E2E insured quality care
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End-to-end insured quality care

Summary
Glenn Steele & David Feinberg review the development of the modern Geisinger healthcare business after its near collapse following the abandoned merger with Penn State AMC 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);
.  After an overview of the business, they describe how a calamity unfolding around them supported building a vision of a better US health care network.  And they explain:

Following our summary of their arguments RSS is Rob's Strategy Studio comments on them.  We frame their ideas with complex adaptive system (CAS) theory. 

ProvenCare How to deliver value-based healthcare the Geisinger way
In Glenn Steele & David Feinberg's book 'ProvenCare' they describe Geisinger's transformation into an
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 architected
, integrated health insurer and care provider serving the nearby residents in Pennsylvania.  Geisinger provided Steele & Feinberg with the opportunity to induce change that helps patients: Steele transformed it into a unique innovation laboratory, and Feinberg then elevated the patient experience to exceptional levels.  They assert the principles can be applied anywhere and aim to show how. 

Geisinger's business model is unusual in US is the United States of America.  
The complexity and problems of the US Health network is described in terms of complex adaptive system (CAS) theory. 

The network:
  • Is deeply embedded in the US nation state. It reflects the conflict between two opposing visions for the US.  The emergence of a parasitic elite further constrains the choices available to improve the efficiency and effectiveness of the network. 
  • Is incented to focus on localized competition generating massive & costly duplication of services within physician based health care operations instead of proven public health strategies.  This process drives increasing research & treatment complexity and promotes hope for each new technological breakthrough. 
  • Is amplified by the legislatively structured separation and indirection of service development, provision, reimbursement and payment. 
  • Is impacted by the different political strategies for managing the increasing cost of health care for the demographic bulge of retirees.  
  • Is presented with acute and chronic problems to respond to.  As currently setup the network is tuned to handle acute problems.  The interactions with patients tend to be transactional. 
  • Includes a legislated health insurance infrastructure which is:
    • Costly and inefficient
    • Structured around yearly contracts which undermine long-term health goals and strategies.  
  • Is supported by increasingly regulated HCIT which offers to improve data sharing and quality but has entrenched commercial EHR products deep within the hospital systems. 
health care
.  It supports Geisinger's innovative is the economic realization of invention and combinatorial exaptation. 
approach to providing health care.  They illustrate this with examples from:
Steele & Feinberg attribute Geisinger's growth and reengineering success to providing better care at lower cost, enabled by:
Steele & Feinberg were looking for better lives for patients in their care:
The Commonwealth Fund which inventoried US wide healthcare quality and value, and President Obama, concluded Steele & Feinberg succeeded, judging Geisinger as one of the few high-quality/low-cost delivery systems. 

Building a better health care network driven by a demerger crisis and suboptimal care
Steele & Feinberg explain the majority of Americans are without the support of integrated
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
health care delivery.  This induces 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, struggling with multiple chronic problems: CHF is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands.  There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation.  Treatments include: digoxin; , CAD is coronary artery disease, also called heart disease or CHD.  It reflects atherosclerosis of the coronary arteries.  , diabetes includes type 1 and type 2.  Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections.  , hypertension 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.  , 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;; who appear repeatedly for ED is emergency department.  Pain is the main reason (75%) patients go to an E.D.  It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital.  The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals.  Unreimbursed care is supported from federal government funds.  E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing.  The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics.  Commercial nature of care requires walk-ins to register to gain access to care.  With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). 
care.  But the ED physicians' limited visibility increases the risk of:
  • A costly admission to the hospital to control the acute threat, and
  • Additional prescribed medications that may conflict with the patients current set, or at least add to the complexity of their care. 
These 10 - 20% of patients account for 80 - 90% of US is the United States of America.   healthcare spending, because of this suboptimal situation.  Steele & Feinberg explain Geisinger has consistently worked to change this, reducing costs and increasing value.  Steele & Feinberg concluded the US healthcare network needed fundamental redesign:
In the post-ACA health care environment Steele & Feinberg argue the needed transformation must include:
By 2000 Geisinger was in chaos from its failed 1997 to 1999 full-asset merger with Penn State Hershey Medical Center: with operating losses, exit of clinical leaders, constraining expense management, failure to integrate and leverage the insurance and care delivery (hospitals & clinics) operations, conflict and finger pointing between the operations. 

