxygen and begin to die. 750,000 patients a year suffer strokes in the US. 85% of those strokes are caused by clots. There are two structural types: Ischemic and hemorrhagic. Thrombectomy has been found to be a highly effective treatment for some stroke situations (Jan 2018).
by 30%.
- The half-life of medical information is five to seven
years. Medical training must be augmented by
information technology: Apple's Siri supported by EHR data;
to remind doctors of the currently best available
approach. Pearl adds doctors don't
benefit from tools like IBM's
Watson that find added details and conflicting
research.
- Pearl contends that age correlates with individualism,
traditional techniques and resistance to change. He
asserts that people
born later than 1980 embrace modern technology and
communication. He concludes they will accept
team organization and leverage of smart machines.
Pearl accepts that the key facet is leadership aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group. John Adair developed a leadership methodology based on the three-circles model.
which is
not limited to one age group.
- Pearl is highly critical of the pernicious impact of current
reimbursement structures: FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment. pays doctors and
hospitals for each procedure, regardless of the value it
adds.
Rather than oppose the direct thrust of some environmental flow agents
can improve their effectiveness with indirect responses.
This page explains how agents are architected to do this and
discusses some examples of how it can be done.
Indirect payment catalyses, an infrastructure amplifier. the
process. Pearl notes that FFV is fee-for-value payment. It may be a bundled payment for a set of services provided by a group of doctors and facilities, or full capitation. In each case the risk has shifted from the payer to the providers of care. , using bundled payments is where the purchaser disburses a single predefined payment to cover certain combinations of hospital, physician, post-acute, or other services performed during an episode of care relating to a particular condition (unlike capitation). This bundling is assumed (Sep 2018) to allow the value delivery system to optimize around low cost high quality long term health care. With one bundled payment physicians & hospitals must coordinate care and reduce the unit costs to remain profitable. And to avoid taking on risk of expensive complications physicians & hospitals are incented to standardize and focus on quality. This optimization is dependent on quantifying the value of the outcome of the episode of care. Previously FFS payments induced excessive treatment activity. Bundled payment is included in CMS ACE demonstrations and BPCI initiatives. There are significant impacts on IT. - It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.
- Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments.
- Care delivery must be re-architected to reduce costs and improve quality.
- Monitoring sensors can be used to feed reports to ensure re-architected operations conform.
or capitation is a global payment for all care for a patient during a specified time period. It forces the provider of care to take a high risk. Managing the risk implies successful population health management. ,
puts a break on the catalysis.
- Pearl concludes that the problem
The agents in complex adaptive
systems (CAS) must model their
environment to respond effectively to it. Samuel
modeling is described as an approach.
model
is supported by the signals, is an emergent capability which is used by cooperating agents to support coordination & rival agents to support control and dominance. In eukaryotic cells signalling is used extensively. A signal interacts with the exposed region of a receptor molecule inducing it to change shape to an activated form. Chains of enzymes interact with the activated receptor relaying, amplifying and responding to the signal to change the state of the cell. Many of the signalling pathways pass through the nuclear membrane and interact with the DNA to change its state. Enzymes sensitive to the changes induced in the DNA then start to operate generating actions including sending further signals. Cell signalling is reviewed by Helmreich. Signalling is a fundamental aspect of CAS theory and is discussed from the abstract CAS perspective in signals and sensors. In AWF the eukaryotic signalling architecture has been abstracted in a codelet based implementation. To be credible signals must be hard to fake. To be effective they must be easily detected by the target recipient. To be efficient they are low cost to produce and destroy.
generated in the environment in which physicians
practice. Financial
rewards are particularly powerful signals.
- Pearl hopes that
The structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
health care
will learn from Uber's positive contribution to
transportation:
Pearl reviews the mental
models of patients too:
- Pearl notes that patients are often significantly impacted
by having to travel to visit their medical staff.
Multiple people may have to disrupt their normal schedules
to get a patient to the required destination. Often
this is a destination selected by medical staff to improve
the efficiency of the physicians. That efficiency
strategy extends to having the patients wait for
indeterminate periods in the waiting and exam rooms.
- Anxiety is manifested in the amygdala mediating inhibition of dopamine rewards. Anxiety disorders are now seen as a related cluster, including PTSD, panic attacks, and phobias. Major anxiety, is typically episodic, correlated with increased activity in the amygdala, results in elevated glucocorticoids and reduces hippocampal dendrite & spine density. Some estrogen receptor variants are associated with anxiety in women. Women are four times more likely to suffer from anxiety. Louann Brizendine concludes this helps prepare mothers, so they are ready to protect their children. Michael Pollan concludes anxiety is fear of the future. Sufferers of mild autism often develop anxiety disorders. Treatments for anxiety differ. 50 to 70% of people with generalized anxiety respond to drugs increasing serotonin concentrations, where there is relief from symptoms: worry, guilt; linked to depression, which are treated with SSRIs (Prozac). But many fear-related disorders respond better to psychotherapy: psychoanalysis, and intensive CBT.
and fear is an emotion which prepares the body for time sensitive action: Blood is sent to the muscles from the gut and skin, Adrenalin is released stimulating: Fuel to be released from the liver, Blood is encouraged to clot, and Face is wide-eyed and fearful. The short-term high priority goal, experienced as a sense of urgency, is to flee, fight or deflect the danger. There are both 'innate' - really high priority learning - which are mediated by the central amydala and learned fears which are mediated by the BLA which learns to fear a stimulus and then signals the central amygdala. presses on the
patient and their family when they think about a coming
visit.
- Doctors rarely consider the visitor's
inconvenience. But Pearl notes tele-health is the use of remote health care. It includes telepharmacy and clinical telehealth for stroke and psychiatry. It also includes sessions between primary care providers and patients and assisted caregiving such as medication reminders and DME usage monitors.
video
'visits' with PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. ,
specialists and other medical staff can transform this
arduous situation. If the medical team all shares
the same EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
,
coordination is enhanced further. But telemedicine
is still the exception. In part this is because the
health care environment encourages providers to focus on
the risks, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. of using
additional technology. And many insurers refuse to
pay for virtual care.
- Doctor's white coats are signals, is an emergent capability which is used by cooperating agents to support coordination & rival agents to support control and dominance. In eukaryotic cells signalling is used extensively. A signal interacts with the exposed region of a receptor molecule inducing it to change shape to an activated form. Chains of enzymes interact with the activated receptor relaying, amplifying and responding to the signal to change the state of the cell. Many of the signalling pathways pass through the nuclear membrane and interact with the DNA to change its state. Enzymes sensitive to the changes induced in the DNA then start to operate generating actions including sending further signals. Cell signalling is reviewed by Helmreich. Signalling is a fundamental aspect of CAS theory and is discussed from the abstract CAS perspective in signals and sensors. In AWF the eukaryotic signalling architecture has been abstracted in a codelet based implementation. To be credible signals must be hard to fake. To be effective they must be easily detected by the target recipient. To be efficient they are low cost to produce and destroy.
of hierarchy.
Pearl argues "long-standing traditions continue far beyond
their logical utility, evidence that health care is
influenced as much by culture is how we do and think about things, transmitted by non-genetic means as defined by Frans de Waal. CAS theory views cultures as operating via memetic schemata evolved by memetic operators to support a cultural superorganism. Evolutionary psychology asserts that human culture reflects adaptations generated while hunting and gathering. Dehaene views culture as essentially human, shaped by exaptations and reading, transmitted with support of the neuronal workspace and stabilized by neuronal recycling. Damasio notes prokaryotes and social insects have developed cultural social behaviors. Sapolsky argues that parents must show children how to transform their genetically derived capabilities into a culturally effective toolset. He is interested in the broad differences across cultures of: Life expectancy, GDP, Death in childbirth, Violence, Chronic bullying, Gender equality, Happiness, Response to cheating, Individualist or collectivist, Enforcing honor, Approach to hierarchy; illustrating how different a person's life will be depending on the culture where they are raised. Culture: - Is deployed during pregnancy & childhood, with parental mediation. Nutrients, immune messages and hormones all affect the prenatal brain. Hormones: Testosterone with anti-Mullerian hormone masculinizes the brain by entering target cells and after conversion to estrogen binding to intracellular estrogen receptors; have organizational effects producing lifelong changes. Parenting style typically produces adults who adopt the same approach. And mothering style can alter gene regulation in the fetus in ways that transfer epigenetically to future generations! PMS symptoms vary by culture.
- Is also significantly transmitted to children by their peers during play. So parents try to control their children's peer group.
- Is transmitted to children by their neighborhoods, tribes, nations etc.
- Influences the parenting style that is considered appropriate.
- Can transform dominance into honor. There are ecological correlates of adopting honor cultures. Parents in honor cultures are typically authoritarian.
- Is strongly adapted across a meta-ethnic frontier according to Turchin.
- Across Europe was shaped by the Carolingian empire.
- Can provide varying levels of support for innovation. Damasio suggests culture is influenced by feelings:
- As motives for intellectual creation: prompting
detection and diagnosis of homeostatic
deficiencies, identifying
desirable states worthy of creative effort.
- As monitors of the success and failure of cultural
instruments and practices
- As participants in the negotiation of adjustments
required by the cultural process over time
- Produces consciousness according to Dennet.
and past norms as by science.
- Pearl asserts that patients are willing to accept less
change from health care because situations of extreme
anxiety & fear initiate an evolved shift of
responsibility to those higher in the hierarchy. That
is not a time for the consumer to demand change. And
- They are loyal to doctors who have saved them or their
families.
- For most of history that made little sense since healers'
actions did more harm than good. Although Pearl notes
that touch, and reassurance, has a powerful therapeutic
mechanism.
- Pearl argues patients value high tech sensors over older
techniques for diagnosis. So he argues that patients
don't require doctors to use information technology because
they accept the doctor knows best. He asserts that
doctors can't be effective without an EHR, even though half
the doctors still use paper records.
- Pearl writes that while
U.S. News Health rates New
York-Presbyterian/Columbia
University Medical Center as the nation's number-three
cardiology and heart-surgery program, the New York
Department of Health found Columbia Presbyterian and
Westchester Medical Center with risk-adjusted mortality
rates significantly higher than the statewide rate. So
he was very puzzled that
- Pearl laments that
The structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
health care
is a consumer exception, void of transparency, technology,
and consumer control that have become the norm and most of
us accept this situation.
- Pearl notes that online retailing is now used
routinely. Initial fears about security have
subsided. Data breaches validly cause concerns.
But Pearl notes medical
errors from lack of data cause little concern.
Medical errors are the third-leading killer in the US is the United States of America. accounting for 10% of all
American's deaths. Pearl notes when doctors use paper
records:
- The information is trapped on paper and unavailable to
people outside the office. But an average person
sees 19 doctors during their lifetime. So when they
don't have access to the records they retest and repeat
questions about: allergies include various conditions: hay fever, food allergies: MMA, Peanut; atopic dermatitis, asthma, and anaphylaxis; caused by over activity of the immune system in response to antigens in the proximate environment. Initially associated with the English upper-class, allergies have spread across the population with general adoption of: small family size, cleanliness, antibiotic use, public health programs; in line with the hygiene hypothesis, with newborns no longer getting exposed to antigens by their older siblings and proximate higher animals.
,
medications, past test results. And one of the
doctors could get the information wrong.
- Closed records mean limited access to your complete
medical history. A trip to the E.D. is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016).
will result in
delays, and potentially mistakes of omission.
- Bad penmanship also kills 7,000 people a
year.
- Pearl argues that today's doctors avoid
direct and compassionate delivery of bad news.
They are more likely to hide from the reality of a patient's
death and offer false hope. Advanced cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
is generally a
killer, except for special cases of leukemia is a group of cancers of blood forming tissues: bone marrow, lymphatic network; where abnormal white blood cells are generated. One type of leukemia is induced when TAD boundaries near the TAL1 gene fail allowing promotors from across the TAD border to distort the operation of the TAL transcription factor. Mutation clusters common in leukemia have been identified in CHIP. and lymphoma is when lymphocytes continue reproducing, and do not die - a blood cancer. . Chemotherapy is the treatment of cancers by highly cytotoxic chemicals: Paclitaxel, Platinum, 6-mercaptopurine; assuming that cancer cells are unusually active and will be differentially poisoned. It has been successful in offering treatments when no other course was available, but non-specificity means that healthy cells also get poisoned resulting in side effects which increase with age: Permanent nerve damage, heart failure (4-5%) and leukemia (0.5-1%). can't
eradicate the disease once it has spread through the blood
and lymph networks to vital organs. But studies
indicate that two-thirds of patients believe the purpose of
their chemotherapy is to cure them. Actually it
shortens their life and makes it more stressful is a multi-faceted condition reflecting high cortisol levels. Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight. As these actions occur the levels of cortisol return to the baseline rate. A stressor is anything that disrupts the regular homeostatic balance. The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis. - The short term response to the stressor
- activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response. The brain's acuity and cognition are stimulated. The immune system is stimulated with beta-endorphin and repair activities curtail. In order for the body to destroy bacteria in wounds, pro-inflammatory cytokines increase blood flow to the area. The induced inflammation signals the brain to activate the insula and through it the ACC. But when the stressor is
- long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues. Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in. Sustained stress provides an evolved amplifier of a position of dominance and status. It is a strategy in female aggression used to limit reproductive competition. Sustained stress:
- Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment!
- Activates the integration between the thalamus and amygdala.
- Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful.
- BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning.
- Makes it easier to learn a fear association and to consolidate it into long-term memory. Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala. And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces. Accuracy of assessing emotions from faces suffers. A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand. The activation of the amygdala seems to determine how the hippocampus responds.
- Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression.
- Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive. It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.
- Increases the risk of autoimmune disease (Jan 2017)
- During depression, stress inhibits dopamine signalling.
- Strategies for stress reduction include: Mindfulness.
.
