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We are products of complexity,
but our evolution has focused our
understanding on the situation of hunter gatherers on the
African savanna.
As humanity has become more powerful we can significantly impact
the systems we depend on. But we struggle to comprehend
them. So this web frame
explores significant real world complex
adaptive systems (CAS):
- Assumptions of randomness & equilibrium allowed the
wealthy & powerful to expand the size and leverage of
stock markets, by placing at risk the insurance and
retirement savings of the working class. The
assumptions are wrong but remain entrenched.
- The US nation was built
from two divergent political
views of: Jefferson and Hamilton. It also
reflects the development
of competing ancient ideas of Epicurus and
Cyril. But the collapse of Bretton Woods forced Wall
Street into a position of power, while the middle and
working class were abandoned by the elites. Housing
financed with cash from oil and derivative transactions
helped hide the shift.
- Most US health care is still
operating the way cars built in the 1940s did.
Geisinger is an example of better solution. But
transforming the whole network is a challenge. And
public health investment has proved far more
beneficial.
- Helping our children learn to be
effective adults is part of our humanity, but we have
created a robust but deeply flawed education system.
Better alternatives have emerged.
- Spoken language, reading and writing emerged allowing our
good ideas to
become a second genetic material.
- The emergence
of the global economy in the 1600s and its subsequent
development;
It explains how the examples relate to each other, why we all
have trouble effectively comprehending these systems and
explains how our inexperience with CAS can lead to catastrophe. It
outlines the items we see as key to the system and why.
Example systems frame |
Dietrich Dorner argues complex adaptive systems (CAS) are hard to understand and
manage. He provides examples of how this feature of these
systems can have disastrous consequences for their human
managers. Dorner suggests this is due to CAS properties
psychological impact on our otherwise successful mental
strategic toolkit. To prepare to more effectively manage
CAS, Dorner recommends use of:
- Effective iterative planning and
- Practice with complex scenario simulations; tools which he
reviews.
Complexity catastrophes |
E. O. Wilson reviews the effect of man on the natural world to
date and explains how the two systems can coexist most
effectively.
Adaptive ecology |
Barton Gellman details the strategies used by Vice President
Cheney to align the global system with his economics, defense, and
energy goals.
US vds alignment |
Kevin Kruse argues that from 1930 onwards the corporate elite
and the Republican party have developed and relentlessly
executed strategies to undermine Franklin Roosevelt and the New Deal. Their
successful strategy used the credibility of conservative
religious leaders to:
- Demonstrate religious issues
with the New Deal.
- Integrate the corporate
elite and evangelicals.
- Use the power of corporate
advertising and Hollywood to reeducate the American
people to view the US as historically religious and
the New Deal and liberalism as anti-religious
socialism.
- Focus the message through evangelicals including Vereide and Graham.
- Centralize the strategy through President Eisenhower.
- Add religious elements to
mainstream American symbols: money, pledge;
- Push for prayer in
public school
- Push Congress to promote prayer
- Make elections more
about religious positions.
Following our summary of his arguments RSS frames them from the
perspective of complex adaptive system (CAS) theory.
Strategy is the art of the possible. But it also depends
on persistence.
Inventing Christian America |
Charles Ferguson argues that the US power structure has become
highly corrupt.
Ferguson identifies key events which contributed to the
transformation:
- Junk bonds,
- Derivative
deregulation,
- CMOs,
ABS and analyst fraud,
- Financial network deregulation,
- Financial network consolidation,
- Short term incentives
Subsequently the George W. Bush administration used the
situation to build
a global bubble, which Wall Street
leveraged. The bursting of the
bubble: managed
by the Bush Administration and Bernanke Federal Reserve;
was advantageous to some.
Ferguson concludes that the restructured and deregulated
financial services industry is damaging to
the American economy. And it is supported by powerful, incentive aligned academics.
He sees the result being a rigged system.
Ferguson offers his proposals
for change and offers hope that a charismatic young FDR will appear.
Following our summary of his arguments, RSS comments on them framed by
complex adaptive system (CAS)
theory. Once the constraints are removed from CAS
amplifiers, it becomes advantageous to leverage the increased flows. And it is often
relatively damaging not to participate. Corruption and parasitism can become
entrenched.