New leadership leveraged the calamity in progress to drive the organization towards a changed mission: Making a positive difference at a national and international level. 

The leaders seized upon the conclusions of two studies.  LeapFrog Group's founder Arnold Milstein found no relationship between cost-of-care and quality-of-care outcomes in the US.  RAND found 45% of care was suboptimal doing: too much, too little and wrong care!  Dr. Steele realized US healthcare, one sixth of the economy, could be reengineered to unlock significant value.  And Geisinger showed that their most expensive patients actually had the worst outcomes.  Reengineering care would improve outcomes, reduce costs and energize Geisinger's clinicians. 

The reengineering required creation of an integrated healthcare delivery organization: doing healing, teaching, discovering, serving patients and the community; which they asserted could be a national model for innovation is the economic realization of invention and combinatorial exaptation. 
.  They aimed to add clinical programs and capture market share.  They would initially reengineer CABG refers to Coronary artery bypass grafting, a treatment provided by cardiac surgeons.  Lower cost angioplasty has disrupted this business but both have been provided by general hospitals.  Christensen argues angioplasty should be part of a radically lower cost business which should disrupt the solution business of the general hospital.  , a real test of what could be gained from an already well led service.  The goals were:
  • Build more specialty & subspecialty programs and demand
  • Solve access issues and stop referral leakage
  • Integrate payers: Blue Cross of Northeastern Pennsylvania (Highmark), Capital BlueCross, Coventry Health Care, Highmark 
  • Focus physician incentives on taking better care of patients
  • Expand research and education using funds recaptured by reengineering
Success has allowed the building of a portfolio of 25 programs spread across ProvenCare Acute, ProvenCare Chronic and ProvenHealth Navigator.  The three major operations were profitable by 2002.  It has attracted strong new leaders and their teams.  Geisinger uses a business leadership triad: physician, administration, finance partnership for each program.  Geisinger looked at how the innovations could be scaled and generalized at other health care organizations. 

Geisinger's five year plans
Geisinger uses a five year
This page looks at schematic structures and their uses.  It discusses a number of examples:
  • Schematic ideas are recombined in creativity. 
  • Similarly designers take ideas and rules about materials and components and combine them. 
  • Schematic Recipes help to standardize operations. 
  • Modular components are combined into strategies for use in business plans and business models. 

As a working example it presents part of the contents and schematic details from the Adaptive Web Framework (AWF)'s operational plan. 

Finally it includes a section presenting our formal representation of schematic goals. 
Each goal has a series of associated complex adaptive system (CAS) strategy strings. 
These goals plus strings are detailed for various chess and business examples. 
planning
cycle: 2001-2005, 2006-2010, 2011-2015; where the first five years were spent getting the operations in order, the second transforming care delivery and innovating, and the third scaling and generalizing the results. 