- Pearl judges that health care delivery quality is
dependent on making the team effective. It is not
governed by individual ability. Pearl asserts it
depends on: the reimbursement is the payment process for much of US health care. Reimbursement is the centralizing mechanism in the US Health care network. It associates reward flows with central planning requirements such as HITECH. Different payment methods apportion risk differently between the payer and the provider. The payment methods include:
- Fee-for-service,
- Per Diem,
- Episode of Care Payment,
- Multi-provider bundled EPC,
- Condition-specific capitation,
- Full capitation.
mechanism, data integration; a context that shapes clinical
performance. Few physicians perform the same procedure
often enough to develop statistical pictures. Cardiac
surgery is a special case with higher complication rates and
a limited set of procedures. But he suggests this is
possible in comparing
one institution with another:
- NCQA is the National Committee for Quality Assurance. It defines metrics for medical success including HEDIS. It identifies primary care practices that meet the standards and processes to be recognized by the NCQA as a PCMH: BSVMG. They reward collection of performance data on: immunizations, treatment of upper respiratory infections, mammograms, Pap smears, colonoscopies, imaging for lower back pain, control of hypertension, medications for CHF; and scheduling transformation, integrated behavioral and mental health, analysis, setting goals and acting to improve practice performance and sharing practice performance data and analysis. The NCQA is developing standards for certifying SMH. provides ratings
of complete health systems,
- CMS is the centers for Medicare and Medicaid services. provides star
ratings for Medicare
Advantage (MA) is a private provider administered health insurance plan providing access to Medicare benefits. It was originally enacted as part of BBA Medicare + Choice or Part C plans. The government funded the plan with an annual fee, based on age and severity of the subscriber's medical conditions, rather than FFS. When a Medicare eligible person enrolls in a MA plan the government pays the private provider a set amount each month. The participant pays the Medicare part B premium and if required a part C premium each month. The MA plans offer a PCP who coordinates care. And the plans have an annual limit on out-of-pocket expenses unlike traditional Medicare. When they obtain treatment they will have to pay a copayment which may be quite high for some specialists. It is the health plan's responsibility to contract the physician network that will provide the care, leaving the risk with the insurer. About 36% of Medicare beneficiaries are enrolled with Medicare Advantage by 2019. The ACA introduced quality outcome and patient satisfaction based differential payments into MA. To measure the performance it added a five-star quality rating scheme. MA plans report their quality and patient satisfaction data to CMS annually and based on the results are awarded one to five stars. The highest rated plans are provided with large additional payments. It was assumed that subscribers would shift to the highest rated plans and the other plans would improve or drop out of MA. And the ACA eliminated subsidies which the federal government used to establish Medicare Advantage. However, the Obama administration has used a $8.5 Billion demonstration project to maintain this funding. It is intended that it will eventually taper off so that the cost of Medicare Advantage coverage will be equivalent to standard Medicare.
programs; based in ratings from
patients.
- Leapfrog
Group identifies the best performing among 2,500
hospitals based on criteria for: preventing errors,
achieving higher quality, and avoiding infections; for its
initiating employers and their employees.
- J.
D. Power provides annual ratings for health system
access and service.
- Pharmaceutical companies subtly incent
doctors to prescribe their products by providing:
food, flattery, friendship, trips, dinners, expert
sponsorship. Since 2010 the Sunshine Act is the physician payments sunshine act of 2010. It is:
- Section 6002 of the ACA.
- It requires pharmaceutical and medical device companies
to release details of payments to doctors and US teaching
hospitals.
has
required pharmaceutical and medical device companies to
release details of their payments to doctors and US
teaching hospitals.
- Once people have been allowed to choose from a set of
alternatives and have been allotted the choice they increase
their relative valuation of that alternative. Pearl
notes that this applies when choosing doctors too.
Pearl concludes that our decisions aren't logical and context
matters greatly. Our minds
distort our perceptions. Disease and death are
feared and alter the choices we make for our health care.
And big participants in health care: insurance companies, drug
manufacturers; contribute to the distortion and negative
impacts.
Pearl reviews the impact
of the major Plans are interpreted and implemented by agents. This page
discusses the properties of agents in a complex adaptive system
(CAS).
It then presents examples of agents in different CAS. The
examples include a computer program where modeling and actions
are performed by software agents. These software agents
are aggregates.
The participation of agents in flows is introduced and some
implications of this are outlined.
agents in US is the United States of America. The structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
health
care on perceptions and network operation, relative to
comparable external networks and how they are perceived:
- Insurers
- how we see the world varies and limits our ability to see
other alternatives
- In countries with government-sponsored health care
coverage for all, citizens view it as a fundamental human
right. While delivered in a variety of ways, the
citizens enjoy the financial security, and tolerate
limitations on choice and delays for routine care.
These countries rank ahead of the U.S. in quality outcomes
and overall population
health.
- In the US the restrictions and delays of the
international solutions are ridiculed. But Pearl
notes the US system includes a ticking time-bomb: health care cost
growth. Pearl laments that powerful
health insurance companies are not structured to address
cost growth effectively. The financial incentives
they control have just distorted the operation of
The structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
health care delivery and
increased the inefficiency. And the insurers respond
problematically to incentives too -- Pearl notes insurers
try to reduce the MLR is medical loss ratio, the percentage of an insurer's premium spent on direct patient care and quality improvement. The ACA requires an MLR of greater than 80 percent for small group policies and 85 percent of the premiums collected from medium and large businesses for direct medical care, Medicare part D, and Medicare Advantage plans. ,
forcing Congress to mandate its value in the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
. With added ACA
constraints, insurers shifted to using narrow networks - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans. This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans. By limiting the number of providers/doctors offered in the plans the few that are included should get more business. Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers). In large cities narrow networks are even more common. Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills. There are problems induced by narrow network constraints: - Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts. Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running. If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016).
to limit health care spending. But instead of
focusing these networks on a limited number of the highest
quality providers, insurers have contracted with providers
who have the lowest costs. And the insurers tried to
expand their market power by merging.
- Hospitals
- Sweden's Jonkoping
hospital is judged exceptional by Pearl. It
has superior outcomes at lower cost. He concludes
that perception (providing medical care is an honor) and culture is how we do and think about things, transmitted by non-genetic means as defined by Frans de Waal. CAS theory views cultures as operating via memetic schemata evolved by memetic operators to support a cultural superorganism. Evolutionary psychology asserts that human culture reflects adaptations generated while hunting and gathering. Dehaene views culture as essentially human, shaped by exaptations and reading, transmitted with support of the neuronal workspace and stabilized by neuronal recycling. Damasio notes prokaryotes and social insects have developed cultural social behaviors. Sapolsky argues that parents must show children how to transform their genetically derived capabilities into a culturally effective toolset. He is interested in the broad differences across cultures of: Life expectancy, GDP, Death in childbirth, Violence, Chronic bullying, Gender equality, Happiness, Response to cheating, Individualist or collectivist, Enforcing honor, Approach to hierarchy; illustrating how different a person's life will be depending on the culture where they are raised. Culture:
- Is deployed during pregnancy & childhood, with parental mediation. Nutrients, immune messages and hormones all affect the prenatal brain. Hormones: Testosterone with anti-Mullerian hormone masculinizes the brain by entering target cells and after conversion to estrogen binding to intracellular estrogen receptors; have organizational effects producing lifelong changes. Parenting style typically produces adults who adopt the same approach. And mothering style can alter gene regulation in the fetus in ways that transfer epigenetically to future generations! PMS symptoms vary by culture.
- Is also significantly transmitted to children by their peers during play. So parents try to control their children's peer group.
- Is transmitted to children by their neighborhoods, tribes, nations etc.
- Influences the parenting style that is considered appropriate.
- Can transform dominance into honor. There are ecological correlates of adopting honor cultures. Parents in honor cultures are typically authoritarian.
- Is strongly adapted across a meta-ethnic frontier according to Turchin.
- Across Europe was shaped by the Carolingian empire.
- Can provide varying levels of support for innovation. Damasio suggests culture is influenced by feelings:
- As motives for intellectual creation: prompting
detection and diagnosis of homeostatic
deficiencies, identifying
desirable states worthy of creative effort.
- As monitors of the success and failure of cultural
instruments and practices
- As participants in the negotiation of adjustments
required by the cultural process over time
- Produces consciousness according to Dennet.
(the homogeneous
population views health care as a public service and
finds collaboration easy) support its efficiency and
highly coordinated care. Total quality control is
rigorously applied.
- US hospital doctors view variation across practice as a
benefit. But Pearl argues the data suggests
otherwise:
- If you are admitted to a US hospital needing immediate
medical care the best results will occur when admitted
on a Monday or Tuesday. Friday and Saturday have
much poorer results (Mar
2019).
- Physician
Specialty Societies such as: ACC is either the
- Anterior cingulate cortex which:
- Includes the subgenual ACC and the paragenual ACC, and
Brodmann areas 24, 25, 32 and
33.
- The gyrus of the ACC has two functional components,
which both operate abnormally in mood disorders: depression, anxiety & bipolar. The
- Rostral/ventral part is involved in emotional processes and
autonomic functions. It connects to the hippocampus, amygdala, orbital prefrontal
cortex, anterior
insula, nucleus
accumbens. It is overactive during regular
or bipolar depression.
- Caudal part is involved in cognition and the control
of behavior. It connects with the dorsal PFC, secondary motor cortex, and posterior cingulate
cortex
- Is a central focus of empathy
supporting people relating
to other's pain. This is dependent on oxytocin.
- In non-human mammals it processes interoceptive signals.
The ACC focuses the internal signals into high level 'gut intuitions.'
Pain catches the ACC's
attention.
- Performs discrepancy detection from the outcome that
was predicted - at a high level. The ACC cares
about the meaning of what is predicted.
- If the ACC has been convinced that a pain killer
placebo has inhibited pain signals, the ACC will stay
silent about actual pain that is signalled from
interoceptive networks.
- The ACC will signal: physical pain, emotional pain,
metaphorical
pain, anxiety, disgust, embarrassment,
social exclusion especially
in adolescence;
as one and the same. The ACC's abnormalities
being associated with major depression.
- Has a bridging role between the empathetic and
self-interested pain monitor. Sapolsky
notes the ACC is essential for learning fear and conditioned avoidance by
observation alone through an intermediate step of shared
representation of self. He concludes "At its core
the ACC is about self-interest, with caring about the
other person in pain as an add-on."
- American College of Cardiology
, AAOS,
ASCO,
AUA;
are dedicated to advancing clinical practice and financial
success for their members.
- Prostate
cancer is cancer of the prostate gland. Genomics detected several common DNA variants associated with increased risk of prostate cancer. Dr. Francis Collins explains that a cluster of these risk variants lies in a stretch of 1 million DNA base pairs on chromosome 8. The cluster contains seven or more risk variants, each of which can raise the risk of prostate cancer by 10 to 30%. The high risk variants occur more frequently in African-American men than European or Asians. African-Americans die from prostate cancer at more than twice the rate of Europeans. Research in mice may explain a link between obesity and prostate cancer (Jan 2018). The average diagnosis is at age 66. Worldwide in 2012 there were 1.1 million cases from which 307,000 died. A common life-saving (Feb 2017) treatment is androgen deprivation therapy, but it has worrying side effects. Various classically defined types of cancer can occur. The most common is adenocarcinoma associated with the epithelial gland cells that generate seminal fluid. Epithelial cell differentiation potency makes these significant cancer agents. Other very rare types of cancer that can start in the prostate are:
- Sarcomas
- Small cell carcinomas
- Neuroendocrine tumors
- Transitional cell carcinomas
screening has proved problematic (May
2016, 2).
Pearl argues that for the urologists is a surgical and medical specialty which deals with diseases of the male and female urinary tract and the male reproductive organs. , operating
on the cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016). was
high priority because their perception was shaped by the
income. He notes everyone else, including the PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. s, developed a
different view.
- The AAOS could not see the opportunity to reduce health
care costs by eliminating meniscus surgery. Pearl
writes "it's not as though the AAOS decided to continue
performing meniscus surgery out of greed. It's that
it couldn't see the value of doing away with it, even
though it was obvious to others."
- Pearl concludes that in the US money and status
reinforce each other. There is a clear perception
that intervening
during a crisis is more difficult and more valuable than
preventing one. This has a huge impact on American
The structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
health care. The medical
schools are training more specialists even though the US
needs more PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. s.
Pearl explains that:
- Residency programs are federally subsidized through Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
.
- The hospitals receive the same reimbursement is the payment process for much of US health care. Reimbursement is the centralizing mechanism in the US Health care network. It associates reward flows with central planning requirements such as HITECH. Different payment methods apportion risk differently between the payer and the provider. The payment methods include:
- Fee-for-service,
- Per Diem,
- Episode of Care Payment,
- Multi-provider bundled EPC,
- Condition-specific capitation,
- Full capitation.
from the government whether they train PCPs or orthopedic is the treatment of the musculoskeletal system which supports multi-cell higher animals and allows them to move about: including correcting deformities, breaks, tears, compression, tendonitis, disc failures, misalignment, fusion to treat damaged discs.
surgeons.
- Administrators respond to the opportunity to attract
attending surgeons by having more orthopedic residents
at their hospital, which will take care of the patients
at night. Admitting physicians appreciate this
service.
- This ensures that more total joint replacements are
performed at the hospital which will improve its
profitability.
- Pearl contrasts the orthopedic surgery strategy used in
Switzerland with that in the US:
- Pearl argues we should shift more dollars from specialty
to primary care. But he accepts that the specialty
societies and their members don't perceive the situation
that way.
- Drug and Device Companies
- Pharmaceutical companies are highly profitable. In
the US is the United States of America. patent protection
and regulations: MMA is:
- The Medicare Modernization Act of 2003. It includes Medicare part D, the Medicare prescription drug benefit, which constrains Medicare from negotiation of its drug prices and created MAC and RAC. It was sponsored by Senator Bill Tauzin and implemented by Tom Scully.
- Mammalian meat allergy which is induced by a month prior tick bite that introduced the allergen alpha-gal. About 1% of bitten humans develop the allergy & prevalence is increasing. Humans & old world primates & monkeys don't make alpha-gal (Jul 2018). Symptoms can include: hives, anaphylactic shock, low blood pressure.
;
support the power
of pharmaceutical companies. Pearl used a
report from the International
Federation of Health Plans comparing prescription
medication costs between the US, Canada, Spain, UK is the United Kingdom of Great Britain and Northern Ireland. , Netherlands; showing
the US unit prices were the highest in all
categories. To illustrate the point:
- Nexium
costs $30 per month in Canada, $42 in UK, $58 in Spain,
$23 in Netherlands, $305 in US.