Financial WMD |
Matt Taibbi describes the phenotypic
alignment of the American justice system. The result
he explains relentlessly grinds the poor and undocumented into
resources to be constrained, consumed and ejected. Even as
it supports and aligns the financial infrastructure into a
potent weapon capable of targeting any company or nation to
extract profits and leave the victim deflated.
Taibbi uses five scenarios to provide a broad picture of the:
activities, crimes, policing, prosecutions, court processes,
prisons and deportation network. The scenarios are:
Undocumented people's neighborhoods, Poor neighborhoods, Welfare
recipients, Credit card debtors and Financial institutions.
Following our summary of his arguments, RSS comments on them framed by
complex adaptive system (CAS) theory. The alignment of the
justice system reflects a set of long term strategies and
responses to a powerful global arms race that the US leadership intends to
win.
Aligned justice |
Jonathan Powell describes how the government of, the former UK Prime Minister, Tony Blair,
actually operated. Powell was Blair's only chief of
staff.
Mechanics of power |
H. A. Hayek compares and contrasts collectivism and
libertarianism.
Libertarianism |
John Doerr argues that company leaders and their
organizations, hugely benefit from Andy Grove's OKRs.
He promotes strategies
that help OKR success: Focus,
Align, Track, Stretch; replaces yearly performance
reviews, and provides illustrative success
stories.
Doerr stresses Dov Seidman's
view that employees are adaptive and will
respond to what they see being measured. He asserts culturally supported OKRs/CFR processes will be transformative.
Following our summary of his arguments, RSS comments on them
framed by complex adaptive system (CAS) theory. Doerr's architecture
is tailored for the startups KPCB
invests in. It is a subset of the general case of schematic plans, genetic operators and Shewhart cycles that drive all
CAS. Doerr's approach limits support of learning and deemphasizes the
association to planning.
Startup PDCA |
David Bodanis illustrates how disruptive effects can take
hold. While the French revolution had many driving forces
including famine and
oppression the emergence of a new philosophical vision ensured
that thoughtful leaders
were constrained and conflicted in their responses to the
crisis.
Voltaire's disruptive network |
An epistatic meme suppressed for a thousand years reemerges
during the enlightenment.
It was a poem
encapsulating the ideas of Epicurus rediscovered by a
humanist book hunter.
Greenblatt describes the process of suppression and
reemergence. He argues that the rediscovery was the
foundation of the modern world.
Complex adaptive system (CAS) models of the memetic mechanisms
are discussed.
Constraining happiness |
Isaacson uses the historic development of the global cloud of
web services to explore Ada
Lovelace's ideas about thinking
machines and poetic
science. He highlights the value of computer
augmented human creativity and the need for liberal arts to
fulfill the process.
Complex adaptive system (CAS) models of agent networks and
collaboration are discussed.
Arts technology & intelligence |
Haikonen juxtaposes the philosophy and psychology of
consciousness with engineering practice to refine the debate on
the hard problem of consciousness. During the journey he
describes the architecture of a robot that highlights the
potential and challenges of associative neural
networks.
Complex adaptive system (CAS) theory is then used to illustrate the
additional requirements and constraints of self-assembling
evolved conscious animals. It will be seen that
Haikonen's neural
architecture, Smiley's Copycat
architecture and molecular biology's intracellular
architecture leverage the same associative properties.
Associatively integrated robots |
Good ideas are successful because they build upon prior
developments that have been successfully implemented.
Johnson demonstrates that they are phenotypic expressions of
memetic plans subject to the laws of complex adaptive systems (CAS).
Developing ideas |
A government sanctioned monopoly
supported the construction of a superorganism
American Telephone and
Telegraph
(AT&T). Within this Bell Labs was at the center of
three networks:
- The evolving global scientific
network.
- The Bell telephone network. And
- The military
industrial network deploying 'fire and missile
control' systems.
Bell Labs strategically leveraged each network to create an innovation
engine.
They monitored the opportunities to leverage the developing
ideas, reorganizing to replace incumbent
opposition and enable the creation and growth of new
ideas.