Systematic & extensive conversations were held to frame, and communicate the planning activity.  It highlighted:
  • Who they were and who they wanted to be
  • What is unique and different about Geisinger and what could be done, that would be hard to emulate.  They concluded it was having a provider and a payer (GHP) operation. 
    • During the 1990s leading consultants had encouraged hospitals to sell off the insurance units: Virginia Mason Health System; so most hospitals do not have this structure.  Geisinger evaluated selling the health plan but eventually rejected the idea. 
Effectively integrating the payer and provider operations required a major cultural 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. 
shift and some luck.  Steele & Feinberg recall that in 2001 these operations viewed each other as the enemy.  The payer was a classical, loss making, HMO is a health maintenance organization.  Originally HMOs were fashioned after Dr. Paul Ellwood's admiration for group practices such as: Kaiser Permanente, Mayo Clinic; which employed salaried physicians and charged fixed fees rather than FFS.  Ellwood argued that this architecture helped keep subscribers healthy which he termed a health maintenance organization.  President Nixon was convinced by Ellwood signing the HMO Act.  But the legislated HMO did not have to conform to Ellwood's group practice architecture.  Instead by 1997 for-profit commercial insurance companies operated two-thirds of the HMO business.  The legislated HMO:
  • Provides or arranges managed care for:
    • Health insurance
    • Self-funded health care benefit plans
    • Individuals
  • Acts as a liaison with health care providers
  • Covers care rendered by those doctors and others who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in return for access to patients.  Treatment choices were often driven by insurance company rules.  Financial incentives often based the contracted physician income on success in reducing expenses rather than health outcomes.  There are a variety of contracts with physicians:
    • Closed panel plan
    • Open panel plan
    • Network model plan
  • Covers emergency care regardless of the providers contracted status. 
; unattractive to customers, rock-bottom priced, with the payer operation pushing 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. 
onto the providers through minimum reimbursements is the payment process for much of US health care.  Reimbursement is the centralizing mechanism in the US Health care network.  It associates reward flows with central planning requirements such as HITECH.  Different payment methods apportion risk differently between the payer and the provider.  The payment methods include:
  • Fee-for-service,
  • Per Diem,
  • Episode of Care Payment, 
  • Multi-provider bundled EPC,
  • Condition-specific capitation,
  • Full capitation.  
.  So the payer's leadership was changed and new products and pricing, along with BBA is the Balanced Budget Act of 1997.  This act aimed to balance the federal budget by 2002.  It was enacted using the budget reconciliation process.  In part it reduced Medicare (replacing MVPS with the SGR and commissioning the MedPAC) and Hospital inpatient and outpatient payment cuts to do this.  It also enacted Medicare Advantage and SCHIP.  BBA mandated risk adjustment and the HCC coding payment model, through CMS rules. 
's fortuitous HCC is:
  • Hepatocellular carcinoma, a cancer of the hepatocytes or 
  • Hierarchical condition category - a BBA mandated and CMS implemented payment model, required for Medicare Advantage reimbursement.  It utilizes diagnoses from all hospital and physician encounters to produce a health-based measure of future medical need or
  • Hospital condition category - an AHA guideline for describing a patient's condition to the media in just one word. 
payments and 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. 
's more generous 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. 
reimbursement, allowed GHP to become truly profitable while enrolling high-severity & high-acuity members.  GHP shared this success with the providers, reducing the animosity and allowing the re-architecting of the business model.  Placing both the payer and provider in the same fiduciary, sharing 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. 
across the membership/patient base, supported successful value reengineering.  Initially the innovations were targeted at the 50% of patients that were GHP members.  But then the executives were given dual roles across payer and provider and reengineering was extended to the whole patient base in line with the strategic direction. 

The compensation of providers, clinical and administrative leaders evolved over the 15 years:
  • Initially incentives were designed to repair the post-merger malaise and ensure the business was moving forward and profitable.  When the operating trends became highly positive the incentives were broadened to include how care was delivered to the benefit of patients with acute and chronic diseases:
    • Fundamental improvements in how patients with prevalent diseases were cared for (where to innovate), 
    • Fundamental change in morbidity & mortality, cost, and patient & professional satisfaction outcomes (quality); which the leadership felt would make Geisinger a continuous innovation machine.  Achieving these goals would make them different to an AMC, or large community hospital
    • A new compensation plan helped physicians and leaders see they would benefit from helping achieve the strategic objectives.  20% of total compensation was focused on contributing to strategic goals: by the front line caregivers and insurance leaders identifying and accomplishing transformative projects.  Leadership was similarly rewarded for their organization meeting strategic aims. 
  • Every employee was made to feel they were being evaluated the same way, by contributing to the strategic innovation goals. 

The foundation of the transformation was achieving and maintaining good operational performance.  This was achieved early by the 2001-2005 strategic plan. 

The 2006-2010 strategic plan explicitly leveraged payer + provider care redesign for all patients, to generate higher quality at lower cost.  Overall lower cost-of-care generates system wide profit.  Internal transfer pricing was used to allow value to be allocated where it was deserved.  Without the constraint of long term negotiated contracts between the payer and provider, clinical innovation is the economic realization of invention and combinatorial exaptation. 
could be
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. 
developed iteratively
.  The benefit was reflected in:

Dr. Steele personally delivered the strategic vision to the organization, meeting with as many people as possible.  55 to 65 town hall meetings were held annually.  The CEO had to be seen showing why Geisinger needed to innovate, why it was setup to do so, and why other organizations could not follow even if they had good people too.  Steele & Feinberg stress the importance of the communication process and how it evolved to cope with a growing organization.  After iterative discussions throughout the organization, four 2001 strategic aims were agreed.  And the innovation was enhancing the brand.  By 2006 the initial strategic aims had been extended and modified, taking advantage of Geisinger's improving reputation to leverage the skills of the national pool of talent interested in working for Geisinger.  This supported the development of ProvenCare Acute, ProvenHealth Navigator and some ProvenCare Chronic bundles.  The 2011 strategic aims were direct extensions of the 2006 set, which encouraged scaling and generalizing Geisinger's innovations beyond Pennsylvania. 