- Gleevec is the Novartis trade name for Imatinib. It is a tyrosine-kinase inhibitor that was designed to treat CML through a partnership between Dr. Brian Druker and Novartis who selected and productized it from a long list of potential small molecule inhibitors. Due to the binding site that Gleevec targets being present in a variety of related cancer inducing proteins Gleevec is being used to successfully treat other types of cancers.
costs
$989 per month in New Zealand, $1,141 in Canada, $8,500
price in an average US health plan (Humira
Jan
2018). Pearl comments that high and rising
prices have kept wages flat to offset the increasing
costs of health care premiums, deductibles and
copayments. Since the legislated lack of power of
Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
pulls
much of the profit taking onto US consumers opening the
US to Canadian drugs would reduce prices. So
drug-company lobbyists press elected officials to
prohibit Americans from buying medications from Canadian
pharmacies.
- US Drugs, Devices and Destiny
- Health care as a Cultural Imperative - Pearl concludes the
laws of the US is the United States of America. and cultures is how we do and think about things, transmitted by non-genetic means as defined by Frans de Waal. CAS theory views cultures as operating via memetic schemata evolved by memetic operators to support a cultural superorganism. Evolutionary psychology asserts that human culture reflects adaptations generated while hunting and gathering. Dehaene views culture as essentially human, shaped by exaptations and reading, transmitted with support of the neuronal workspace and stabilized by neuronal recycling. Damasio notes prokaryotes and social insects have developed cultural social behaviors. Sapolsky argues that parents must show children how to transform their genetically derived capabilities into a culturally effective toolset. He is interested in the broad differences across cultures of: Life expectancy, GDP, Death in childbirth, Violence, Chronic bullying, Gender equality, Happiness, Response to cheating, Individualist or collectivist, Enforcing honor, Approach to hierarchy; illustrating how different a person's life will be depending on the culture where they are raised. Culture:
- Is deployed during pregnancy & childhood, with parental mediation. Nutrients, immune messages and hormones all affect the prenatal brain. Hormones: Testosterone with anti-Mullerian hormone masculinizes the brain by entering target cells and after conversion to estrogen binding to intracellular estrogen receptors; have organizational effects producing lifelong changes. Parenting style typically produces adults who adopt the same approach. And mothering style can alter gene regulation in the fetus in ways that transfer epigenetically to future generations! PMS symptoms vary by culture.
- Is also significantly transmitted to children by their peers during play. So parents try to control their children's peer group.
- Is transmitted to children by their neighborhoods, tribes, nations etc.
- Influences the parenting style that is considered appropriate.
- Can transform dominance into honor. There are ecological correlates of adopting honor cultures. Parents in honor cultures are typically authoritarian.
- Is strongly adapted across a meta-ethnic frontier according to Turchin.
- Across Europe was shaped by the Carolingian empire.
- Can provide varying levels of support for innovation. Damasio suggests culture is influenced by feelings:
- As motives for intellectual creation: prompting
detection and diagnosis of homeostatic
deficiencies, identifying
desirable states worthy of creative effort.
- As monitors of the success and failure of cultural
instruments and practices
- As participants in the negotiation of adjustments
required by the cultural process over time
- Produces consciousness according to Dennet.
of the health
care network's businesses
make the impact of the legacy players greater in the US than
elsewhere. This reflects the way the individual,
freedom, science & technology achievement are especially
valued in America. But Pearl laments that this
produces a health care system that tolerates major variation
in practice, insufficient experience, and frequent medical
errors. The legacy players are motivated to
resist change. But Pearl suggests the inertia is due
to the power of perception. Each actor holds to their
perspective and remains happy with the current situation.
Commonly accepted ideas are highly
robust, but are sometimes wrong and can always be improved.
Pearl explores some notable examples:
- The cause of stomach ulcers was finally identified as due
to infection by Helicobacter
pylori is a gram-negative bacteria, found in the stomach microbiome. Having been identified as the causative agent of stomach ulcers and stomach cancer it has been a focus of eradication campaigns. However, it has been subsequently realized that it limits acid reflux and esophageal cancer, and may be a necessary component of the infant microbiome.
by Australian internal medicine doctor Barry
Marshall & pathologist Robin Warren in 1985. But
Pearl laments it was not until Marshall and Warren were
awarded the Nobel Prize in 2005 that anyone responded to the
report and abandoned the accepted wisdom that stomach ulcers
were due to stress and hot food and should be treated with
surgical removal.
- The germ
theory of disease is a platform of related discoveries in microbiology by Koch (postulates developed from 1870s) and Pasteur (1880) and antiseptic surgery by Joseph Lister (1879). These innovations were made necessary by the stresses of the industrial revolution
was proposed by Ignaz Semmelweis,
but he was ridiculed. Much later Pasteur was able to
convince a skeptical world.
- HIV is human immunodeficiency virus, an RNA retrovirus which causes AIDS. It infects T-lymphocytes destroying the host's immune system. Some HIV's enter the lymphocytes by leveraging the T cells CCR5 protein. The HIV X4 variant leverages CXCR4.
progresses to AIDS is acquired auto-immune deficiency syndrome, a pandemic disease caused by the HIV. It also amplifies the threat of tuberculosis. Initially deadly, infecting and destroying the T-lymphocytes of the immune system, it can now be treated with HAART to become a chronic disease. And with an understanding of HIV's mode of entry into the T-cells, through its binding to CCR5 and CD4 encoded transmembrane proteins, AIDS may be susceptible to treatment with recombinant DNA to alter the CCR5 binding site, or with drugs that bind to the CCR5 cell surface protein preventing binding by the virus. Future optimization of drug delivery may leverage nanoscale research (May 2016). once the CD4+ T
helper cell count falls below 200. But it was proposed
this occurred because the immune system was attacking
infected helper cells. Warner Greene found that 95% of
the time the body destroys resting helper cells, not the
infected ones. A key part of the destruction is the
body deploying a signal to attract more helper cells which
are then destroyed. Drugs were subsequently deployed
that blocked a protein that participates in this
process.
- Public health is the proactive planning, coordination and execution of strategies to improve and safeguard the wellbeing of the public. Its global situation is discussed in The Great Escape by Deaton. Public health in the US is coordinated by the PHS federally but is mainly executed at the state and local levels. Public health includes:
- Awareness campaigns about health threatening activities including: Smoking, Over-eating, Alcohol consumption, Contamination with poisons: lead; Joint damage from over-exercise;
- Research, monitoring and control of disease agents, processes and vectors by agencies including the CDC.
- Monitoring of the public's health by institutes including the NIH. This includes screening for cancer & heart disease.
- Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.
- Development, deployment and maintenance of vaccination strategies.
- Development, deployment and maintenance of fluoridation.
- Development, deployment and maintenance of family planning services.
- Regulation and constraint of foods, drugs and devices by agencies including the FDA.
strategies are often far more scalable and cost effective
than treatments for improving well-being indicates the state of an organism is within homeostatic balance. It is described by Angus Deaton as all the things that are good for a person: - Material wellbeing includes income and wealth and its measures: GDP, personal income and consumption. It can be traded for goods and services which recapture time. Material wellbeing depends on investments in:
- Infrastructure
- Physical
- Property rights, contracts and dispute resolution
- People and their education
- Capturing of basic knowledge via science.
- Engineering to turn science into goods and services and then continuously improve them.
- Physical and psychological wellbeing are represented by health and happiness; and education and the ability to participate in civil society through democracy and the rule of law. Life expectancy as a measure of population health, highly weights reductions in child mortality.
. In
the US this is reflected in the most important factors
contributing to health outcomes: zip code where person was
born, race, family income; not choice of hospital or
doctor. The CDC is the HHS's center for disease control and prevention based in Atlanta Georgia. and
WHO is World Health Organization a United Nations organization. have researched these
social determinants of health. They found over a third
of all US deaths are due to: education, racial segregation,
social support system, and poverty.
- Cigarettes
are still used by one sixth of Americans. The
information about carcinogens and habit allow higher organisms: humans, rats, flies; to perform important behaviors automatically, without involvement of consciousness. Habits are adaptive, being promoted by the release of dopamine into the PFC and striatum, generating a feeling of pleasure and conditioning us. As the dopamine detaches from the synaptic receptors in the PFC and striatum the motivation to perform the behavior subsides. If the dopamine remains at the synapse for an extended period, because it is not removed as occurs when cocaine is present, or when too much dopamine is generated, the habit can become an addiction. forming chemicals
in cigarettes is widely distributed. But cigarettes
account for 20% of all deaths in the US. Non-smokers
are horrified by the relative risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty.
of smoking.
Smokers see cigarettes and the risk differently. They
see friends and relatives who are alive and smoking.
They see the absolute risk of only 14% of smokers dying from
lung cancer affects 200,000 Americans each year. Inflammation is a driver of lung cancer spread (Aug 2017). All these cancers are carcinomas. There are two main hystological types: - Non-small-cell carcinomas are of three sub-types:
- Adenocarcinomas (40% of lung cancers) are typically peripherally situated and mostly induced by smoking.
- Squamous-cell carcinomas (30% of lung cancers) arise in the large bronchi an are highly correlated with smoking.
- Large-cell carcinomas (5 to 10% of lung cancers).
- Small-cell carcinomas.
, and
judge the risk as low. No one treats cigarette
companies as murderers. Pearl suggests this is because
we differentiate
between direct and indirect causality uses fMRI to follow brain activity of subjects during Josh Greene's experiments with the trolley problem. He used two scenarios, (1) The five people are doomed, would you pull the lever so the trolley will hit and kill someone: (2) Would you push someone onto the tracks to stop the trolley? Consistently 60-70% of people say yes to scenario (1) but only 30% say yes to scenario (2). The fMRI showed the more the vmPFC and/or amygdala activate the more likely the person is to refuse to act in either case. Greene concludes that intuitions about intentionality are what is changing. Pushing that kills someone feels morally wrong. Greene developed a third scenario where the subject throws the switch to save the five but in doing so pushes a person out of the way and in falling to the ground they die. This seems more acceptable. Then Greene adjusts scenario (1) making the side loop switch back to the main track so that if the trolley is not stopped by the body of a person the five will still die - the same result as scenario (2). Described this way 60-70% find pulling the lever acceptable. Greene concludes our intuitions are very local and the additional indirection in this last scenario stops us feeling disturbed. . He sees
the same scenario in the differentiation of malpractice and
mistreatment, even when both are associated with the death
of a patient. Pearl notes that these judgments are
also dependent on personal circumstance and social
context. Kentucky has a cigarette culture, 30% of
residents smoke and smoking accounts for 40% of all cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016). -related
deaths.
- Obesity is an addictive disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). Brain images of drug-addicted people and obese people have found similar changes in the brain. Obese people's reward network tends to be less responsive to dopamine and have a lower density of dopamine receptors. Obesity spreads like a virus through a social network with a 171% likelihood that a friend of someone who becomes obese will also become so. Obesity is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes, asthma and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016).
generates
$190 billion in yearly US medical spending. It induces
type 2 diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
.
And it is growing in frequency to epidemic
proportions. It is well understood that eating less
and exercising more will reduce obesity. But the easy
availability of low
cost sugary sodas and fast-food and sedentary
life style support obesity. And this
life-style is contagious to the proximate network.
Dr. Pearl reviews proposals to constrain obesity:
- Clayton
Christensen argues businesses become more profitable
if they reduce employee medical expenses. He argues
employers need to provide financial incentives that reward
employees who exercise, limit weight gains and get
preventative screenings.
- Malcolm Gladwell promotes Thaller & Sunstein's
nudges as a solution.
- Chip Heath proposes a psychological solution. He
argues that most self-help has huge [imagined] startup
costs. Heath suggests simple, actionable advice will
be catalytic, an infrastructure amplifier. .
Pearl laments that obesity is no one person's biggest
immediate problem, rather like
sepsis is an infection triggered over-reaction by the immune system which causes general inflammation resulting in a cascade of problems: Blood clots, Leaky blood vessels; impeding blood flow to vital organs which can induce septic shock: Blood pressure drops, multiple organ failure, Heart damage and death. For every hour without antibiotics the probability of death increases 8%. Most cases start before people are hospitalized. People over 65, infants under 1 year, people with chronic diseases such as diabetes, or weakened immune systems and healthy people with incorrectly treated infections are most likely to contract sepsis. Most often the infections are of: lungs, urinary tract, skin, gut or intestines. Typically such infections were the result of a previous visit to a clinic or hospital. Symptoms of sepsis include: chills or fever, extreme pain or discomfort, clammy or sweaty skin, confusion or disorientation, shortness of breath and high heart rate. Dr. Diane Craig noted that sepsis had become the leading cause of death among hospitalized patients. Using patient matching on: age, symptoms, degree of illness; from the hospital system EHR, Craig identified the blood-lactate test as the key diagnostic that supported early, aggressive treatment of sepsis. She argued that whenever a patient had two symptoms of significant infection a lactate test be used along with EGDT treatment for patients with lactate counts as low as 2.5 millimoles/liter. This reduced sepsis mortality to 40% below the national average. But only half the hospitals in the US followed Craig's recommendations. Dr. Robert Pearl concludes this is because of the high risk of killing a patient with EGDT treatment, even though the protocol will reduce overall mortality by half. Doctors don't want to be responsible for killing patients so they opt not to order the lactate test. In 2017 sepsis is estimated to cost the US health care system more than $20 billion a year. The C.D.C. is concerned (Sep 2016) with antibiotic resistance generating more sepsis.
.
- Stress is a multi-faceted condition reflecting high cortisol levels. Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight. As these actions occur the levels of cortisol return to the baseline rate. A stressor is anything that disrupts the regular homeostatic balance. The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis.
- The short term response to the stressor
- activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response. The brain's acuity and cognition are stimulated. The immune system is stimulated with beta-endorphin and repair activities curtail. In order for the body to destroy bacteria in wounds, pro-inflammatory cytokines increase blood flow to the area. The induced inflammation signals the brain to activate the insula and through it the ACC. But when the stressor is
- long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues. Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in. Sustained stress provides an evolved amplifier of a position of dominance and status. It is a strategy in female aggression used to limit reproductive competition. Sustained stress:
- Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment!