Once the monopoly was
dismantled, AT&T disrupted.
Complex adaptive system (CAS) models of the innovation mechanisms are
discussed.
Strategic innovation |
Roger Cohen's New York Times opinion about the implications of
BREXIT is summarized. His ideas are then framed by complex
adaptive system (CAS) theory and
reviewed.
BREXIT |
Scott Galloway argues that Apple, Amazon, Facebook and Google
are monopolists that
trade workers for technology. Monopolies that he argues
should be broken up to ensure the return of a middle
class.
Following our summary of his arguments, RSS comments on these arguments
assuming they relate to a complex adaptive system (CAS).
While Scott's issue is highly significant his analysis conflicts
with relevant CAS history and theory.
Monopoly job killers |
The IPO of Netscape is
defined as the key emergent event of
the New Economy by Michael Mandel. Following the summary
of Mandel's key points the complex adaptive system (CAS) aspects are highlighted.
New economy |
Ed Conway argues that Bretton Woods produced a unique set of
rules and infrastructure for supporting the global economy. It was
enabled by the experience of Keynes
and White during and after the First World War, their dislike of the Gold Standard,
the necessity of improving
the situation between the wars and the opportunity created
by the catastrophe of the Second
World War.
He describes how it was planned
and developed. How it
emerged from the summit.
And he shows how the opportunity inevitably allowed the US to replace the UK at the center of the global economy.
Like all plans there are
mistakes and Conway takes us through them and how the US recovered the situation as
best it could.
And then Conway describes the period after
Bretton Woods collapsed. He explains what followed
and also compares the relative performance of the various
periods before during and after Bretton Woods.
Following our summary of his arguments RSS comments from the
perspective of Complex Adaptive System (CAS)
theory. Conway's book illustrates the rule making and
infrastructure that together build an evolved amplifier.
He shows the strategies at play of agents that were for and
against the development
and deployment of the system. And The Summit provides a
key piece of the history of our global economic CAS.
Bretton woods |
A key agent in the 1990 - 2008
housing expansion Countrywide is linked into the residential
mortgage value delivery system (VDS)
by Paul Muolo and Mathew Padilla. But they show the VDS
was full of amplifiers and control points. With no one
incented to apply the brakes the bubble grew and burst.
Following the summary of Muolo and Padilla's key points the
complex adaptive system (CAS)
aspects are highlighted.
Housing amplifiers |
Satyajit Das uses an Indonesian company's derivative trades to
introduce us to the workings of the international derivatives
system. Das describes the components of the value delivery
system and the key
transactions. He demonstrates how the system
interacted with emerging economies
expanding them, extracting profits and then moving on as the
induced bubbles burst. Following Das's key points the
complex adaptive system (CAS)
aspects are highlighted.
Derivative systems |
Johnson & Kwak argue that expanding the national debt
provides a hedge against unforeseen future problems, as long as
creditors are willing to continue lending. They illustrate
different approaches to managing the debt within the US over its history and of the
eighteenth century administrations of England and France.
The US embodies two different political and economic systems which
approach the national debt differently:
- Taxes to support a sinking
fund to ensure credit to leverage fiscal power in:
Wars, Pandemics, Trade disputes, Hurricanes, Social
programs; Starting with Hamilton,
Lincoln & Chase,
Wilson, FDR;
- Low taxes, limited infrastructure, with risk assumed by
individuals: Advocated by President's Jefferson & Madison,
Reagan,
George W. Bush (Gingrich);
Johnson & Kwak develop a model of what the US
government does. They argue that the conflicting
sinking fund and low tax approaches leaves the nation 'stuck in
the middle' with a future problem.
And they offer their list of 'first principles' to help
assess the best approach for moving from 2012 into the
future.
They conclude the question is still political. They hope
it can be resolved with an awareness of their detailed
explanations. They ask who is willing to
push all the coming risk onto individuals.
Following our summary of their arguments RSS frames them from the
perspective of complex adaptive system (CAS) theory.
Historically developing within the global cotton value delivery
system, key CAS features are highlighted.
