Bad medical models

Summary

Mistreated Why we think we're getting good health care--and why we're usually wrong

• Celebrates his father's life and laments the failings of the US is the United States of America.   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 patent-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. 
  

• 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, DNA 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. 
  

• 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:
  1. 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. 
     
  2. 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:
  1. 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. 
     
  2. 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:
• Education, at which physicians typically excelled, tends to deal with hard sciences: physics, chemistry; and mathematics where the scientific method and logic can be applied.  Physicians gain experience with identifying the right answers.  
• Medicine involves dealing with patients and trying to understand their specific situation and personality from incomplete information.  Sometimes the situations are complex and no evidence-based approach can be applied.  Still
  
• Pearl asserts: Much of clinical practice has a best approach; If physicians followed available evidence based guidelines hundreds of thousands of lives would be saved each year; but many physicians don't adopt this approach because they aren't supported by technologies: EHR refers to electronic health records which are a synonym of EMR.  EHRs have 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-patent 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!
    
  ; that remind them of the situation and make the action efficient and easy.  So community standards often lag best medical practice and allow a wide variety of options.  
• 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:
1. How well individual physicians are supported by information technology
2. How well their entire medical team works together
3. How consistently the doctors on the team follow best national guidelines
4. 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 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. 
  
  1. It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.  
  2. Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments. 
     
  3. Care delivery must be re-architected to reduce costs and improve quality. 
     
  4. 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 health care will learn from Uber's positive contribution to transportation:
• Uber changed the environment for drivers, from the taxi cab monopoly is a power relation within:
  
  • A state in which a group has enough power to enforce its will on other citizens.  If this is a central authority with a cohesive military, it can overpower other warlords and stabilize the society. 
    
  • An economy in which one business has enough share in a market segment to control margins to its advantage.  An economic monopoly can be broadly beneficial: AT&T monopoly, US patent monopoly rights;
    
  , which shifted driver and consumer expectations.  And by providing riders with full details of the driver the trust model changed. 
  
• Pearl argues that health care can: change its patient experience, pay physicians for the quality of their outcomes; and expectations would shift to assuming fewer medical errors and a greater emphasis on preventative medicine.  He assumes that patients' expectations can drive the change. 
  

• 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.  Major anxiety results in elevated glucocorticoids and reduces hippocampal dendrite & spine density.  Some estrogen receptor variants are associated with anxiety in women. 
  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.  EHRs have 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-patent 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.  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.  
  • 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
  
• President Clinton went for cardiac surgery to Columbia twice!  Similarly
  
• President George W. Bush had a stent is a small wire cage that can be inserted into an artery to prop it open.  They were introduced as an alternative to bypass surgery in the 1990s.  Stents are expensive.  Medicare payments vary depending on what kind of stent is used and how many, but are generally in the range $10,000 to $17,000 in 2015.   Double blind trials show that stents have no effect on chest pain relief (Nov 2017)
  deployed in a narrowed artery even though there is no data indicating the procedure is helpful, and performing the operation adds risk.  But doctors and even presidential patients perceive more care is better care.  
• Pearl laments that 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, 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.  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 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.  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 25% of Medicare beneficiaries are enrolled with Medicare Advantage.  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. 
  

• 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 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 patent-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.  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.  
  • 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. 
  
• If you are admitted during the weekend for a non-life threatening problem:
  
• Treatment will be delayed. 
• The patient will spend an extra day in hospital on average.  Pearl judges that extra day as additional risk because hospitals are dangerous:
• Bacteria abound
• HAC is Hospital-Acquired Condition.   infections affect 700,000 people in acute care facilities.  10% of these infections result in death.  
• Hospitals choose to understaff at the weekends to keep costs lower.  If the total staff were shifted across the full week doctors would have to dedicate more of their weekends to working.  
• Hospitalized patients who suffer cardiac arrest is a sudden halt in the effective blood circulation due to the heart not contracting effectively.  This prevents delivery of oxygen and glucose to the body.  It can be caused by a heart attack.  CHF in contrast, typically has substandard circulation but the heart is still pumping sufficient blood to sustain life.  Cardiac arrest may be reversed with effective treatment.  The treatment regime and effectiveness vary significantly.  They can include:
  • CPR which needs endurance training to sustain for at least 45 minutes of deployment needed for success.  If no pulse is detected after 20 minutes more powerful treatments should be deployed. 
    