Three scaling and generalizing operational engines were developed to help overcome the skepticism, by other hospital systems' executives, about the wider applicability of Geisinger's strategies:
  1. Merger & acquisitions to drop the integrated payer provider business model into other hospital systems:
    • Wilkes-Barre/Scranton
    • Harrisburg, Pennsylvania
    • Atlantic City, New Jersey
  2. Expand insurance operations:
    • Beyond Pennsylvania
    • With non-Geisinger providers
  3. Establish xG Health Solutions joint venture

Effective governance of Geisinger
Steele & Feinberg argue that its ownership has a major impact on any organization.  Geisinger's governance was setup in 1981, cascading from the Geisinger Health System Foundation Board.  This single fiduciary, limited silo thinking at the top of Geisinger, supporting a holistic business delivering the best quality and value care.  During the Penn State merger a constituent governance model was setup which was highly polarizing.  Steele & Feinberg also note that with the mergers with Harrisburg's Holy Spirit Health System, and New Jersey's Atlanticare, the Foundation board became a holding corporation to delegate aspects of fiduciary responsibility to local market system boards.  

A strategic focus was to ensure payer and provider operations were not polarized.  This was achieved by having a health plan board with independent committees, but with: the CEO of Geisinger as the health plan board chair, overlapping board membership, meshing of senior management across the organizations. 

As Geisinger progressed with its strategy of national transformation it reconstructed its board to support the expanded scope.  Steele & Feinberg assert this ensured a steady-state, optimally functioning board.  It asks tough questions and demands crisp answers.  The Foundation board chair and CEO have always been the key leadership relationship at Geisinger.  Frank Henry & Dr. Steele worked in partnership.  William Alexander & Dr. Feinberg continued the tradition.  Chairman John Bravman similarly supports the development and deployment of the Geisinger vision including governance structure changes to reflect Geisinger's mergers and acquisitions. 

Starting the transformation
Steele & Feinberg relate how Dr. Steele's father underwent suboptimal CABG refers to Coronary artery bypass grafting, a treatment provided by cardiac surgeons.  Lower cost angioplasty has disrupted this business but both have been provided by general hospitals.  Christensen argues angioplasty should be part of a radically lower cost business which should disrupt the solution business of the general hospital.   surgery, experiencing sausage machine care, complications, detached nursing, charges for the additional surgery to fix issues from the initial CABG; seeding Dr. Steele's interest in health care reengineering.  He knew this implied: changing what doctors do and had been taught.  And that he would have to overcome the personality traits that had got them selected for medical school: Independence, creativity, hardworking, valuing autonomy, protective of the patient doctor relationship.  Getting Geisinger's medical practices reengineered would be challenging. 

Steel & Feinberg explain it was decided they should coopt the most successful clinical practice at Geisinger: Its leaders would then help move the other doctors towards the approach.  The metrics chosen to select success included: high PHC4 is the Pennsylvania health care cost containment council aims to: increase access to health care, and address the growing cost.  It develops independent assessments of health care quality in Pennsylvania. 
rating of a high-volume, high-cost, high-visibility, hospital-associated episode of care - An episode of care is the treatment of a specific medical condition during a set period of time.  After MedPac recommended episode based payment bundling for inpatient hospital care it has become a key focus of Medicare incentive strategies. 
; Pick a care pathway which had been carefully evaluated by the main disciplines, resulting in agreed upon outcome metrics; which lead them to select elective CABG refers to Coronary artery bypass grafting, a treatment provided by cardiac surgeons.  Lower cost angioplasty has disrupted this business but both have been provided by general hospitals.  Christensen argues angioplasty should be part of a radically lower cost business which should disrupt the solution business of the general hospital.   and interventional cardiology is the diagnosis and treatment of: Congenital heart defects, CAD, Heart failure, Valvular heart disease; by cardiologists.   for 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)
placement.  And the strategy worked: other disciplines were pulled in by the impact of the early wins.  For ambulatory care they selected CPSL as it was large, innovative is the economic realization of invention and combinatorial exaptation. 
and well run. 