- Activates the integration between the thalamus and amygdala.
- Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful.
- BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning.
- Makes it easier to learn a fear association and to consolidate it into long-term memory. Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala. And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces. Accuracy of assessing emotions from faces suffers. A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand. The activation of the amygdala seems to determine how the hippocampus responds.
- Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression.
- Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive. It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.
- Increases the risk of autoimmune disease (Jan 2017)
- During depression, stress inhibits dopamine signalling.
- Strategies for stress reduction include: Mindfulness.
, depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult;, and anxiety is manifested in the amygdala mediating inhibition of dopamine rewards. Anxiety disorders are now seen as a related cluster, including PTSD, panic attacks, and phobias. Major anxiety, is typically episodic, correlated with increased activity in the amygdala, results in elevated glucocorticoids and reduces hippocampal dendrite & spine density. Some estrogen receptor variants are associated with anxiety in women. Women are four times more likely to suffer from anxiety. Louann Brizendine concludes this helps prepare mothers, so they are ready to protect their children. Michael Pollan concludes anxiety is fear of the future. Sufferers of mild autism often develop anxiety disorders. Treatments for anxiety differ. 50 to 70% of people with generalized anxiety respond to drugs increasing serotonin concentrations, where there is relief from symptoms: worry, guilt; linked to depression, which are treated with SSRIs (Prozac). But many fear-related disorders respond better to psychotherapy: psychoanalysis, and intensive CBT. are endemic in
the US, originating from jobs, financial pressure, families,
relationships & health issues. And they undermine
healthy lifestyles. Chronic health problems also
induce chronic stress in a vicious cycle. Pearl
concludes that both the mental and physical components of
chronic diseases must be recognized and treated. But
the The structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
health care network is not
well structured for coordination and management of these
broad issues.
- Childhood trauma
is a significant inducer of stress, depression and
anxiety. The CDC is the HHS's center for disease control and prevention based in Atlanta Georgia.
has identified adverse childhood experience as one of the
leading causes of poor health in the US is the United States of America. .
- Domestic abuse is another major issue with health
implications. The ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
raised the priority of domestic-violence screening.
But the situation is often cloaked in secrecy and hard to
identify.
- Race and socioeconomic group have significant impact on
health and life
expectancy is a measure of the average life time of a new born baby. Without public health assistance many children die in the first five years of life significantly lowering the life expectancy of the whole group. There are representational and data capture problems with the model:
- Not knowing the risk of dying in the newborn's future, demographers use the risks present at that time to predict impacts in the future of the person. No adjustment can be made for increased wellbeing.
- Saving the lives of children has a far larger effect on increasing life expectancy than extending the lives of the elderly
- Impacts that occur in a particular year, such as a epidemic or pandemic, are treated as permanent effects for that years life expectancy even though they may be handled by public health strategies and hence be transients. For life expectancy calculations in subsequent years the impact is ignored.
- Programs that reduced the impacts of infectious diseases, such as antibiotics and vaccine deployment, have reduced the variability of life expectancy following their introduction.
- Vital registration systems gather accurate data for life expectancy. But most countries do not have the infrastructure and instead estimates are generated from demographic and health surveys.
. Many factors interact:
- Genetics
- Health insurance coverage disparities. The ACA was
designed to address this disparity but the SCOTUS Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births.
expansion
decision limited the impact.
- Health care providers screening programs do not cover
all groups similarly. Blood pressure monitoring,
Cholesterol monitoring, Breast cancer is a variety of different cancerous conditions of the breast tissue. World wide it is the leading type of cancer in women and is 100 times more common in women than men. 260,000 new cases of breast cancer will occur in the US in 2018 causing 41,000 deaths. The varieties include: Hormone sensitive tumors that test negative for her2 (the most common type affecting three quarters of breast cancers in the US, BRCA1/2 positive, ductal carcinomas including DCIS, lobular carcinomas including LCIS. Receptor presence on the cancer cells is used as a classification: Her2+/-, estrogen (ER)+/-, progesterone (PR)+/-. Metastasis classes the cancer as stage 4. Genetic risk factors include: BRCA, p53, PTEN, STK11, CHEK2, ATM, GATA3, BRIP1 and PALB2. Treatments include: Tamoxifen, Raloxifene; where worrying racial disparities have been found (Dec 2013). International studies indicate early stage breast cancer typed by a genomic test: Oncotype DX, MammaPrint; can be treated without chemotherapy (Aug 2016, Jun 2018)
screening. Dr. Pearl notes the power of
multi-faceted programs that attack the underlying social
determinants. But he also accepts that people who
have not had firsthand experience of these complex issues
are likely to blame the individual.
- Exciting & fresh solutions are often perceived as the
best. Pearl recalls the excitement and backing for
Elizabeth Holmes and Theranos.
He notes that this and other high tech solutions have
provided marginal, or no, improvements in benefit at
considerable increase in cost. Policy experts promised
to find the 5% of hot
spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community. patients that generate 50% of health care costs
and reduce their cost of treatment. But Pearl explains
the 5% is heterogeneous. 33% appear because of a
one-time event, 33% are so sick that no level of focus will
change the outcome and cost profile. The other 33% can
have their cost profile altered, but the investment to do so
is often prohibitive. This is because:
- Deploying additional health care solutions requires more
doctors and nurses.
- The targeted solution does not help all of the
5%.
- Genomics combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes. & personalized
medicine is a medical strategy where decisions, practices, and products are tailored to the individual patient. Research is looking at the impact of providing potentially deleterious genomic testing information to people: The REVEAL study found no increased anxiety induced by hearing that one's genome implied increased risk of developing late onset Alzheimer's disease. The take-up of personalized medicine benefits from the focus on genomics, enabled by next generation sequencing of DNA, and detailed by the NIH director Francis Collins and includes:
- NCCN intensive cell therapies
- Direct to consumer genomic testing
- Direct to consumer diagnostics
- Pharmacogenomics tailored drug treatments reducing the risk and cost of adverse drug reactions.
based on a person's own DNA (DNA), a polymer composed of a chain of deoxy ribose sugars with purine or pyrimidine side chains. DNA naturally forms into helical pairs with the side chains stacked in the center of the helix. It is a natural form of schematic string. The purines and pyrimidines couple so that AT and GC pairs make up the stackable items. A code of triplets of base pairs (enabling 64 separate items to be named) has evolved which now redundantly represents each of the 20 amino-acids that are deployed into proteins, along with triplets representing the termination sequence. Chemical modifications and histone binding (chromatin) allow cells to represent state directly on the DNA schema. To cope with inconsistencies in the cell wide state second messenger and evolved amplification strategies are used. promise to transform
diagnosis and treatment. In a few instances the new
approach has been transformative: Cystic fibrosis is a deadly, recessive genetic disease caused by a variety of single gene mutations in the CFTR gene, most commonly occurring in people of northern European background. Screening would work best if applied to couples prior to conception but this is not how carrier screening is organized as of 2015. Cystic fibrosis can result in: fibrous cysts in the pancreas; which does not secrete its normal digestive enzymes inducing serious malnutrition, intestinal blockages, infertility in males and lung damage due to accumulation of a thick, sticky secretion followed by recurrent infections. Symptoms vary among sufferers because: - Modifier genes which vary between individuals.
- Environmental differences:
- Second hand smoke exposure is a significant contributor to cystic fibrosis effects
- Medical interventions such as: pancreatic enzyme capsules, chest physical therapy, antibiotics, aerosolized enzyme therapy, saltwater mists and double lung transplants; can reduce the effects
- Diet
,
Sickle cell
anemia is a recessive single gene disease where the sufferer's hemoglobin causes the red blood cells to distort. It is a side effect of the evolved protection from malaria provided by sickle cell trait. Potential treatments include gene therapy and drugs that block the sickling of red blood cells. Carrier screening was undermined by there being no effective prenatal test limiting the benefit of the information and because the white doctors were not trusted by their black patients. In the future iPS cells could have the problem mutations replaced with ex vivo gene therapy. , BRCA is breast cancer type 1 or 2 susceptibility gene. The two types provide related cellular functions maintaining the validity of the cell. If either gene product fails there is an increased likelihood of cancer. Still individuals with mutations in BRCA1/2 genes account for only 5 to 10 percent of breast cancers. The: - Type 1 gene codes for a protein that supports DNA repair and where this is not possible can stimulate cell death. Hence if the protein becomes defective one or both of these key caretaker functions may stop and increase the susceptibility to cancer. The BRCA1 protein has multiple actions. It:
- Combines with other tumor suppressors, DNA damage sensors and cellular signal transducers to form the BASC surveillance complex monitoring the health of the cells DNA.
- Associates with RNA pol II to support transcription.
- Interacts with histone deacetylase to regulate transcription.
- It is a marker of high risk of breast and uterine cancer.
- It was collaboratively researched by Dr. Mary-Claire King and Francis Collins's labs studying chromosome 17 using genomics.
- In 1990 Dr. King had reported to ASHG evidence of 'this' single gene linked to a highly heritable form of breast cancer.
- Over the next two years the labs gathered details of BRCA1, allowing families with the mutation to understand their individual risk and plan for their futures.
- In 1993 BRCA1 was identified by Mark Skolnick of Myriad Genetics.
- Type 2 gene codes for a protein that binds both single stranded DNA and the recombinase RAD51 to facilitate homologous recombination.
- Advice from Dr. Collins, for families who have a history of breast or ovarian cancer includes:
- Counselling women with the high risk BRCA mutations, about the risk of breast and ovarian cancer and the treatments available
- Telling women who choose watchful waiting to have periodic MRIs. And warn that watchful waiting is unreliable for ovarian cancer allowing metastasis before detection.
- Prophylactically removing the ovaries and Fallopian tubes on completion of childbearing.
- Teaching about breast reconstruction and recommending prophylactic mastectomy.
- Males with BRCA mutations should have careful surveillance for: Prostate, Pancreatic and breast cancer.
- No one being given the test without being fully counselled beforehand about the implications of the result. Negative results may bring survivor guilt while positive results will need careful management.
1 breast is a variety of different cancerous conditions of the breast tissue. World wide it is the leading type of cancer in women and is 100 times more common in women than men. 260,000 new cases of breast cancer will occur in the US in 2018 causing 41,000 deaths. The varieties include: Hormone sensitive tumors that test negative for her2 (the most common type affecting three quarters of breast cancers in the US, BRCA1/2 positive, ductal carcinomas including DCIS, lobular carcinomas including LCIS. Receptor presence on the cancer cells is used as a classification: Her2+/-, estrogen (ER)+/-, progesterone (PR)+/-. Metastasis classes the cancer as stage 4. Genetic risk factors include: BRCA, p53, PTEN, STK11, CHEK2, ATM, GATA3, BRIP1 and PALB2. Treatments include: Tamoxifen, Raloxifene; where worrying racial disparities have been found (Dec 2013). International studies indicate early stage breast cancer typed by a genomic test: Oncotype DX, MammaPrint; can be treated without chemotherapy (Aug 2016, Jun 2018) and ovarian cancer is a relatively uncommon disease but is often fatal. It has been associated with use of talcum powder (May 2016). .
But Pearl laments for most diseases this new personalized
approach will occur in the distant future.
- Choice of health insurance plan and the in-network
providers that become available alters the quality of
clinical outcome and chance of dying by more than 20%.
The ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
was architected
to help new players to enter the insurance market. Oscar
Health argued it revolutionized health insurance
through technology, data and design. But Pearl notes
it has lost money every year and looks like a smaller
version of the same old insurance plan.
- Wearable health devices have promised to support healthy
lifestyles. But they have had very limited impact on
wearers health. Most people abandon the devices within
six months. And most of the data streamed back from
the devices does not benefit doctors. It is in danger
of obscuring important facts in the EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses:
- The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
. Only doctors and
nurses currently administer treatments to bring the body
back into homeostasis is, according to Damasio, the fundamental set of operations at the core of life, from the earliest and long-vanished point of its beginning in early biochemistry to the present. It is the powerful, unthought, unspoken imperative, whose discharge implies, for every living organism, small or large, nothing less than enduring and prevailing. Damasio stresses that the operations that ensure prevailing ensure life is regulated within a range that is not just compatible with survival but also conducive to flourishing, to protection of life into the future of an organism or a species. Prevailing implies mechanisms for monitoring and modeling the state of the organism, controlling and constraining the flows of energy and resources through schematic agency, and to facilitate exploring the environment and acting on signals of modeled opportunities and threats. Global homeostasis of multi-organ animals requires endocrine, immune, circulatory and nervous 'systems' and results in the emergence of minds, feelings, consciousness, machinery of affect and complex movements. The emergence of feelings allowed the homeostatic process to become enhanced by a subjective representation of the organism's state and proximate environment within the mind. Feelings operating in minds allowed conscious decisions to extend homeostasis to the sociocultural domain. .
- Medical technology claims to be revolutionizing the
practice of medicine. Pearl judges it isn't because:
- Many big ideas don't address the problem.
- Technology companies avoid malpractice risk. So
instead of acting on the raw data and making decisions and
issuing advice manufacturers stream all the data to the
doctor.
- All the participants in a care episode think someone
else should pay for new technology.
- Physicians view technology as impersonal or
threatening. And they worry that they will not be
paid if care is wireless.
- Pearl notes that seat belts are one of the few cost
effective life-saving innovations is the economic realization of invention and combinatorial exaptation. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy.
of the past fifty years. They are uninteresting but
deliver.
- Vaccines are a core strategy of public health and have significantly extended global wellbeing over 200 years. Smallpox & polio were virtually eradicated. Recent successes include: HPV vaccine: Gardasil. They induce active acquired immunity to a particular disease. But the development and deployment of vaccines is complex:
- The business model for vaccine development has been failing (Aug 2015):
- No Zika vaccine was available as the epidemic grew (Mar 2016). No vaccine for: CMV;
- Major foundations: Michael J. Fox, Gates, Wellcome; are working to improve the situation including sponsorship of the GAVI alliance. A geographic cluster is forming in Seattle including PATH (Apr 2016).