  • ECMO which is more widely used in Japan and South Korea than in the US.  
  • Once circulation is restored additional interventions are required for success, but their application is not benchmarked, standardized or regulated:
  • Therapeutic hypothermia - people who remain comatose after being in cardiac arrest should be cooled for at least 24 hours to a temperature between 89.6 and 96.8 F. 
    
  • Avoiding toxic amounts of oxygen
  • Maintaining normal co2 levels
  • Maintaining high blood pressure
  • If needed cardiac catheterization. 
    
  are more likely to die if this occurs over the weekend.  
• Pearl asserts that if hospitals could not bill insurance for the extra day of delay, or they had to reveal average time delays from weekend staffing levels, these issues would be fixed.  
• Physician Specialty Societies such as: ACC is either the
  
  • Anterior cingulate cortex which:
  • 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 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 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 hosptial. 
    
  • Part B: Medical insurance
    
  • Part C: Medicare Advantage 
  • Part D: 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. 
    
  • 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.  
    
  • 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 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:
• A dozen surgeons perform all the total joint surgeries for the 8 million people in Switzerland.  These surgeons are among the top orthopedic specialists in the world, because they have five to ten times the experience of their US equivalents. 
  
• In the US this strategy would require about 500 surgeons.  Instead there are about 5000, which impact expertise and the quality of results for patients.  He laments that the same economic forces undermine the quality and treatment choices of specialists across the US.  This is demonstrated by the Dartmouth Atlas is the Dartmouth Institute's map of the US on which is documented spending by Medicare.  As of 2015 it demonstrates extraordinary variation in spending on health-care from place to place with a negative correlation between expenditure and quality of outcome. 
  
  which shows: In the US where there are fewer resources there is less care, but where there are more resources, more money is spent but quality improvement is not correlated.  He notes it will typically be worse because the complications exceed the benefits of oversupply of surgeons.  
• 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 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 hosptial. 
    
  • Part B: Medical insurance
    
  • Part C: Medicare Advantage 
  • Part D: 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. 
    
  • 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.  
    
  • 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
  
• Pearl notes that patients have little choice but to purchase the drugs they need.  That is leveraged by the pharmaceutical companies.  He explains that Mylan has not spent a single dollar on R&D for EpiPen.  But it increased the price by 600% between 2007 & 2015 as its CEO compensation rose 671% from $2.5 million to $18.9 million a year.  Mylan has lobbied for legislation which requires the use of branded EpiPens and has sidestepped requests to reduce the product's price.  Pearl presents Gilead's pricing of Sovaldi (sofosbuvir) is Gilead Sciences hepatitis-C drug.  It is the first effective cure with acceptable side effects.  Sofosbuvir was originally developed by Pharmasset which sold the rights to Gilead for $11 billion.  In 2014 Sovaldi costs $84,000 for a typical course of treatment. 
  as similar, except Gilead sent a signal to the industry that no one could constrain predatory pricing.  Shkreli read the signal and repeated the action at Turing with Daraprim.  Pearl explains that lobbying of Congress by pharmaceutical companies has successfully limited legislative pricing constraints being enacted.  
• Pearl laments that consumers are easily influenced by marketing of valued signals including technology and fame.  He explains that as we watch influential adverts and our brains are monitored with fMRI is functional magnetic resonance imaging.  Seiji Ogawa leveraged the coupling of neuronal circuit activity and blood flow through the associated glial cells to build a 3 dimensional picture of brain cell activity.  As haemoglobin gives up its oxygen to support the neural activity it becomes magnetic and acts as a signal detected by the fMRI.  fMRI easily visualizes the state of activity in the living human brain at millimeter resolution, up to several times a second but it cannot track the time course of neural firing so it is augmented with EEG. 
  it is clear that the sensory signals become integrated with signals from the pleasure centers that responded approvingly to the association of technology or a famous person.  Medical device companies promote the hospitals that use their high technology devices as being better choices.  Pearl notes the hospitals leveraging these signals then increase prices to pay for the devices, insurers pay up and then increase the premiums they charge next year.  
• Pearl notes the drug addiction epidemic is driven by prescriptions for pain killers.  Drug companies carefully transformed the perception of doctors to use of opioids for pain.  
• 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.  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.  
  • 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.  