The strategy for achieving success in reengineering clinical practice was:
External awareness of the transformation successes occurred during 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. 
planning.  Geisinger was proposed as one model for 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. 
.  ACA legislative development included Geisinger payer & provider representatives.  This resulted in Geisinger reengineered care being reflected in the virtual and real integrated models promoted by the legislation for: Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare 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. 
managed care contracts together its subscribing patients with particular groups of doctors and hospitals who agree to provide contracted care for a particular price which the managed care organization reimburses.  It was based on the group practice organizations: Kaiser, Mayo Clinic; operations.  The initial HMOs, supported by the HMO act and PPOs has subsequently been joined by other forms of managed care.  Original capitation based implementations were problematic with only Kaiser succeeding.  Managed care is now enhanced by inclusion of upside measures as in alternative quality contracts. 
, commercial managed care, and 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. 
managed care. 

Catalyzing reengineering at the Geisinger clinician patient interface
Steele & Feinberg note it takes more than a vision, repeatedly articulated by the CEO, to drive change to the front line caregivers.  They assert they had to:
Geisinger was keen to scale the reengineering beyond their own system.  They setup three scaling and generalizing engines to achieve this:
  • Use growth of payer/provider offer into additional areas of Pennsylvania and then beyond: Atlantic City, New Jersey; to demonstrate credible scaling.  
  • Expand insurance plan into additional states: Delaware, Maine, New Jersey & West Virginia.  Such partnering with other providers, was enabled by the 2013 formation of:
  • xG Health Solutions consulting group.  It was shown that changing the: relationship of hospital and doctor, improving ambulatory care for complex comorbid cases; happened just as quickly in these cases. 
But Steele & Feinberg admit that reengineering sustainability had limits:
And Geisinger struggled to convince leaders of other hospital systems, who came to their quarterly innovation conferences, that the Geisinger approach would work for them.  But once 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. 
added more pressure to shift to FFV is fee-for-value payment.  It may be a bundled payment for a set of services provided by a group of doctors and facilities, or full capitation.  In each case the risk has shifted from the payer to the providers of care. 
, Geisinger concluded their was a business opportunity in helping other systems with the shift by forming a new for profit organization focused on the reengineering transformation: xG Health Solutions; with Oak Investment Partners

ProvenCare Acute: Implementing the reengineering
Steele & Feinberg explain that the ProvenCare method is designed to provide quality care at a reduced price for:
  • Acute hospital-based surgical procedures
  • Select chronic diseases treated in out-patient settings
Formerly, acute care generated cost and problems due to unjustified variation in providing care.  Steele & Feinberg note this is easy to detect by:
So they rejected traditional strategies: Overdependence on diligence & hard work, Benchmarking to the mean, Clinical autonomy, Lack of understanding of human error; for a formal process. 

ProvenCare acute combines current EBM is evidence based medicine where explicit and judicious use of current best practice evidence is used in making decisions about the care of patients.  There are differences in the application to individuals and populations.  Still the goal was to replace subjective use of basic and clinical research with:
  • Prioritization of clinical trial results to build conclusions. 
  • Adoption of processes that translated epidemiological methods to physician decision making. 
  • Widely used but innapropriate procedures were abandoned.  
  • There is now explicit evaluation of evidence of effectiveness before issuing practice guidelines.  A rational for adoption is required.  
  • HHS appointed USPSTF to develop evidence based recommendations.  
best practices into a work flow to reduce unwarranted variation in tests, procedures and care delivery.  This is done through six components:
  1. Documenting the appropriateness of care
  2. Establishing all key elements of EBM or consensus-based best practices
  3. Socializing and making routine the complex clinical systems that embed default best practices into new provider behaviors for everyday patient flow
  4. Activating patients and families so they are fully engaged in the care process redesign and implementation
  5. Negotiating a single bundled price for the entire episode of care - An episode of care is the treatment of a specific medical condition during a set period of time.  After MedPac recommended episode based payment bundling for inpatient hospital care it has become a key focus of Medicare incentive strategies. 
    with the payer or actual buyer
  6. Transferring 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. 
    for the financial effects of preventable complications to the provider and the health system via a bundled payment 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.  