- Commercial developers include: Affiris, Cell Genesis, Chiron, CSL, Sanofi, Valeant;
- Vaccine deployment traditionally benefited from centrally managed vertical health programs. But political issues are now constraining success with less than 95-99% coverage required for herd immunity (Aug 2015, Sep 2015, Nov 2015, Nov 2016, Jul 2018).
- Where clinics have been driven into local neighborhoods health improves (Apr 2016).
- Retail clinics (Mar 2016): CVS Minute Clinics focus on vaccination.
- NNT is a useful metric for vaccine benefit. Influenza vaccine has an NNT of between 37 and 77, is cheap and causes little harm, so it is very beneficial.
- Key vaccines include: BCG, C. difficile (May 2015), Cholera (El Tor), Cervical Cancer (Gardasil HPV Jun 2018, Oct 2018), Dengvaxia (Mexico Dec 2015), Gvax, Influenza, Malaria vaccine, Provenge, Typbar-TCV (XDR typhoid Pakistan Apr 2018);
- Regulation involves: FDA (CBER), with CMS monitoring (star ratings, PACE (Aug 2016), Report cards (Sep 2015)) & CDC promoting vaccines: as a sepsis measure, To control C. difficile (May 2015);
- Research on vaccines includes:
- NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.
- NCI:
- Roswell Park clinical trial of immuno-oncology vaccine cimavax.
- Geisinger: effective process leverage in treatment.
- Stanford Edge immuno-oncology for cancer vaccines.
- P53-driven-cancer focused, gene therapy (Jun 2015).
are also
effective life-savers globally. But a growing
anti-vaccine movement is reducing the heard immunity that
vaccines leverage. The resistance is puzzling given
the very low associated risk, ensured by large-scale
clinical trials. Pearl notes that parents hear of
issues with vaccines and associate them with their child
even though the prevention rate is far more
significant.
- Prevention is poorly and inconsistently executed by the US
The structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
health care network relative to
other industrialized nations. Providers that focus on
prevention lower hypertensive is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers.
disease, stroke is when brain cells are deprived of oxygen and begin to die. 750,000 patients a year suffer strokes in the US. 85% of those strokes are caused by clots. There are two structural types: Ischemic and hemorrhagic. Thrombectomy has been found to be a highly effective treatment for some stroke situations (Jan 2018). , heart attack is an AMI. It can induce cardiac arrest. Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI. Risk factors include: taking NSAID pain killers (May 2017). There is uncertainty about why AMI occur. Alternative hypotheses include: - Plaques started to gather in the coronary arteries and grew until no blood flow was possible. If this is true it makes sense to preventatively treat the buildup with angioplasty.
- Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot. If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors.
rates
10 to 30% relative to the national average. The data
on the most effective preventative providers is publically
available but is rarely used in selecting them. So
Pearl concludes that 200,000 avoidable deaths occur each
year.
In part two Dr. Pearl
describes his 'dull but effective' solutions: ACA transforming perceptions,
Pearl's four major
shifts, Understanding the current systems failings and what people want and need;
which he judges have the potential to change perceptions and
alter behavior for the better.
Pearl reviews the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
:
- Unavailability
bias is the reverse effect of availability bias for objects that we don't encounter very often.
in operation. Pearl notes that insured
Americans don't generally think about uninsured Americans,
even though prior to the ACA there were 50 million of
them. So it did not appear to be a significant problem
to the majority of the electorate. And due to
unavailability bias that would make it a difficult situation
to change unless perceptions could be updated.
President Obama and his architects deployed seven bets they
felt would shift perceptions:
- Covering the forgotten, 18 million who didn't qualify
for Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births.
in
their state but would once the bar was raised to 138% of
the federal
poverty level is based on the Johnson War on Poverty valuation of $3000 as the relative needed income. It was justified using Mollie Orshansky's modelling of the price of food to limit hunger. It was adopted as an official US poverty line in August 1969 and has remained unchanged except for adjustments for price inflation. by the ACA. Pearl notes this Johnson & Kwak argue that expanding the national debt
provides a hedge against unforeseen future problems, as long as
creditors are willing to continue lending. They illustrate
different approaches to managing the debt within the US over its history and of the
eighteenth century administrations of England and France.
The US embodies two different political and economic systems which
approach the national debt differently:
- Taxes to support a sinking
fund to ensure credit to leverage fiscal power in:
Wars, Pandemics, Trade disputes, Hurricanes, Social
programs; Starting with Hamilton,
Lincoln & Chase,
Wilson, FDR;
- Low taxes, limited infrastructure, with risk assumed by
individuals: Advocated by President's Jefferson & Madison,
Reagan,
George W. Bush (Gingrich);
Johnson & Kwak develop a model of what the US
government does. They argue that the conflicting
sinking fund and low tax approaches leaves the nation 'stuck in
the middle' with a future problem.
And they offer their list of 'first principles' to help
assess the best approach for moving from 2012 into the
future.
They conclude the question is still political. They hope
it can be resolved with an awareness of their detailed
explanations. They ask who is willing to
push all the coming risk onto individuals.
Following our summary of their arguments RSS frames them from the
perspective of complex adaptive system (CAS) theory.
Historically developing within the global cotton value delivery
system, key CAS features are highlighted.
proposal was politically divisive.
- Covering the excluded, who prior to the ACA were the
most in need of health insurance and were blocked from
obtaining it. President Obama bet that covering all
Americans would yield major economic and health benefits
in the future. Access to preventative screenings and
treatment for chronic illnesses, better coordination with
PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
s and less use of ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). s would result in long
term savings to offset the initial additional
expenses. For the insurance to be sustainable the
increased risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty.
introduced by these individuals would have to be offset by
the low risk participation of healthy individuals, which
was required by ACA
title 1 is ACA quality affordable care for all Americans. It mandates community rating & essential health benefits. It includes: - Subtitle A: Immediate improvements in health care for all Americans.
- Subtitle B: Immediate actions to preserve and expand coverage.
- Subtitle C: Quality health insurance coverage for all Americans. Which reforms the health insurance markets and prohibits preexisting condition exclusions and forms of health status discrimination.
- Subtitle D: Available coverage choices for all Americans.
- Subtitle E: Affordable coverage choices for all Americans.
- Subtitle F: Shared responsibility for health care which mandates individuals and employers to pay for insurance.
- The employer mandate requires employers with more than 50 full-time workers to offer most of their employees insurance or face penalties.
subtitle F mandate for individuals to pay
for insurance. But Pearl notes that requiring
people purchase health insurance is politically
problematic.
- Creating the insurance
exchanges was intended to allow internet shopping
for health insurance comparable in experience to Expedia
or Amazon,
for those people who would not qualify for Medicaid or
Medicare with salaries between $33,000 and $88,000.
The web sites would offer simple to compare and understand
plans with details of providers and prices. Credits
and subsidies were also provided to increase the incentive
to purchase the insurance. President Obama was
assuming that as these offers became honed companies would
move their employees over to the exchange based policies
as well. But the price
of the policies rose rapidly before the 2016 elections
helping candidates who campaigned against "Obama Care is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
." Pearl
concludes the effect of these first three bets left
President Trump & the Republican controlled Congress
with:
- Caring for seniors and rewarding excellence by
- Recognizing the impact on the Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
Hospital
Insurance and Supplementary Medical Insurance trust
funds of the retirement of the baby boomers.
- Leveraging the FFV is fee-for-value payment. It may be a bundled payment for a set of services provided by a group of doctors and facilities, or full capitation. In each case the risk has shifted from the payer to the providers of care.
architecture already built into Medicare
Advantage (MA) is a private provider administered health insurance plan providing access to Medicare benefits. It was originally enacted as part of BBA Medicare + Choice or Part C plans. The government funded the plan with an annual fee, based on age and severity of the subscriber's medical conditions, rather than FFS. When a Medicare eligible person enrolls in a MA plan the government pays the private provider a set amount each month. The participant pays the Medicare part B premium and if required a part C premium each month. The MA plans offer a PCP who coordinates care. And the plans have an annual limit on out-of-pocket expenses unlike traditional Medicare. When they obtain treatment they will have to pay a copayment which may be quite high for some specialists. It is the health plan's responsibility to contract the physician network that will provide the care, leaving the risk with the insurer. About 36% of Medicare beneficiaries are enrolled with Medicare Advantage by 2019. The ACA introduced quality outcome and patient satisfaction based differential payments into MA. To measure the performance it added a five-star quality rating scheme. MA plans report their quality and patient satisfaction data to CMS annually and based on the results are awarded one to five stars. The highest rated plans are provided with large additional payments. It was assumed that subscribers would shift to the highest rated plans and the other plans would improve or drop out of MA. And the ACA eliminated subsidies which the federal government used to establish Medicare Advantage. However, the Obama administration has used a $8.5 Billion demonstration project to maintain this funding. It is intended that it will eventually taper off so that the cost of Medicare Advantage coverage will be equivalent to standard Medicare. . The ACA extended the incentives is a CMS quality bonus payment. The ACA established Star Ratings as the basis of these payments.
for Medicare Advantage health plans achieving high quality
ratings Star ratings are CMS quality ratings of health care domains. They reflect measures of outcomes including intermediate outcomes, patient experience, access and process. Care coordination (assessed by CAHPS survey) and quality improvement measures have been added. Data is sourced from health and drug plans, from CMS contractors, from surveys of enrollees, and from CMS administrative data. They reflect HEDIS data. The ACA established Star Ratings as the basis of QBPs. 5-star health plans benefit from being able to market all year round, and beneficiaries can join at any time via a SEP. Health plans with less than 3-star ratings can be terminated by CMS starting in 2015. Star ratings cover 9 domains: - Ratings of health plans (part C)
- Staying healthy: screening, tests, vaccines
- Managing chronic (long-term) conditions
- Member experience with the health plan
- Member complaints, problems getting services, and improvements in the health plans performance
- Health plan customer service
- Ratings of drug plans (part D)
- Drug plan customer service
- Member complaints, problems getting services, and improvements in the drug plan's performance
- Member experience with the drug plan
- Patient safety and accuracy of drug pricing
.
- Integrating a fragmented system by
- Expanding insurance coverage and
- Integrating the care delivery system by encouraging
independent primary- and specialty-care physicians to
join with a hospital and align incentives to form ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination.
- CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
s which could then
compete at delivering value based care. But Pearl
explains the ACO legislation was only partially complete
when it was frozen by the death of Senator Kennedy and
subsequent election of Republican Scott Brown.
This left undefined which patients were assigned to
particular ACOs and did not limit patients to obtaining
care from only the ACO doctors. ACOs delivered
cost savings but the systems, technology and leadership
costs undermined the savings. Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
Pioneer ACOs is a CMS Innovation Center initiative to support ACOs in providing more coordinated care to beneficiaries (individuals and populations) at lower cost to Medicare. It leverages the ACA shared savings program and tests an alternative 'pioneer ACO' model. Pioneers are assumed to be organizations with experience offering coordinated, patient-centered care, and operating in ACO-like arrangements. A first performance period Jan 1 2012 - 2014 tests a shared savings and shared losses payment arrangement with higher levels of reward and risk than in the shared savings program. In year three Pioneer ACOs that have showed savings over the first two years can move to a population based payment model. Two alternative payment models were added which allow pioneer ACOs more flexibility in the speed at which they assume financial risk. Pioneers must also commit to having greater than 50% of primary care providers meet meaningful use of certified EHRs for receipt of payments through Medicare and Medicaid EHR Incentive Programs. Pioneers must have > 15000 beneficiaries enrolled in original FFS part A and part B Medicare. Organizations were selected using these criteria.
have struggled to operate to goal.
- Finding a meaningful
use is the set of standards defined by CMS Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria. It aims to ensure that ARRA subsidies for HIS are used to generate health improvements. It is staged:
- 2011-2012 Data capture and sharing - Criteria focus on electronically capturing health information in a standardized format. Using that information to track key clinical conditions. Communicating that information for care coordination processes. Initiating the reporting of clinical quality measures and public health information. Using information to engage patients and their families in their care. Achieving meaningful use stage 1 requires meeting all core and selected menu objectives.
- 2014 Advance clinical processes - More rigorous health information exchange requirements. Increased requirements for e-prescribing and incorporating lab results. Electronic transmission of patient care summaries across multiple settings. More patient-controlled data. A patient portal is required. CMS hospital core measures, CMS hospital menu set measures, NPRMs of stage 2 meaningful use and certification criteria have been announced (2013).
- MU2 requires EHR systems to support direct messaging to send PHI to registered users.
- 2016 Improved outcomes - Improving quality, safety, and efficiency, leading to improved health outcomes. Decision support for national high-priority conditions. Patient access to self-managed tools. Access to comprehensive patient data through patient-centered HIE. Improving population health.
for the EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
technology deployed by the HITECH the Health Information Technology and Economic and Clinical Health Act 2009. Central to the act is the establishment of the Medicare and Medicaid EHR incentive programs which make available $27 Billion over 10 years to encourage eligible professionals and hospitals to adopt and meaningfully use certified EHR technology. It is assumed that over time use of the new infrastructure will grow exponentially. HITECH established a formal mechanism for public input into HIT policy - the HITPC and HITSC. Hitech is a key evolved amplifier driving the migration to and installation of Epic and Cerner EHR systems. act.
Obama noted that VistA is the veterans' health information systems and technology architecture. It includes: VistA imaging system; and a GUI CPRS. It is composed of over 150 applications built using a MUMPS accessed data store. It was originally called decentralized hospital computer program (DHCP). It had three core aspects: - System/database management
- Administrative management - supporting normal hospital admin (scheduling, etc)
- Clinical management - information provision in the lab, pharmacy etc. The EHR facilities were built via the clinical records project with support for order entry/results reporting, health summary, problem index, allergies/adverse reactions, progress notes, crisis warnings, consults, clinical observations and clinical measurements.
had hugely reduced the costs of any doctor getting access
to a veteran's health record, while the general The structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
health care network was still
using paper at a cost of $25 to just access a patient
record. Pearl argues that effective integration
based on EHR capabilities should result in: improved
prevention, This page reviews the strategy of architecting an end-to-end
solution in a complex adaptive system (CAS).