• 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. 
  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 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 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 a 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).  It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes 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.  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.  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.  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 state which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels; and an accumulation of traumatic events.  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, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure.  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.  There is an association between depression and particular brain regions: Hippocampal dendrite and spine number reductions, Dorsal raphe nucleus linked to loneliness, Abnormalities of the ACC.  Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable.  Treatments include: CBT, UMHS depression management.  As of 2010 drug treatments take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony.   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.  Major anxiety results in elevated glucocorticoids and reduces hippocampal dendrite & spine density.  Some estrogen receptor variants are associated with anxiety in women. 
  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 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 patent-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.  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. 
  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, DNA 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 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 patent-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.  EHRs have 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-patent 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. 
  
• Medical technology claims to be revolutionizing the practice of medicine.  Pearl judges it isn't because:
1. Many big ideas don't address the problem. 
   
2. 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. 
   
3. All the participants in a care episode think someone else should pay for new technology. 
   
4. 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 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.  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), Dengvaxia (Mexico Dec 2015), Gvax, 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);  
  • Coding : CVX, MVX;
    
  • 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 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. 
  

• 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:
1. 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.  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. 
   
2. 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. 
   
3. 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 patent-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:
• 17 million newly insured Americans
• A legal requirement to insure people without considering preexisting conditions. 
  
• US wide websites and infrastructure for e-purchasing individual insurance plans.  But the Republicans could and did undermine the exchange subsidies, individual mandate, & funding for Medicaid expansion. 
  
4. 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 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 hosptial. 
    
  • Part B: Medical insurance
    
  • Part C: Medicare Advantage 
  • Part D: 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. 
    
  • 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.  
    
  • 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.  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 25% of Medicare beneficiaries are enrolled with Medicare Advantage.  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
    
  . 
  
5. 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 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 hosptial. 
    
  • Part B: Medical insurance
    
  • Part C: Medicare Advantage 
  • Part D: 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. 
    
  • 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.  
    
  • 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. 
  
6. 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:
   1. 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. 
      
   2. 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. 
     
   3. 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.  EHRs have 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-patent 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:
   1. System/database management
   2. Administrative management - supporting normal hospital admin (scheduling, etc)
      
   3. 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 observationsand clinical measurements. 
      
   had hugely reduced the costs of any doctor getting access to a veteran's health record, while the general 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:
   1. Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history.  It needs to be updated periodically and after new diagnosis and other changes in health or functional status. 
      
   2. Creation and updating of proactive plan of care
      
   3. Communication
   4. Facilitation of transitions: typical transition problems are detailed by Project Boost.  A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff. 
      
   5. Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness. 
      
   6. Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.  
   , 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. 
   
7. 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:
• Pharmaceutical companies need to be monitored and constrained from monopolistic is a power relation within:
  
  • A state in which a group has enough power to enforce its will on other citizens.  If this is a central authority with a cohesive military, it can overpower other warlords and stabilize the society. 
    
  • An economy in which one business has enough share in a market segment to control margins to its advantage.  An economic monopoly can be broadly beneficial: AT&T monopoly, US patent monopoly rights;
    
  pricing and introduction of product line extensions which have no proof of added efficacy.  He notes Genentech's development of Avastin and subsequent line extension of the same active ingredients as Lucentis targeted at wet AMD is an age related, rapidly irreversible, destruction of foveal vision.  It occurs in 20% of AMD and can damage the retina within a 12 month period.  It is due to aberrant blood vessel development in the choroid, pushing through the RPE and disrupting it.  Treatments using locally deployed VEGF and POGF receptor blockers inhibit the problematic angiogenesis.   for a vastly higher price.  
• America's pharmaceutical and medical device companies are highly focused on three strategic priorities: money, volume, and risk.  So they focus on:
  
• Products with profits that can be protected by patents and marketing.  
• Diseases that affect a large population of patients
• Low investment need and high probability of finding a receptive market.  This focus drives them to line extend into similar drugs while using their capital is the sum total nonhuman assets that can be owned and exchanged on some market according to Piketty.  Capital includes: real property, financial capital and professional capital.  It is not immutable instead depending on the state of the society within which it exists.  It can be owned by governments (public capital) and private individuals (private capital). 
  to fund marketing.  
• 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:
1. 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. 
   