National debt |
Robert Gordon argues that the inventions of the second
industrial revolution were the foundation for
American economic growth. Gordon shows how flows of people
into difficult rural America built a population base
which then took the opportunity to move on to urban settings: Houses, Food in supermarkets,
Clothes in
department stores;
that supported increasing productivity and standard of living.
The deployment of nationwide networks: Rail, Road, Utilities;
terminating in the urban housing and work places allowing the workers to
leverage time saving goods and services, which helped grow
the economy.
Gordon describes the concomitant transformation of:
- Communications
and advertising
- Credit
and finance
- Public
health and the health
care network
- Health insurance
- Education
- Social
and welfare services
Counter intuitively the constraints
introduced before and in the Great Depression and the demands of World War 2
provide the amplifiers that drive the inventions deeply and
fully into every aspect of the economy between 1940 and 1970
creating the exceptional growth and standard of living of post
war America.
Subsequently the
rate of growth was limited until the shift of women
into the workplace and the full networking of
voice and data supported the Internet and World Wide Web
completed the third industrial revolution, but the effects were
muted by the narrow reach of the technologies.
The development of Big Data, Robots,
and Artificial Intelligence may support additional growth,
but Gordon is unconvinced because of the collapse of
the middle class.
Following our summary of Gordon's book RSS frames his arguments from
the perspective of complex adaptive system (CAS) theory.
American growth |
Carl Menger argues that the market induced the emergence of
money based on the attractive features of precious metals.
He compares the potential for government edicts to create money
but sees them as lacking.
Following our summary of his arguments RSS frames his arguments from
the perspective of complex adaptive system (CAS) theory.
With two hundred years of additional knowledge we conclude that
precious metals are not as attractive as Menger asserts.
Government backed promissory notes are analogous to:
- Other evolved CAS forms of ubiquitous high energy
transaction intermediates and
- Schematic strategies that are proving optimal in
supporting survival and replication in the currently
accessible niches.
Emergence of money |
Eric Beinhocker sets out to answer a question Adam Smith
developed in the Wealth of Nations: what is wealth? To do
this he replaces traditional
economic theory, which is based on the assumption that an
economy is a system in
equilibrium, with complexity
economics in which the economy is modeled as a complex
adaptive system (CAS).
He introduces Sugerscape
to illustrate an economic CAS model in action. And then he
explains the major features of a CAS economy: Dynamics,
Agents, Networks, Emergence, and
Evolution.
Building on complexity economics Beinhocker reviews how evolution applies to
the economy to build wealth. He explains how design spaces
map strategies to instances of physical and
social
technologies. And he identifies the interactors and
selection mechanism of economic
evolution.
This allows Beinhocker to develop a new definition
of wealth.
In the rest of the book Beinhocker looks at the consequences of
adopting complexity economics for business and society: Strategy, Organization, Finance,
& Politics
& Policy.
Following our summary of his arguments, RSS explores his conclusions
and aligns Beinhocker's model of CAS with the CAS theory and evidence we
leverage.
Economic complexity |
Sven Beckert describes the historic transformation of the
growing, spinning, weaving, manufacture of cotton goods and
their trade over time. He describes the rise of a first global
commodity, its dependence on increasing: military power, returns for
the control points in the value delivery system(VDS), availability of land
and labor to work it including slaves.
He explains how cotton offered the opportunity for
industrialization further amplifying the productive capacity of
the VDS and the power of the control points. This VDS was quickly
copied. The increased capacity of the industrialized
cotton complex adaptive system (CAS) required more labor to
operate the machines. Beckert describes the innovative introduction of wages
and the ways found to
mobilize industrial labor.
Beckert describes the characteristics of the industrial cotton
CAS which made it flexible enough to become globally interconnected.
Slavery made the production system so cost effective that all
prior structures collapsed as they interconnected. So when
the US civil war
blocked access to the major production nodes in the
American Deep South the CAS began adapting.
Beckert describes the global
reconstruction that occurred and the resulting destruction of the traditional ways
of life in the global countryside. This colonial expansion
further enriched and empowered the 'western' nation
states. Beckert explains how other countries responded
by copying the colonial strategies and creating the
opportunities for future armed conflict among the original
colonialists and the new upstarts.