The mechanism and its costs and benefits are discussed.
end-to-end coordinated
care aims to transfer information between the patient and each care participant as required and establish accountability by defining who is responsible for each care delivery activity, the extent of that responsibility and when that responsibility will be transferred to other care participants or the patient and family. Successful care coordination requires face-to-face interactions. It also requires aligned incentives (ACO, Bundled payments). AHRQ defines quality measures for care coordination. The situation is usually complex and adaptive due to the interactions of all the providers, settings, the patients' preferences, and the number of physical health problems, treatments, and the patients' social situation. The potentially exponential increase in complexity as the number of these factors present increases leads to patient hot spots requiring explicit proactive coordination of care. It is argued that care coordination must include six specific activities: - Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history. It needs to be updated periodically and after new diagnosis and other changes in health or functional status.
- Creation and updating of proactive plan of care
- Communication
- Facilitation of transitions: typical transition problems are detailed by Project Boost. A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff.
- Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness.
- Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.
, rapid intervention; resulting in savings of
around $600 billion. But those savings haven't
happened. While the technology has changed there are
still needed transformations of care delivery which
manifest as EHR systems slowing doctors down. Pearl
judges the incentives designed into ACA Meaningful Use
Stage 2 as pushing care delivery to change. But the
vendors providing the EHR systems have little
incentive to abandon their proprietary control points
leaving the patient records locked inside these
systems. As long as this interoperability barrier
remains, HCIT is health care information technology. The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets. Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.; will add
to health care costs.
- Measuring quality and effectiveness with the PCORI is the patient centered outcomes research institute executes a program that selects, designs, and conducts clinical effectiveness research, comparing drugs, devices, medical interventions and different delivery-system approaches. Robert Pearl explains it uses public and private funding to support President Obama's goal of clarifying which approaches achieve better health outcomes for patients at lower cost.
. Pearl sees
a huge need for the PCORI:
- Perception & health care reform - Pearl considers
Obama accurately assessed the challenges that remained: "Too
many Americans still strain to pay for their physician
visits and prescriptions, cover their deductibles, or pay
their monthly insurance bills; struggle to navigate a
complex, sometimes bewildering system; and remain
uninsured." Pearl judges the results as:
- Coverage expansion for the poor through Medicaid, young
adults up to age 26 on their parent's plan and patients
with existing conditions
- Medicare's five-star system has moved enrollees into the
higher-performing programs
- Online exchanges have insured 10 million individuals
- Computers have not succeeded in transforming patient
care
- ACOs and comparative research have achieved little and
are probably under threat from the Trump
administration.
- The Affordable Care Act and Beyond: Pearl suggests the
result of the 2016 election was due to general discontent
and deep-seated distrust of the traditional political
process. Pearl had found six years into the ACA
deployment many from the medical community did not
accurately understand the legislation - a huge perception
gap:
- Disappointed that the population's health had not
significantly improved. But Pearl notes the
beneficiaries were only 5% of the US population so a huge
percentage change in the newly insured would hardly alter
the health of the country overall.
- Frustration at the large 2017 premium increases.
Pearl notes that the initial premiums for the newly
insured were set at the US average but many had
preexisting conditions so the rates will rise as treatment
rates increase.
- Pearl concluded people's dissatisfaction reflected their
health care experiences: high costs, inconvenience, and
lack of transparency; as much as the legislation.
And he asserts the Trump administration will also
experience the dilemma:
- Address the growing cost of health care and
unhappiness will grow
- Ignore the cost growth and health care will suck away
most of the revenue needed for funding President Trump's
plans.
- Remove the insurance coverage and Trump voters in
Pennsylvania, Michigan, Ohio & Wisconsin will
struggle. Pearl recalls that today's health care
difficulties reflect a half century of evolution.
But President Trump's perceptions will reflect his
background and life experiences. And Pearl notes
he is hard to predict. Still he suggests
- Trump will likely try to reduce the role of the
federal government in the health care process. So
block grants may be attractive.
- He is a pragmatist so will retain popular aspects of
the ACA: preexisting condition exclusions and children
on their parents insurance
- He campaigned arguing to allow drug imports from other
countries, allowing interstate sale of insurance and
allowing Medicare to negotiate drug prices for
beneficiaries but Pearl thinks these proposals are up in
the air.
- Reconciliation will allow reversal of the: Medicaid
expansion, Individual mandate, Medical-device taxes, and
Cadillac tax.
- Beyond Politics - Pearl proposes four questions that
predict the future health and wellbeing of the US:
- Will the expectations of patients change in the
future? Pearl sees a critical aspect being whether
patients choose high-rated Medicare Advantage and
insurance exchange plans, or they cling to the past
approach.
- Will care providers and insurers move to new
reimbursement models? Bundled payments is where the purchaser disburses a single predefined payment to cover certain combinations of hospital, physician, post-acute, or other services performed during an episode of care relating to a particular condition (unlike capitation). This bundling is assumed (Sep 2018) to allow the value delivery system to optimize around low cost high quality long term health care. With one bundled payment physicians & hospitals must coordinate care and reduce the unit costs to remain profitable. And to avoid taking on risk of expensive complications physicians & hospitals are incented to standardize and focus on quality. This optimization is dependent on quantifying the value of the outcome of the episode of care. Previously FFS payments induced excessive treatment activity. Bundled payment is included in CMS ACE demonstrations and BPCI initiatives. There are significant impacts on IT.
- It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.
- Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments.
- Care delivery must be re-architected to reduce costs and improve quality.
- Monitoring sensors can be used to feed reports to ensure re-architected operations conform.
and capitation is a global payment for all care for a patient during a specified time period. It forces the provider of care to take a high risk. Managing the risk implies successful population health management.
require physicians and hospitals to agree how to allocate
the payments whereas FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment.
benefits them today.
- Will doctors make the changes necessary to realize the
benefits of technology? Pearl argues the difficulty
here is that doctors must change the way they practice to
allow patients to benefit from the opportunities of new
technology.
- Will our definition of the "best" medical care reflect
our modern realities? Pearl asserts that the best
approach to health care requires a transition to being:
- Team delivered
- Provided in large centers-of-excellence; but he notes
health care has a history of: rigid culture, and
slow-changing perceptions. The powerful legacy
players know the current situation cannot be sustained,
so they are attempting to restructure to maximize short
term profit and so cope with the eventual challenges
from a position of strength. Instead Pearl
proposes a four point plan to flatten the cost
curve.
Pearl's four
pillars of transformation - a well-integrated EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
system can support a health
care transformation. Empowered clinical staff can respond
to signals from and inconsistencies in the patient's health
record by identifying problems and enabling corrective
action. That depends on the system and culture as much as
the staff's personality describes the operation of the mind from the perspective of psychological models and tests based on them. Early 'Western' models of personality resulted in a simple segmentation noting the tension between: individual desires and group needs, and developing models and performing actions. Dualistic 'Eastern' philosophies promote the legitimacy of an essence which Riso & Hudson argue is hidden within a shell of personality types and is only reached by developing presence. The logic of a coherent essence is in conflict with the evolved nature of emotions outlined by Pinker. Terman's studies of personality identified types which Friedman and Martin link to healthy and unhealthy pathways. Current psychiatric models highlight at least five key aspects: - Extroversion-introversion - whether the person gains energy from socializing or retiring
- Neuroticism-stability - does a person worry or are they calm and self-satisfied
- Agreeableness-antagonism - is a person courteous & trusting or rude and suspicious
- Conscientiousness-un-directedness - is a person careful or careless
- Openness-non-openness - are they daring or conforming
,
work ethic or values. The whole team has to be incented to
fix the patients broad problems. FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment. reimbursement is the payment process for much of US health care. Reimbursement is the centralizing mechanism in the US Health care network. It associates reward flows with central planning requirements such as HITECH. Different payment methods apportion risk differently between the payer and the provider. The payment methods include: - Fee-for-service,
- Per Diem,
- Episode of Care Payment,
- Multi-provider bundled EPC,
- Condition-specific capitation,
- Full capitation.
and
disconnected specialists undermine this integrated empowered
team strategy. Pearl asserts that four shifts can together
create a more efficient and effective model of care delivery:
- A team of physicians working together on your
behalf. Pearl argues that there are three types of
health care venue today:
- Community-based
providers - which being small and discrete have
become market leaders focusing on customer intimacy but
can't directly: invest in HCIT is health care information technology. The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets. Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.;
infrastructure, collaborate broadly with colleagues,
leverage economies of scale; which he asserts raise
quality and reduce
costs in high volume health care settings,
- University
clinics and hospitals (AMC is Academic medical center. They perform education, research and patient care. They include one or more health professions schools, such as a medical school and a hospital. The major AMCs are represented by the United HealthSystem Consortium. The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. AMCs offer researchers clinical research support: Virus vectors (Nov 2017);
)s
which focus on product differentiation, signal their
scientific acumen and high technology but the high costs
of this differentiation are being pressured by insurers
who can attempt to exclude the AMCs from their narrow networks - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans. This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans. By limiting the number of providers/doctors offered in the plans the few that are included should get more business. Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers). In large cities narrow networks are even more common. Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills. There are problems induced by narrow network constraints: - Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts. Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running. If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016).
,
- Integrated
delivery networks (Pearl refers to Mayo
Clinic, Ochsner
Health, Virginia
Mason as examples) who focus on operational
excellence leveraging: integration to maximize
collaboration and cooperation, scale using patient volume
to allow specialists to gain expertise and improve
clinical outcomes, and lower costs.
- Pearl accepts that trying to excel at all three
strategies at once has historically failed - Porter's
stuck in the
middle. But he asserts that technology and medical
practice advances now allow this! He argues:
- Technology will bring patient and medical team
together building intimacy
- Mobile and video technologies will support product
differentiation - sophisticated treatments and coordinated
care aims to transfer information between the patient and each care participant as required and establish accountability by defining who is responsible for each care delivery activity, the extent of that responsibility and when that responsibility will be transferred to other care participants or the patient and family. Successful care coordination requires face-to-face interactions. It also requires aligned incentives (ACO, Bundled payments). AHRQ defines quality measures for care coordination. The situation is usually complex and adaptive due to the interactions of all the providers, settings, the patients' preferences, and the number of physical health problems, treatments, and the patients' social situation. The potentially exponential increase in complexity as the number of these factors present increases leads to patient hot spots requiring explicit proactive coordination of care. It is argued that care coordination must include six specific activities:
- Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history. It needs to be updated periodically and after new diagnosis and other changes in health or functional status.
- Creation and updating of proactive plan of care
- Communication
- Facilitation of transitions: typical transition problems are detailed by Project Boost. A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff.
- Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness.
- Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.
, while eliminating redundancy and
inefficiency.
- Operational excellence is built with improved systems
of care.
- Pearl judges that effective integration will also need
physicians trained as business leaders. Together
these changes will enable health care network wide
integration: integration of the form Atul
Gawande highlighted in describing the Camden Coalition
which had previously
been too costly to implement broadly. If
integrated delivery networks can improve customer
intimacy they will outperform other types of hospital
strategy. In part this will be due to improved wellbeing indicates the state of an organism is within homeostatic balance. It is described by Angus Deaton as all the things that are good for a person:
- Material wellbeing includes income and wealth and its measures: GDP, personal income and consumption. It can be traded for goods and services which recapture time. Material wellbeing depends on investments in:
- Infrastructure
- Physical
- Property rights, contracts and dispute resolution
- People and their education
- Capturing of basic knowledge via science.
- Engineering to turn science into goods and services and then continuously improve them.
- Physical and psychological wellbeing are represented by health and happiness; and education and the ability to participate in civil society through democracy and the rule of law. Life expectancy as a measure of population health, highly weights reductions in child mortality.
reducing the demand for hospital beds which will
undermine the community
hospitals business model. Pearl notes that improved
transportation infrastructure already undermine
the strategy
of having small local hospitals. He sees PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. s as providing
essential coordination leadership and the expertise
needed to manage and defeat today's chronic
illnesses.
- Aim for people to stay healthy, which is better and
cheaper. Pearl notes that FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment. does not reward doctors
and hospitals for optimal care, just to do more. Pearl
wants incentives to reward preventing problems, improving
quality, maximizing safety and minimizing cost.
- Effective interoperable technology is essential to fully
enable responsive, convenient, well informed care. 10
million EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses:
- The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
s provides a
database which supports predictions of which: Hospital
patients will require subsequent ICU is intensive care unit. It is now being realized that the procedures and environment of the ICU is highly stressful for the patients. In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD. Intubation and catheterization are also traumatic. Sometimes seperated into MICU and SICU. eICU skill centralization may bring down costs. admission so early
intervention can remove this possibility; Patients will
return to the ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). after
discharge, so their release can be delayed while their
recovery is monitored. But only a handful of US
hospitals apply advanced data analytics, leaving problems
hidden. The data can differentiate between situations
where watchful waiting is best and surgery is
required. Pearl laments that EHR interoperability
is held back by business constraints. And hospitals
also need to augment the EHR with all the data about the
patient gathered at other sites. Big data encompasses the IT systems and processes necessary to do population based data collection, management and analysis. The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass. Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms: Precision medicine, Protein folding modeling (Feb 2019) assumes coevolutionary methods can be applied to identify contact points in a protein's tertiary structure. Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure: - Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Complex data models must include clinical aspects of the patient specific data, including disease state population wide.
- A key aspect is providing clear signals about the nature of the data using data visualization.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
helps doctors
determine which clinical approaches best match a
situation. Pearl notes that Kaiser
has provided a million virtual doctor visits a month.
But most hospitals still don't offer these
capabilities. Insurance policies and state medical
boards have constrained action but are slowly
shifting. Pearl discusses This page reviews Christensen's disruption
of a complex adaptive system (CAS).
The mechanism is discussed with examples from biology and
business.
Clayton
Christensen's US healthcare is ripe for
disruption. Christensen, Grossman and Hwang argue that
technologies are emerging which will support low cost business
models that will undermine the current network. Applying
complex adaptive system (CAS)
theory to these arguments suggests that the current power hierarchy can effectively resist
these progressive forces.
disruption of
healthcare as an enabler of change.
- Physicians must be trained to be effective leaders aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group. John Adair developed a leadership methodology based on the three-circles model.