Implementing ProvenCare acute requires months of dedicated focus by reengineering and care teams to gain understanding, acceptance and commitment to the benefits of the reengineering by participating: patient & family, care givers, and clinical leaders. 
Geisinger bet that ProvenCare acute would reduce complications, generating improved quality while reducing the cost structure.  They checked the complications that occurred over the 90 days following an acute care episode.  With a picture of the available margin they:
  • Negotiated deals with non-Geisinger payers that allowed for an incentive for their members to travel to Geisinger for their care. 
  • Split the margin between: sustaining the business model, back to the buyer of care, men & women who changed their behaviors; resulting in better quality and lower costs for patients
  • Linked top-down system commitments to innovation is the economic realization of invention and combinatorial exaptation. 
    to the bottom-up service line commitments to ProvenCare goal setting via paid compensation
Geisinger systematized the ProvenCare acute reengineering process.  Steele & Feinberg illustrate this for the CABG package, which Dr. Steele used to treat his coronary occlusions is a partial or full obstruction of blood flow in a coronary artery. 
.  They stress that CABG refers to Coronary artery bypass grafting, a treatment provided by cardiac surgeons.  Lower cost angioplasty has disrupted this business but both have been provided by general hospitals.  Christensen argues angioplasty should be part of a radically lower cost business which should disrupt the solution business of the general hospital.   was already a high quality, high volume program with strong clinical leaders, which helped ensure early success for the reengineering effort.  This made it easy to make documented best practice the default. 

CABG success pulled in other service lines:

Reengineering expansion to include chronic illness
In 2006 the ProvenCare portfolio was expanded to include chronic illnesses, enabled by the success of the acute program.  Additional service lines is a strategic focus and structuring by a general hospital to optimize for the most locally profitable areas of diagnosis and treatment such as: Cardiovascular, Neurology or Cancer; to respond to competition from specialist focused health care facilities such as the Texas heart institute and local low cost outpatient facilities.  It does not abandon other services which the community as a whole needs but limits the losses they generate.  A successful service line can: Diagnose and treat a high volume of service specific problems ensuring quality and efficiency, be profitable enough to gain additional investment and attract top physicians.  To be effective service line strategies require:
  • A clear view of the hospital's competitive environment. 
  • Visibility of the revenue, costs (activity based rather than top down) and benefits of particular procedures and bundles of care.  Cost estimates are often averaged by hospital accounting models. 
  • Effective management of PCP referrals to the hospital and its competitors. 
  • Changes to the: Organization structure, Incentive plans for doctors, Relationship with physicians (potentially including co-management) - who must own the problems of their service line, Business development, HCIT - which will need to capture all details of a service, HR who will need to support the employees during and after the transition. 
& disciplines wished to provide the reengineering benefits to their patients & payers.  Most acute care episodes - An episode of care is the treatment of a specific medical condition during a set period of time.  After MedPac recommended episode based payment bundling for inpatient hospital care it has become a key focus of Medicare incentive strategies. 
were part of a broader ongoing chronic problem. 

A chronic care reengineering program required cooperation of a network of 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 specialists.  Steele & Feinberg explain Geisinger leveraged its community practice service line leaders to identify the first chronic disease to work on.  A reengineering activity that would deliver a high-impact, high-probability of success: 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


Steele & Feinberg note that Geisinger intended to totally alter the interaction between patients, their families, payers, specialists and PCPs.  Care was to be performed near to where the patients lived.  And the focus was on patients with extraordinarily difficult diabetes management.  These were identified in a stratification of the patients based on the payer data.  The initial strategy was to only target the patients with the most intense care and apply the specialty knowledge of the endocrinologists along with the management of the community based PCPs, to them. 

A similar approach was used with CHF is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands.  There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation.  Treatments include: digoxin; .  It leveraged hospital-based cardiology specialists and community PCPs and moved 80% of the caregiving to the community practices.