Completing the adaptive
shifts, Beckert describes the advocates for industrialization in
the colonized global south and how over time they joined
the global cotton CAS disrupting the early western manufacturing
nodes and creating the current global CAS
dominated by merchants like Wal-Mart
pulling goods through a network of clothing manufacturers,
spinning and weaving factories, and growers competing with each
other on cost.
Following our summary of Beckert's book, RSS comments from the
perspective of CAS theory. The transformation of
disconnected peasant farmers,
pastoral warriors and their lands into a supply chain for a
highly profitable industrial CAS required the development over
time: of military force, global transportation and communication
networks, perception and representation control networks, capital stores and flows,
models, rules, standards and markets; along with the support at
key points of: barriers, disruption, and infrastructure and
evolved amplifiers. The emergent
system demonstrates the powerful constraining influence of
extended phenotypic alignment.
Globalization from cotton |
The structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Globalization connects disparate environments in a network. At the edges,
humans are drastically altering the biosphere. That
is reducing the proximate natural environment's
connectedness, and leaving its end-nodes disconnected and
far less diverse. This disconnects predators from
their prey, often resulting in local booms and busts that
transform the local parasite
network and their reservoir and amplifier
hosts. The situation is setup so that man is
introduced to spillover
from the local parasites' hosts. Occasionally, but
increasingly, the spillover results in humanity becoming
broadly infected. The evolved
specialization of the immune system
to the proximate environment during development
becomes undermined as the environment transforms.
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
Health care |
Deaton describes the wellbeing
of people around the world today. He explains the powerful benefit of public
health strategies and the effect of growth in
material wellbeing but also the corrosive effects of
aid.
Following our summary of Deaton's arguments RSS comments from the
perspective of complex adaptive system (CAS)
theory. The situation he describes is complex including
powerful amplifiers, alignment and incentives that overlap
broadly with other RSS summaries of adaptations of: The
biosphere, Politics, Economics,
Philosophy and Health care.
Improving wellbeing |
Donald Barlett and James Steele write about their investigations
of the major problems afflicting US
health care as of 2006.
Problems of US health care |
E2E insured quality care |
Robert Pearl explains the perspectives of a health care leader
and son who know that the current health care network interacts
with human behavior to induce a poorly performing system that
caused his father's death. But he is confident that these
problem perceptions can be changed. Once that occurs he
asserts the network will become more integrated, coordinated,
collaborative, better led, and empathetic to their
patients. The supporting technology infrastructure will be
made highly interoperable. All that will reduce medical
errors and make care more cost effective.
Following our summary of his arguments RSS comments on them. We
frame his ideas with complex adaptive system (CAS) theory
including synergistic examples of these systems in
operation. The health care network is built out of
emergent human agents. All agents must model the signals
they perceive to represent and respond to them. Pinker
explains how this occurs. Sapolsky explains why fear and
hierarchy are so significant. He includes details of Josh
Green's research on morality and death. Charles Ferguson
highlights the pernicious nature of financial incentives.
Bad medical models |
US healthcare is ripe for
disruption. Christensen, Grossman and Hwang argue that
technologies are emerging which will support low cost business
models that will undermine the current network. Applying
complex adaptive system (CAS)
theory to these arguments suggests that the current power hierarchy can effectively resist
these progressive forces.
Disrupting health care |
Atul Gawande writes about the opportunity for a thirty per cent
improvement in quality in medicine by organizing
to deploy as agent based teams using shared schematic
plans and distributed signalling or as he puts it the use of checklists.
With vivid examples from a variety of situations including construction, air crew support and global health care Gawande illustrates
the effects of
complexity and how to organize to cope with it.
Following the short review RSS
additionally relates Gawande's arguments to its models of
complex adaptive systems (CAS) positioning his discussion within
the network of US health care,
contrasting our view of complexity, comparing the forces shaping
his various examples and reviewing facets of complex
failures.