. As
CEO of a major Kaiser medical group and a member of the Stanford
business school faculty Pearl's experience led him to
conclude leaders must touch their colleague's heart, brain
and guts. Pearl explains:
- Engaging the heart - doctors participate in patients
intimate and emotional experiences and so doctors must act
empathetically is the capability to relate to another person from their perspective. It is implemented by spindle neurons. Empathy towards others is controlled by the right-hemisphere supramarginal gyrus. Empathy is context dependently mediated by estrogen. It develops over time: Piaget's preoperational stage includes rudimentary empathy, Theory of mind supports the development; initially feeling someone's pain as one integrated being, then for them and eventually as them. In adults, when someone else is hurt the anterior cingulate cortex, amygdala & insula activates projecting [scapegoating] to the vmPFC. If the pain is physical the PAG activates and motor neurons for the area where the other person was injured. The intertwining of the ACC amygdala & insula in adults results in attribution of fault even when there is none which can make it hard to step in and actually help. But in seven-year-olds the activation is concrete: PAG and sensory & motor cortexes with minimal coupling to the rudimentary vmPFC. In older children the vmPFC is coupled to limbic structures. Ten to twelve year olds abstract empathy to classes of people. Brizendine asserts young girls develop empathy earlier than boys, because their evolved greater neuronal investment in communication and emotion networks. Year old girls are much more responsive to the distress of other people than boys are. At 18 months girls are experiencing infantile puberty. By adolescence the vmPFC is coupled to theory of mind regions and intentional harm induces disgust via the amygdala. Sapolsky explains adolescent boys are utilitarian and tend to accept inequality more than girls do. But both sexes accept inequality as the way it is. Sociopaths do not develop empathy. .
Pearl suggests picking leaders who have demonstrated they
are interested in and value everyone they work with.
- Stimulating the brain - detailing why changes are
necessary, working closely with physicians to ensure that
required
The complexity of behavior is explored through Sapolsky
developing scenarios of our best and worst behaviors across time
spans, and scientific subjects including: anthropology,
psychology, neuroscience, sociology. The rich network of
adaptive flows he outlines provides insights and highlight
challenges for scientific research on behavior.
Complex adaptive system (CAS) theory builds on Sapolsky's
details highlighting the strategies that evolution has captured
to successfully enter niches we now occupy.
behaviors are
understood to be achievable and providing feedback on
performance.
- Knowing when to trust your gut - Pearl feels doctors
will only act to support change if they interoceptively indicate the body's internal homeostatic state: Pain, Fatigue; seconds to minutes before. The signals are conveyed to the CNS via unmyelinated C fibers or lightly myelinated A delta fibers. Damasio suggests this is key to the fabrication of feelings, allowing interaction with the surrounding chemical environment and cross talk between axons. These signals operate unconsciously unless mapped by feelings into consciousness. The interoceptive 'networks': default mode network; project to brain regions that implement social emotions.
trust and distrust are evolved responses to sham emotions. During a friendship where no sham emotions have been detected trust will build up. their leaders on
the issue. That trust is
built by building
personal rapport, being seen to tell the truth and
leading.
Pearl views his four pillars as a vision to strive for. In
particular he hopes politicians will use the vision as a way to
improve the competitive advantage of American business and so
will support legislation that encourages such a
transformation.
Pearl explains what
he, doctors, patients; everyone wants and needs - he loves:
sports, team sports in particular and baseball most, because of
its happy associations with his father and his childhood.
And he adds baseball, like our bodies, requires every agent to
work together to succeed. Similarly teamwork generates the
best results in health care.
Recently Pearl laments baseball and health care have become
overly profit oriented to the detriment of pleasure and
fulfillment.
The perverse incentives of health care are due to imbalances:
Pearl writes that doctors are unhappy with these imbalances,
resulting in low personal and professional satisfaction, depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult;, burn-out and
suicides. Practitioners see themselves as embattled and
powerless. Pearl notes that doctors have to cope with the
deaths of their patients. Events that remain vividly with
the family and health care professionals, especially when
improvements in the system could have changed the outcome.
The environment in which health care is administered has a major
impact on clinical quality. It alters perception which
transforms The complexity of behavior is explored through Sapolsky
developing scenarios of our best and worst behaviors across time
spans, and scientific subjects including: anthropology,
psychology, neuroscience, sociology. The rich network of
adaptive flows he outlines provides insights and highlight
challenges for scientific research on behavior.
Complex adaptive system (CAS) theory builds on Sapolsky's
details highlighting the strategies that evolution has captured
to successfully enter niches we now occupy.
behavior. Some
group practice leaders This page reviews the inhibiting effect of the value delivery system on the
expression of new phenotypic
effects within an agent.
demonstrate
use of inappropriate but lucrative coding and billing which then
shifts the perceptions of new members. Pearl describes
examples of loss aversion which are more influential when they
are concrete (cash loss) than indirect (credit catalyzes the purchase of homes and durable goods by spreading out the payment into a series and removing the need to obtain the entire purchase price in advance as described by Gordon. It is supported by an evolved amplifier, including: a clear benefit to the purchaser, a profit stream captured by the lender, enforceable contractual agreements, within a schematic regulatory framework. Taibbi describes the amplifier's architecture as deployed by Chase. Nineteenth century US rural purchases were credit based but with a large initial commitment. Cash purchases increased between 1890 and 1910. Between 1910 and 1915 cash purchasing shifted back to leveraging credit. By 1920 credit accounts were offered at department stores. Installment plans, provided by finance companies: GMAC; with minimal upfront commitments supported the purchase of costly durable items including automobiles. ). This
type of mental distortion is amplified by health insurance which
ensures the cost impact of care is highly indirect. And
since physicians decide the demand for a procedure and its
price, while patients have little choice but to pay, supply and
demand are decoupled. Medical
research displays similar biases. Drug and device
companies monitor who is using and prescribing their most
profitable products. These doctors are rewarded with food,
flattery and friendship.
Still Pearl concludes the massive scope of the transformational
change requires everyone to recognize our health care decisions
affect ourselves, our families and our communities. People
want:
- Affordable effective coverage - where they aren't excluded
from needed care for pre-existing conditions or they can't
afford the care. FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment.
induces a tragedy
of the commons reflects the lack of incentive for individuals to cooperate to sustain a common good when there is no immediate disincentive, even when over time the result will be collapse of the resource base sustaining the group. Josh Greene notes the issue is how to jump-start and maintain cooperation. Sapolsky notes evolution has solved this problem by leveraging bootstrapping processes and helping groups to discourage individuals being selfish. Institutions: religion, nationalism, ethnic pride, team spirit; provide green-beard markers to support this process.
.
- Limited out-of-pocket expenses - but 40% of people now
have HDHP is a high-deductible health plan which has lower premiums and a higher deductable than traditional health insurance plan such as a HMO plan or PPO plan.
.
- Convenient access
- Clinically excellent, knowledgeable and compassionate doctors who
participate in coordinated
care aims to transfer information between the patient and each care participant as required and establish accountability by defining who is responsible for each care delivery activity, the extent of that responsibility and when that responsibility will be transferred to other care participants or the patient and family. Successful care coordination requires face-to-face interactions. It also requires aligned incentives (ACO, Bundled payments). AHRQ defines quality measures for care coordination. The situation is usually complex and adaptive due to the interactions of all the providers, settings, the patients' preferences, and the number of physical health problems, treatments, and the patients' social situation. The potentially exponential increase in complexity as the number of these factors present increases leads to patient hot spots requiring explicit proactive coordination of care. It is argued that care coordination must include six specific activities:
- Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history. It needs to be updated periodically and after new diagnosis and other changes in health or functional status.
- Creation and updating of proactive plan of care
- Communication
- Facilitation of transitions: typical transition problems are detailed by Project Boost. A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff.
- Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness.
- Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.
. This all demands Carlo Rovelli resolves the paradox of time.
Rovelli initially explains that low level physics does not
include time:
- A present that is common throughout the universe does not exist
- Events are only partially ordered. The present is
localized
- The difference between past and future is not foundational.
It occurs because of state that through our blurring appears
particular to us
- Time passes at different speeds dependent on where we are and how fast we travel
- Time's rhythms are due to
the gravitational field
- Our quantized physics shows neither
space nor time, just processes transforming physical
variables.
- Fundamentally there is no time. The basic equations
evolve together with events, not things
Then he
explains how in a physical world without time its perception can
emerge:
- Our familiar time emerges
- Our interaction with the world is partial, blurred,
quantum indeterminate
- The ignorance determines the existence of thermal time
and entropy that quantifies our uncertainty
- Directionality of time is real
but perspectival. The entropy of the world in
relation to us increases with our thermal time. The
growth of entropy distinguishes past from future: resulting in
traces and memories
- Each human is a
unified being because: we reflect the world, we
formed an image of a unified entity by
interacting with our kind, and because of the perspective
of memory
- The variable time: is one
of the variables of the gravitational field.
With our scale we don't
register quantum fluctuations, making space-time
appear determined. At our speed we don't perceive
differences in time of different clocks, so we experience
a single time: universal, uniform, ordered; which is
helpful to our decisions
time
and empathy is the capability to relate to another person from their perspective. It is implemented by spindle neurons. Empathy towards others is controlled by the right-hemisphere supramarginal gyrus. Empathy is context dependently mediated by estrogen. It develops over time: Piaget's preoperational stage includes rudimentary empathy, Theory of mind supports the development; initially feeling someone's pain as one integrated being, then for them and eventually as them. In adults, when someone else is hurt the anterior cingulate cortex, amygdala & insula activates projecting [scapegoating] to the vmPFC. If the pain is physical the PAG activates and motor neurons for the area where the other person was injured. The intertwining of the ACC amygdala & insula in adults results in attribution of fault even when there is none which can make it hard to step in and actually help. But in seven-year-olds the activation is concrete: PAG and sensory & motor cortexes with minimal coupling to the rudimentary vmPFC. In older children the vmPFC is coupled to limbic structures. Ten to twelve year olds abstract empathy to classes of people. Brizendine asserts young girls develop empathy earlier than boys, because their evolved greater neuronal investment in communication and emotion networks. Year old girls are much more responsive to the distress of other people than boys are. At 18 months girls are experiencing infantile puberty. By adolescence the vmPFC is coupled to theory of mind regions and intentional harm induces disgust via the amygdala. Sapolsky explains adolescent boys are utilitarian and tend to accept inequality more than girls do. But both sexes accept inequality as the way it is. Sociopaths do not develop empathy. as well
as skill and specialization. Physicians must be able
to accept their limitations and let go.
Pearl feels that the best health care must provide all these
wants as one to its patients. He asserts this requires the
The structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
health care network to work together
learning from each other, to reduce medical
error and improve coordination. They will need to
have and use integrated information systems to do this.
That will allow them to address social disparities in health
outcomes. Insurers must shift from FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment. to FFV is fee-for-value payment. It may be a bundled payment for a set of services provided by a group of doctors and facilities, or full capitation. In each case the risk has shifted from the payer to the providers of care. and stop demanding prior authorization is a constraint imposed by some insurance companies prior to their agreeing to cover some prescribed medications or medical procedures. The constraint may be due to: age, medical necessity, availability of a generic alternative, or to check drug interactions. After a healthcare provider orders a service for a patient, the provider's staff will contact the patient's insurer to determine if they require prior authorization. This should result in an exception process which may involve the provider's staff manual faxing a prior authorization form to the insurer. If the service is rejected, the healthcare provider may file an appeal based on the provider's medical review process. It may take 30 days for the insurer to approve the request.
to do what's right. The synergies will improve quality and
drive down costs.
Eventually US healthcare is ripe for
disruption. Christensen, Grossman and Hwang argue that
technologies are emerging which will support low cost business
models that will undermine the current network. Applying
complex adaptive system (CAS)
theory to these arguments suggests that the current power hierarchy can effectively resist
these progressive forces.
disruption of the current
health care businesses must occur. But private
practice doctors fear what change may bring. Those near
retirement may give up but Pearl hopes they won't because their
expertise is needed. He views reduced medical error as
providing the needed cost savings instead of the reduced
reimbursements the doctors' fear. New doctors can choose
how they will practice medicine. But Pearl warns without
change cost inflation will induce rationing of care.
Pearl's assessment is the health care delivery system still
needs fixing:
Pearl hopes that once: physicians, politicians, insurance and
drug-company executive, patients; understand these system
failings they will insist on doing something about it.
That will mean his father's
unfortunate death served a purpose.
This page introduces the complex adaptive system (CAS) theory
frame. The theory is positioned relative to the natural
sciences. It catalogs the laws and strategies which
underpin the operation of systems that are based on the
interaction of emergent agents.
John Holland's framework for representing complexity is
outlined. Links to other key aspects of CAS theory
discussed at the site are presented.
CAS theory views the people and
businesses of the US is the United States of America. health
care This page discusses the effect of the network on the agents participating in a complex
adaptive system (CAS). Small
world and scale free networks are considered.
network as Russ Abbott explores the impact on science of epiphenomena and
the emergence of agents.
emergent Plans are interpreted and implemented by agents. This page
discusses the properties of agents in a complex adaptive system
(CAS).
It then presents examples of agents in different CAS. The
examples include a computer program where modeling and actions
are performed by software agents. These software agents
are aggregates.
The participation of agents in flows is introduced and some
implications of this are outlined.
agents.
As such they must The agents in complex adaptive
systems (CAS) must model their
environment to respond effectively to it. Samuel
modeling is described as an approach.
model their
proximate environment to operate effectively within it.
Over evolutionary Carlo Rovelli resolves the paradox of time.
Rovelli initially explains that low level physics does not
include time:
- A present that is common throughout the universe does not exist
- Events are only partially ordered. The present is
localized
- The difference between past and future is not foundational.
It occurs because of state that through our blurring appears
particular to us
- Time passes at different speeds dependent on where we are and how fast we travel
- Time's rhythms are due to
the gravitational field
- Our quantized physics shows neither
space nor time, just processes transforming physical
variables.