The outcome metrics were: decreased acute care needs, decreased frequency of secondary disease, and decreased cost of care over time.  All-or-nothing measures is used by Geisinger because it closely matches the wants and needs of patients to slow chronic disease progression and prevent additional diseases and their impacts by delivery of optimal treatment, and drives care givers to achieve all goals.  It also provides a sensitive scale for measuring improvements.  Not all patients will achieve every measure, but the set encourages the patient, their family, the PCP and specialists to engage and develop a shared understanding. 
were adopted because they reflect the patients' wants and needs.  While surrogate markers were initially used to track change, Steele would 'so what' the changes to ensure the care activities were moving patients towards the outcome metrics.  After 3 years the diabetes bundle resulted in less: heart attacks 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. 
, strokes 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). 
, retinopathy; and significantly decreased cost of care. 

Bundled best practice sets were subsequently constructed for: 20,000 CAD is coronary artery disease, also called heart disease or CHD.  It reflects atherosclerosis of the coronary arteries.  patients, 260,000 preventative care patients; with PCPs adopting all the literature recommended preventative measures. 


Responding to hot spot patients with ProvenHealth Navigator
To support and manage 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, including those with: CHF is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands.  There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation.  Treatments include: digoxin; , and diabetes includes type 1 and type 2.  Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections.  ; in the community, care teams were constructed which included health plan employees.  Geisinger embed health plan nurse care managers, at Geisinger, are employees of the health plan who are embedded in primary care offices, and especially advanced medical homes (Geisinger's PHN).  Nurse care managers are tasked with support of the sickest patients in the practice: medication adherence, keeping appointments, encourage use of preventative measures; to maintain health and avoid repeated hospitalizations.  Their focus on these patients ensures they detect problems early, and makes them ideally placed to support patient safety and minimize the impact of attending appointments. 
at primary care consists of providing accessible, comprehensive, longitudinal, and coordinated care in the context of families and community.  Interpreting the meaning of many streams of information and working together with the patient to make decisions based on the fullest understanding of this information relative to the patient's values and preferences is key to PCP providing value. 
offices, including advanced medical homes are primary care architectures which deliver: patient-centered, accessible, coordinated, comprehensive care of high quality and safety (Dec 2015).  The models have been made more significant due to Affordable Care Act payment reform requirements.  The goal is to reduce treatment costs and improve population health by reengineering of the traditional silo'd provider network.  See PCMH. 
/neighborhoods is an extension to the PCMH which supports coordination of care across providers connecting with specialty and subspecialties that are essential to the treatment of chronic illnesses.  The PCMH hospital-based specialists and community practitioner team located near where the patients live, must have an effective relationship with ambulatory care, pharmacists, SNF, HHA, and others.   (PHN).  This strategy minimizes costly hospitalizations, frees up the time of the limited number of available 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 helps the patients maintain health. 

Steele & Feinberg stress the PHN depends on the PCPs and nurse care managers.  But these key roles are enabled by technology:
Non-PCP care team members also provided the PCPs with more time for care giving, by offloading tasks including: rooming the patients. 

After beta testing the product, it was scaled out to 42 Geisinger-owned primary care practices, 40 non-Geisinger that worked closely with GHP, and others.  The scaling indicated that:
  • Paying attention to the data flows between the payer and provider
  • Looking at variations in care in 'near' real-time. 
Steele & Feinberg are very pleased with the benefits of PHN: reduced admissions and readmissions have become a source of increased revenue for hospitals.  But with government interested in reducing the US health care cost curve ACA's HRRP (pay-for-performance), BPCI and CTI and Interact discharge initiative have all increased the focus on unnecessary readmissions.  Now the end-to-end process is under scrutiny with hospitals reengineering discharge (RED) and PAC providers using RAI and TCN. 
, patients with improved health & disease outcomes and happy with their links to the nurse care managers, and satisfied physicians.  Higher quality was finally correlated with lower cost!  Physicians responded they get better data and results with PHN.  And Steele & Feinberg see PHN reflected 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. 
's 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. 