Complexity checklists |
Friedman and Martin leverage the lifelong data collected on
1,528 bright individuals selected by Dr. Lewis Terman
starting in 1921, to understand what aspects of the subjects'
lives significantly affected their longevity. Looking
broadly across each subject's: Personality,
Education, Parental impacts,
Energy
levels, Partnering,
Careers, Religion,
Social networks,
Gender, Impact from war and
trauma; Friedman and Martin are able to develop a set of model pathways,
which each individual could be seen to select and travel
along. Some paths led to the traveler having a long
life. Others were problematic. The models imply that
the US approach to health and
wellness should focus
more on supporting
the development and selection of beneficial pathways.
Following our summary of their arguments RSS comments from the
perspective of CAS theory. The pathways are most
applicable to bright individuals with the resources and support
necessary to make and leverage choices they make. Striving
to enter and follow a beneficial pathway seems sensible but may
be impossible for individuals trapped in a collapsing network,
starved of resources.
Promoting longevity |
Gawande uses his personal experience, analytic skills and lots
of stories of innovators to demonstrate better ways of coping
with aging and death. He introduces the lack of focus on
aging and death in traditional medicine. And goes on to
show how technology has amplified
this stress point. He illustrates the traditional possibility of the
independent self, living fully while aging with the
support of the extended family. Central
planning responded to the technological and societal changes
with poorly designed infrastructure and funding. But
Gawande then contrasts the power of
bottom up innovations created by experts responding to
their own family situations and belief
systems.
Gawande then explores in depth the challenges
that unfold currently as we age and become infirm.
He notes that the world is following the US path. As such it will
have to understand the dilemma of
integrating medical treatment and hospice
strategies. He notes that all parties
involved need courage to cope.
He proposes medicine must aim to assure
well being. At that point all doctors will practice
palliative care.
Complex adaptive system (CAS) models of agency, death,
evolution, cooperation and adaptations
to new technologies are discussed.
Agent death |
Sonia Shah reviews the millennia old (500,000 years) malarial arms race between Humanity, Anopheles
mosquitoes and Plasmodium. 250 - 500 million people are
infected each year with malaria and one million die.
Malaria |
Peter Medawar writes about key historic events in the evolution
of medical science.
Medical science events |
Using John Holland's theory of adaptation in complex
systems Baldwin and Clark propose an evolutionary theory of
design. They show how this can limit the interdependencies
that generate complexity
within systems. They do this through a focus on
modularity.
Modular designed systems |
Lou Gerstner describes the challenges he faced and the
strategies he used to successfully restructure the computer
company IBM.
Compartmented systems |
Grady Booch advocates an object oriented approach to computer
software design.
Object based systems |
Bertrand Meyer develops arguments, principles and strategies for
creating modular software. He concludes that abstract data
types and inheritence make object orientation a superior
methodology for software construction. Complex adaptive
system (CAS) theory suggests agents provide an alternative strategy
to the use of objects.
Software construction |
Tools and the businesses that produce them have evolved
dramatically. W Brian Arthur shows how this occurred.
Tools |
Matt Ridley demonstrates the creative effect of man on the
World. He highlights:
- A list of
preconditions resulting in
- Additional niche
capture & more free time
- Building a network
to interconnect memes processes & tools which
- Enabling inter-generational
transfers
- Innovations
that help reduce environmental stress even as they leverage fossil
fuels
Memetic trading networks |
E O. Wilson argues that campfire gatherings on the savanna supported
the emergence of human creativity. This resulted in man
building cultures and
later exploring them, and their creator, through the humanities. Wilson
identifies the transformative events, but he notes many of these
are presently ignored by the humanities. So he calls for a
change of approach.
He:
- Explores creativity:
how it emerged from the benefits of becoming an omnivore hunter-gatherer,
enabled by language & its catalysis of invention, through stories told in the
evening around the campfire. He notes the power of
fine art, but suggests music provides the most revealing
signature of aesthetic
surprise.
- Looks at the current limitations of the
humanities, as they have suffered through years of neglect.
- Reviews the evolutionary processes of heredity and
culture:
- Ultimate causes viewed
through art, & music
- The bedrock of:
- Ape senses and emotions,
- Creative arts, language, dance, song typically studied
by humanities,
&
- Exponential change in science and
technology.
- How the breakthrough from
our primate past occurred, powered by eating meat,
supporting: a bigger brain, expanded memory &
language.