- Fundamentally there is no time. The basic equations
evolve together with events, not things
Then he
explains how in a physical world without time its perception can
emerge:
- Our familiar time emerges
- Our interaction with the world is partial, blurred,
quantum indeterminate
- The ignorance determines the existence of thermal time
and entropy that quantifies our uncertainty
- Directionality of time is real
but perspectival. The entropy of the world in
relation to us increases with our thermal time. The
growth of entropy distinguishes past from future: resulting in
traces and memories
- Each human is a
unified being because: we reflect the world, we
formed an image of a unified entity by
interacting with our kind, and because of the perspective
of memory
- The variable time: is one
of the variables of the gravitational field.
With our scale we don't
register quantum fluctuations, making space-time
appear determined. At our speed we don't perceive
differences in time of different clocks, so we experience
a single time: universal, uniform, ordered; which is
helpful to our decisions
time scales the
models have become sophisticated enough to allow us to presume
we see reality. But illusions demonstrate that this is not
the case. We construct our reality from the signals we
perceive:
- Medicine is complex:
- Dr. Pearl sees
a generational
opportunity, Deming argued that most new ideas are adopted by new entrants to the field, trained with the new ideas. The incumbents are replaced as they retire, or their positions become non-viable. Just as happened with the germ theory of disease.
to transform medical practice.
Millennial acceptance of information technology and the
Internet may help to bind medical teams together.
Developing complex operational paradigms based on Plans emerge in complex adaptive
systems (CAS) to provide the
instructions that agents use to
perform actions. The component architecture and structure
of the plans is reviewed.
schematic Flows of different kinds are essential to the operation of
complex adaptive systems (CAS).
Example flows are outlined. Constraints on flows support
the emergence of the systems.
Examples of constraints are discussed.
control
and prioritization can leverage This page reviews the implications of selection, variation and
heredity in a complex adaptive system (CAS).
The mechanism and its emergence are
discussed.
evolutionary
action. But it can still become constrained by This page reviews the inhibiting effect of the value delivery system on the
expression of new phenotypic
effects within an agent.
extended phenotypic alignment and
contragrade
forces. And without careful design of the Agents use sensors to detect events in their environment.
This page reviews how these events become signals associated
with beneficial responses in a complex adaptive system (CAS). CAS signals emerge from
the Darwinian information model. Signals can indicate decision summaries and level of
uncertainty.
signalling infrastructure, chaos provides an explanation for the apparently random period between water droplets falling from a tap. Typically the model of the system is poor and so the data captured about the system looks unpredictable - chaotic. With a better model the system's operation can be explained with standard physical principles. Hence chaos as defined here is different from complexity. and inefficiency
can result. Dr. Pearl's approach must address:
The complexity of behavior is explored through Sapolsky
developing scenarios of our best and worst behaviors across time
spans, and scientific subjects including: anthropology,
psychology, neuroscience, sociology. The rich network of
adaptive flows he outlines provides insights and highlight
challenges for scientific research on behavior.
Complex adaptive system (CAS) theory builds on Sapolsky's
details highlighting the strategies that evolution has captured
to successfully enter niches we now occupy.
Human behavior evolved to detect,
leverage and accept hierarchy. While Geisinger
& Kaiser
have had some success with flattening the clinical
organization, it is not clear that the resulting structure
is robust over time.
- Charles
Ferguson
Charles Ferguson argues that the US power structure has become
highly corrupt.
Ferguson identifies key events which contributed to the
transformation:
- Junk bonds,
- Derivative
deregulation,
- CMOs,
ABS and analyst fraud,
- Financial network deregulation,
- Financial network consolidation,
- Short term incentives
Subsequently the George W. Bush administration used the
situation to build
a global bubble, which Wall Street
leveraged. The bursting of the
bubble: managed
by the Bush Administration and Bernanke Federal Reserve;
was advantageous to some.
Ferguson concludes that the restructured and deregulated
financial services industry is damaging to
the American economy. And it is supported by powerful, incentive aligned academics.
He sees the result being a rigged system.
Ferguson offers his proposals
for change and offers hope that a charismatic young FDR will appear.
Following our summary of his arguments, RSS comments on them framed by
complex adaptive system (CAS)
theory. Once the constraints are removed from CAS
amplifiers, it becomes advantageous to leverage the increased flows. And it is often
relatively damaging not to participate. Corruption and parasitism can become
entrenched.
describes the massive
distortions generated by the incentives of the US is the United States of America. financial
network.
- Atul
Gawande
Gawande uses his personal experience, analytic skills and lots
of stories of innovators to demonstrate better ways of coping
with aging and death. He introduces the lack of focus on
aging and death in traditional medicine. And goes on to
show how technology has amplified
this stress point. He illustrates the traditional possibility of the
independent self, living fully while aging with the
support of the extended family. Central
planning responded to the technological and societal changes
with poorly designed infrastructure and funding. But
Gawande then contrasts the power of
bottom up innovations created by experts responding to
their own family situations and belief
systems.
Gawande then explores in depth the challenges
that unfold currently as we age and become infirm.
He notes that the world is following the US path. As such it will
have to understand the dilemma of
integrating medical treatment and hospice
strategies. He notes that all parties
involved need courage to cope.
He proposes medicine must aim to assure
well being. At that point all doctors will practice
palliative care.
Complex adaptive system (CAS) models of agency, death,
evolution, cooperation and adaptations
to new technologies are discussed.
explores the relationship
between death and medicine.
- Statistical
analysis of complexity is difficult. Dorner
Dietrich Dorner argues complex adaptive systems (CAS) are hard to understand and
manage. He provides examples of how this feature of these
systems can have disastrous consequences for their human
managers. Dorner suggests this is due to CAS properties
psychological impact on our otherwise successful mental
strategic toolkit. To prepare to more effectively manage
CAS, Dorner recommends use of:
- Effective iterative planning and
- Practice with complex scenario simulations; tools which he
reviews.
reviews the issues and an
approach to cope. Assuming normal distributions apply
has caused huge difficulties for economics is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics. as Beinhocker
Eric Beinhocker sets out to answer a question Adam Smith
developed in the Wealth of Nations: what is wealth? To do
this he replaces traditional
economic theory, which is based on the assumption that an
economy is a system in
equilibrium, with complexity
economics in which the economy is modeled as a complex
adaptive system (CAS).
He introduces Sugerscape
to illustrate an economic CAS model in action. And then he
explains the major features of a CAS economy: Dynamics,
Agents, Networks, Emergence, and
Evolution.
Building on complexity economics Beinhocker reviews how evolution applies to
the economy to build wealth. He explains how design spaces
map strategies to instances of physical and
social
technologies. And he identifies the interactors and
selection mechanism of economic
evolution.
This allows Beinhocker to develop a new definition
of wealth.
In the rest of the book Beinhocker looks at the consequences of
adopting complexity economics for business and society: Strategy, Organization, Finance,
& Politics
& Policy.
Following our summary of his arguments, RSS explores his conclusions
and aligns Beinhocker's model of CAS with the CAS theory and evidence we
leverage.
explains.
- Steven
Pinker
Computational
theory of the mind and evolutionary
psychology provide Steven Pinker with a framework on which
to develop his psychological arguments about the mind and its
relationship to the brain. Humans captured a cognitive niche by
natural selection 'building out'
specialized aspects of their bodies and brains resulting in a system of mental organs
we call the mind.
He garnishes and defends the framework with findings from
psychology regarding: The visual
system - an example of natural
selections solutions to the sensory challenges
of inverse
modeling of our
environment; Intensions - where
he highlights the challenges of hunter gatherers - making sense
of the objects they
perceive and predicting what they imply and natural selections powerful solutions; Emotions - which Pinker argues are
essential to human prioritizing and decision making; Relationships - natural selection's
strategies for coping with the most dangerous competitors, other
people. He helps us understand marriage, friendships and war.
These conclusions allow him to understand the development and
maintenance of higher callings: Art, Music, Literature, Humor,
Religion, & Philosophy; and develop a position on the meaning of life.
Complex adaptive system (CAS) modeling allows RSS to frame Pinker's arguments
within humanity's current situation, induced by powerful evolved
amplifiers: Globalization,
Cliodynamics, The green revolution
and resource
bottlenecks; melding his powerful predictions of the
drivers of human behavior with system wide constraints.
The implications are discussed.
explains how This page discusses the interdependence of perception and
representation in a complex adaptive system (CAS). Hofstadter
and Mitchell's research with Copycat is
reviewed. The bridging of a node from a network of 'well
known' percepts to a new representational instance is discussed
as it occurs in biochemistry, in consciousness and
abstractly.
perceptions are constructed and The agents in complex adaptive
systems (CAS) must model their
environment to respond effectively to it. Samuel
modeling is described as an approach.
modeled.
- Angus
Deaton
Deaton describes the wellbeing
of people around the world today. He explains the powerful benefit of public
health strategies and the effect of growth in
material wellbeing but also the corrosive effects of
aid.
Following our summary of Deaton's arguments RSS comments from the
perspective of complex adaptive system (CAS)
theory. The situation he describes is complex including
powerful amplifiers, alignment and incentives that overlap
broadly with other RSS summaries of adaptations of: The
biosphere, Politics, Economics,
Philosophy and Health care.
analyses the wellbeing indicates the state of an organism is within homeostatic balance. It is described by Angus Deaton as all the things that are good for a person: - Material wellbeing includes income and wealth and its measures: GDP, personal income and consumption. It can be traded for goods and services which recapture time. Material wellbeing depends on investments in:
- Infrastructure
- Physical
- Property rights, contracts and dispute resolution
- People and their education
- Capturing of basic knowledge via science.
- Engineering to turn science into goods and services and then continuously improve them.
- Physical and psychological wellbeing are represented by health and happiness; and education and the ability to participate in civil society through democracy and the rule of law. Life expectancy as a measure of population health, highly weights reductions in child mortality.
of the
world.
- Robert
Sapolsky
The complexity of behavior is explored through Sapolsky
developing scenarios of our best and worst behaviors across time
spans, and scientific subjects including: anthropology,
psychology, neuroscience, sociology. The rich network of
adaptive flows he outlines provides insights and highlight
challenges for scientific research on behavior.
Complex adaptive system (CAS) theory builds on Sapolsky's
details highlighting the strategies that evolution has captured
to successfully enter niches we now occupy.
describes the significance
of: culture and us versus them.
He describes the operation
of morality including Josh
Green's work on inducing death uses fMRI to follow brain activity of subjects during Josh Greene's experiments with the trolley problem. He used two scenarios, (1) The five people are doomed, would you pull the lever so the trolley will hit and kill someone: (2) Would you push someone onto the tracks to stop the trolley? Consistently 60-70% of people say yes to scenario (1) but only 30% say yes to scenario (2). The fMRI showed the more the vmPFC and/or amygdala activate the more likely the person is to refuse to act in either case. Greene concludes that intuitions about intentionality are what is changing. Pushing that kills someone feels morally wrong. Greene developed a third scenario where the subject throws the switch to save the five but in doing so pushes a person out of the way and in falling to the ground they die. This seems more acceptable. Then Greene adjusts scenario (1) making the side loop switch back to the main track so that if the trolley is not stopped by the body of a person the five will still die - the same result as scenario (2). Described this way 60-70% find pulling the lever acceptable. Greene concludes our intuitions are very local and the additional indirection in this last scenario stops us feeling disturbed. .
- Johnson
& Kwak
Johnson & Kwak argue that expanding the national debt
provides a hedge against unforeseen future problems, as long as
creditors are willing to continue lending. They illustrate
different approaches to managing the debt within the US over its history and of the
eighteenth century administrations of England and France.
The US embodies two different political and economic systems which
approach the national debt differently:
- Taxes to support a sinking
fund to ensure credit to leverage fiscal power in:
Wars, Pandemics, Trade disputes, Hurricanes, Social
programs; Starting with Hamilton,
Lincoln & Chase,
Wilson, FDR;
- Low taxes, limited infrastructure, with risk assumed by
individuals: Advocated by President's Jefferson & Madison,
Reagan,
George W. Bush (Gingrich);
Johnson & Kwak develop a model of what the US
government does. They argue that the conflicting
sinking fund and low tax approaches leaves the nation 'stuck in
the middle' with a future problem.
And they offer their list of 'first principles' to help
assess the best approach for moving from 2012 into the
future.
They conclude the question is still political. They hope
it can be resolved with an awareness of their detailed
explanations. They ask who is willing to
push all the coming risk onto individuals.
Following our summary of their arguments RSS frames them from the
perspective of complex adaptive system (CAS) theory.
Historically developing within the global cotton value delivery
system, key CAS features are highlighted.
review the US is the United States of America. national debt is a pool of payment promises developed to finance costly discrete and transient activities, Johnson & Kwak explain. Repayments of the capital and interest are made regularly through mechanisms such as a sinking fund. Charles Montague first setup such an indirect arrangement that allowed thirteen and a half million pounds in British war debt (using a million-pound loan serviced by 99 years of new excise duties sold to the public as annuities) to persist in 1693 and supported it with a sinking fund in 1696. This strategy was viewed as scandalous by conservatives at the time. The conservatives argued the debt should be liquidated but Montague's strategy allowed Britain to develop and sustain, until the 20th century, a triple-A fiscal reputation and allowed it to use financial leverage as a weapon of war. Montague's strategy was enabled by the revenues Britain's merchants were obtaining from its developing global trade. CAS theory looks at the pool as a collection of commitments to provide energy to the owners' of the promises.
including health
care cost growth and future financing
strategies. President Trump's tax cuts (Dec
2017), that were enacted after Johnson & Kwak's
book was published; make the revenue shortfall even more
significant.
- Deming
noted the problem of robust, poorly formed ideas which he
ascribed to the germ
theory of management, Deming argued that most new ideas are adopted by new entrants to the field, trained with the new ideas. The incumbents are replaced as they retire, or their positions become non-viable. Just as happened with the germ theory of disease.
.
- Innovation is the economic realization of invention and combinatorial exaptation. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy.
is
explored by:
- Steele
and Feinberg explain how hot spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community. theory has
been used to control treatment costs at Geisinger.
Dr. Pearl's moving and thoughtful book challenges our mental
models of good health care. Hopefully we can integrate his
insights into the strategic process used for understanding and
improving the US is the United States of America. The structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
health network.
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 Politics, Economics & Evolutionary Psychology |
Business Physics Nature and nurture drive the business eco-system Human nature Emerging structure and dynamic forces of adaptation |
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integrating quality appropriate for each market |
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