Geisinger's reengineering helped the physicians, as well as the patients:

Leveraging the expanding development of biologics
Geisinger recognized the opportunity and risks of biologics are drugs made in living cells.  Typically they are proteins developed using genetic engineering to develop the cellular host, and to customize animal source, DNA to produce human target proteins.  Biologics solve the problem of previous protein sources, extracted from animals or human sources, of contamination and immune responses.  The strategy is very effective for blood transported proteins such as antibodies, hormones and blood factors.  But intra-cellular proteins still demand delivery and accurate cell targeting.  This creates analogous problems to those of gene therapy. 
.  They are expensive & associated with questionable utilization practices.  But Steele & Feinberg note they were clearly medically compelling.  ProvenCare Biologics aimed to use reengineering to improve their cost effectiveness.  The program, which integrates Geisinger's Caresite specialty pharmacy dispense specialty medications.  They aim to save health plans money by: teaching patients how to apply their medicines and deal with side effects, ensure they take the full course and limit waste.  These specialized channels can be used by drug companies to limit competition to their drugs since access in constrained.  Generic drugs rebranded as specialty medications may escape competition, remove copayment and formulary exclusion sales inhibitors and obtain considerable pricing power. 
, was deemed necessary for treatments including:

Reengineering healing with ProvenExperience
Steele & Feinberg explain that Geisinger concluded in 2014 that it wanted recapture the patient-centric feeling that existed when it was just two hospitals.  It:

Geisinger's vision of the future
Steele & Feinberg see Geisinger's reengineering extending into 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.  
.  But they stress the goal is great healing based on being the most caring organization anywhere.  That means:


This page introduces the complex adaptive system (CAS) theory frame.  The theory is positioned relative to the natural sciences.  It catalogs the laws and strategies which underpin the operation of systems that are based on the interaction of emergent agents. 
John Holland's framework for representing complexity is outlined.  Links to other key aspects of CAS theory discussed at the site are presented. 
CAS theory
views
The complexity and problems of the US Health network is described in terms of complex adaptive system (CAS) theory. 

The network:
  • Is deeply embedded in the US nation state. It reflects the conflict between two opposing visions for the US.  The emergence of a parasitic elite further constrains the choices available to improve the efficiency and effectiveness of the network. 
  • Is incented to focus on localized competition generating massive & costly duplication of services within physician based health care operations instead of proven public health strategies.  This process drives increasing research & treatment complexity and promotes hope for each new technological breakthrough. 
  • Is amplified by the legislatively structured separation and indirection of service development, provision, reimbursement and payment. 
  • Is impacted by the different political strategies for managing the increasing cost of health care for the demographic bulge of retirees.  
  • Is presented with acute and chronic problems to respond to.  As currently setup the network is tuned to handle acute problems.  The interactions with patients tend to be transactional. 
  • Includes a legislated health insurance infrastructure which is:
    • Costly and inefficient
    • Structured around yearly contracts which undermine long-term health goals and strategies.  
  • Is supported by increasingly regulated HCIT which offers to improve data sharing and quality but has entrenched commercial EHR products deep within the hospital systems. 
US health care
as a
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
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
adapting to: each other,  the American people and their government, and the operations of the US economy.  Within this network:

Steele & Feinberg present a vision of
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 architected
health care.  They explain how it was done at Geisinger, and how they worked to help others do the same.  They successfully implemented
This presentation reviews just-in-time manufacturing with analysis based on complex adaptive system (CAS) theory. 
JIT manufacturing
ideas in US is the United States of America.   health care while coping with the
This page introduces the complex adaptive system (CAS) theory frame.  The theory is positioned relative to the natural sciences.  It catalogs the laws and strategies which underpin the operation of systems that are based on the interaction of emergent agents. 
John Holland's framework for representing complexity is outlined.  Links to other key aspects of CAS theory discussed at the site are presented. 
CAS
nature of the problem and striving to be great healers. 




























































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This page looks at schematic structures and their uses.  It discusses a number of examples:
  • Schematic ideas are recombined in creativity. 
  • Similarly designers take ideas and rules about materials and components and combine them. 
  • Schematic Recipes help to standardize operations. 
  • Modular components are combined into strategies for use in business plans and business models. 

As a working example it presents part of the contents and schematic details from the Adaptive Web Framework (AWF)'s operational plan. 

Finally it includes a section presenting our formal representation of schematic goals. 
Each goal has a series of associated complex adaptive system (CAS) strategy strings. 
These goals plus strings are detailed for various chess and business examples. 
Strategy
| Design |
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  • A program approach can ensure strategic alignment. 
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