- Accelerating changes now driven by genetic cultural coevolution.
- The impact on human nature.
- Considers our emotional attachment to the natural world: hunting, gardens; we are
destroying.
- Reviews our love of metaphor, archetypes,
exploration, irony, and
considers the potential for a third enlightenment,
supported by cooperative
action of humanities and science
Following our summary of his arguments RSS frames these from the
perspective of complex adaptive system (CAS) theory:
- The humanities are seen to be a functionalist framework
for representing the cultural CAS while
- Wilson's desire
to integrate the humanities and science gains support from
viewing the endeavor as a network of layered CAS.
Evening campfire rituals |
Brynjolfsson and McAfee explore the effects of Moore's law on the
economy. They argue it has generated exponential
growth. This has been due to innovation.
It has created a huge bounty of
additional wealth.
But the wealth is spread unevenly across
society. They look at the short and long term implications of
the innovation bounty and spread
and the possible future of
technology.
Following our summary of their arguments RSS comments from the
perspective of CAS theory.
Brilliant technologies |
Salman Khan argues that the evolved global education system is
inefficient and organized around constraining and corralling
students into accepting dubious ratings that lead to mundane
roles. He highlights a radical and already proven
alternative which offers effective self-paced deep learning
processes supported by technology and freed up attention of
teams of teachers. Building on his personal experience of
helping overcome the unjustified failing grade of a relative,
Khan:
- Iteratively learns how to teach: Starting with Nadia, Leveraging
short videos focused on content,
Converging on mastery,
With the help of
neuroscience, and filling
in dependent gaps; resulting in a different approach
to the mainstream method.
- Assesses the broken US education system: Set in its ways, Designed for the 1800s,
Inducing holes that
are hidden by tests, Tests
which ignore creativity.
The resulting teaching process is so inefficient it needs to
be supplemented with homework.
Instead teachers were encouraging their pupils to use his tools at home so
they could mentor them while they attended school, an
inversion that significantly improves the economics.
- Enters the real world: Builds a scalable service,
Working with a
real classroom, Trying stealth
learning, At Khan Academy full time, In the curriculum at
Los Altos, Supporting life-long
learning.
- Develops The One World Schoolhouse: Back to the future with
a one
room school, a robust
teaching team, and creativity enabled;
so with some catalysis
even the poorest can
become educated and earn credentials
for current jobs.
- Wishes he could also correct: Summer holidays, Transcript based
assessments, College
education;
- Concludes it is now possible to provide the infrastructure
for creativity to
emerge and to support risk taking.
Following our summary of his arguments RSS frames them from the
perspective of complex adaptive system (CAS) theory. Disruption is a powerful force for
change but if its force is used to support the current teachers
to adopt new processes can it overcome the extended phenotypic alignment and evolutionary amplifiers sustaining the
current educational network?
Education versus guilds |
Amy Chua and Jed Rubenfeld's New York Times opinion based on The
Triple Package is summarized. Their ideas are then framed
by CAS theory and reviewed.
What drives success |
Peter Turchin describes how major pre-industrial empires
developed due to effects of geographic boundaries constraining
the empires and their neighbors' interactions. Turchin
shows how the asymmetries of breeding rates and resource growth
rates results in dynamic cycles within cycles. After the
summary of Turchin's book complex adaptive system (CAS) theory
is used to augment Turchins findings.
Warrior groups |
Through the operation of three different food chains Michael
Pollan explores their relative merits. The application of
complex adaptive system (CAS)
theory highlights the value of evolutionary
testing of the food chain.
Natural systems |
E. O. Wilson & Bert Holldobler illustrate how bundled cooperative strategies can
take hold. Various social insects have developed
strategies which have allowed them to capture the most valuable
available niches. Like humans they invest in
specialization and cooperate to subdue larger, well equipped
competitors.
Insect superorganisms |
Computational
theory of the mind and evolutionary
psychology provide Steven Pinker with a framework on which
to develop his psychological arguments about the mind and its
relationship to the brain. Humans captured a cognitive niche by
natural selection 'building out'
specialized aspects of their bodies and brains resulting in a system of mental organs
we call the mind.