2. 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 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. 
   
   1. It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.  
   2. Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments. 
      
   3. Care delivery must be re-architected to reduce costs and improve quality. 
      
   4. 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.  
3. 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. 
   
4. 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. 
  

1. 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:
  1. Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history.  It needs to be updated periodically and after new diagnosis and other changes in health or functional status. 
     
  2. Creation and updating of proactive plan of care
     
  3. Communication
  4. Facilitation of transitions: typical transition problems are detailed by Project Boost.  A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff. 
     
  5. Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness. 
     
  6. Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.  
  , 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 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. 
  
2. 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. 
   
3. 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.  EHRs have 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-patent 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.  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. 
   
4. 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.  It 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.  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 state: Pain, Fatigue; seconds to minutes before.  The interoceptive 'networks' 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. 
  

• Specialty versus 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. 
  salaries
  
• Drug prices versus drug innovations
• Focus on intervention versus prevention
• Doing more to patients versus doing right by them
  

• 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:
  1. Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history.  It needs to be updated periodically and after new diagnosis and other changes in health or functional status. 
     
  2. Creation and updating of proactive plan of care
     
  3. Communication
  4. Facilitation of transitions: typical transition problems are detailed by Project Boost.  A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff. 
     
  5. Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness. 
     
  6. Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.  
  .  This all demands time and empathy is the capability to relate to another person from their perspective.  It is implemented by spindle neurons.  It 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.  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. 
  

• Doctors are not yet working in collaboration to effectively care for their patients and reduce medical errors. 
  
• They have not all converted to using EHR refers to electronic health records which are a synonym of EMR.  EHRs have 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-patent 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!
    
  systems that would ensure planned care is provided. 
  
• Doctors are still struggling with being honest and compassionate during end-of-life care.  
• It is not the doctors' fault.  These are system problems:  The tools are missing, the incentives are wrong, Infrastructure is missing. 
  

• Medicine is complex:
• It is best viewed through the major
  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 of adaptive in evolutionary biology is a trait that increased the number of surviving offspring in an organism's ancestral lineage.  In Deacon's conception of evolution an adaptation is the realization of a set of constraints on candidate mechanisms, and so long as these constraints are maintained, other features are arbitrary.  
  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.  
• Christensen
  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. 
  
  explains that some diseases have been fully characterized.  But other diseases are complex and have to be diagnosed and treated intuitively.  
• The nature of human development depends on environment and genetics ensuring subtle differences between each patient.  
• 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:
• Doing the 'thing' right.  His assessment identifies critical issues here and ways to address them, making the network more optimal. 
  
• Doing the right thing. 
  This page reviews the implications of selection, variation and heredity in a complex adaptive system (CAS).  The mechanism and its emergence are discussed. 
  
  Evolutionary search works to identify the
  This page discusses the potential of the vast state space which supports the emergence of complex adaptive systems (CAS).  Kauffman describes the mechanism by which the system expands across the space. 
  
  proximate niches and provide tools to enter them.  Dr. Pearl's optimizations introduce the 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 health care undermining this mechanism and becoming trapped or 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. 
  
• 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. 
  
  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 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. 
  is explored by:
• Stephen Johnson looking at
  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). 
  
  how good ideas emerge.  
• Jon Gertner describing the strategic formation of
  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:
  

  1. The evolving global scientific network. 
     
  2. The Bell telephone network.  And
     
  3. 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. 
  
  
  an innovation factory.  
• 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. 
  theory has been used to control treatment costs at Geisinger. 
  

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