He garnishes and defends the framework with findings from
psychology regarding: The visual
system - an example of natural
selections solutions to the sensory challenges
of inverse
modeling of our
environment; Intensions - where
he highlights the challenges of hunter-gatherers -
making sense of the objects
they perceive and predicting what they imply and natural
selections powerful solutions; Emotions - which Pinker argues are
essential to human prioritizing and decision making; Relationships - natural selection's
strategies for coping with the most dangerous competitors, other
people. He helps us understand marriage, friendships and war.
These conclusions allow him to understand the development and
maintenance of higher callings: Art, Music, Literature, Humor,
Religion, & Philosophy; and develop a position on the meaning of life.
Complex adaptive system (CAS) modeling allows RSS to frame Pinker's arguments
within humanity's current situation, induced by powerful evolved
amplifiers: Globalization,
Cliodynamics, The green revolution
and resource
bottlenecks; melding his powerful predictions of the
drivers of human behavior with system wide constraints.
The implications are discussed.
Computationally adapted mind |
The stages of development of the human female, including how her brain changes and the
impacts of this on her 'reality' across a full life span:
conception, infantile
puberty, girlhood,
juvenile pause, adolescence, dating years, motherhood, post-menopause; are
described. Brizendine notes the significant difference in
how emotions are processed
by women compared to men.
Complex adaptive system (CAS) theory associates the stages with
the evolutionary under-pinning, psychological implications and
behavioral CAS.
Evolved female brain |
The complexity of behavior is explored through Sapolsky
developing scenarios of our best and worst behaviors across time
spans, and scientific subjects including: anthropology,
psychology, neuroscience, sociology. The rich network of adaptive flows he
outlines provides insights and highlight challenges for
scientific research on behavior.
Complex adaptive system (CAS) theory builds on Sapolsky's
details highlighting the strategies that evolution has captured
to successfully enter niches we now occupy.
CAS behavior |
Carlo Rovelli resolves the paradox of time.
Rovelli initially explains that low level physics does not
include time:
- A present that is common throughout the universe does not exist
- Events are only partially ordered. The present is
localized
- The difference between past and future is not foundational.
It occurs because of state that through our blurring appears
particular to us
- Time passes at different speeds dependent on where we are and how fast we travel
- Time's rhythms are due to
the gravitational field
- Our quantized physics shows neither
space nor time, just processes transforming physical
variables.
- Fundamentally there is no time. The basic equations
evolve together with events, not things
Then he
explains how in a physical world without time its perception can
emerge:
- Our familiar time emerges
- Our interaction with the world is partial, blurred,
quantum indeterminate
- The ignorance determines the existence of thermal time
and entropy that quantifies our uncertainty
- Directionality of time is real
but perspectival. The entropy of the world in
relation to us increases with our thermal time. The
growth of entropy distinguishes past from future: resulting in
traces and memories
- Each human is a
unified being because: we reflect the world, we
formed an image of a unified entity by
interacting with our kind, and because of the perspective
of memory
- The variable time: is one
of the variables of the gravitational field.
With our scale we don't
register quantum fluctuations, making space-time
appear determined. At our speed we don't perceive
differences in time of different clocks, so we experience
a single time: universal, uniform, ordered; which is
helpful to our decisions
Emergence of time |
Consciousness has confounded philosophers and scientists for
centuries. Now it is finally being characterized
scientifically. That required a transformation of
approach.
Realizing that consciousness was ill-defined neuroscientist
Stanislas Dehaene and others characterized and focused on conscious access.
In the book he outlines the limitations of previous
psychological dogma. Instead his use of subjective
assessments opened the
window to contrast totally unconscious
brain activity with those
including consciousness.
He describes the research methods. He explains the
contribution of new sensors and probes that allowed the
psychological findings to be correlated, and causally related to
specific neural activity.
He describes the theory of the brain he uses, the 'global neuronal
workspace' to position all the experimental details into a
whole.
He reviews how both theory and practice support diagnosis and
treatment of real world mental illnesses.
The implications of Dehaene's findings for subsequent
consciousness research are outlined.
Complex adaptive system (CAS) models of the brain's development and
operation introduce constraints which are discussed.
Conscious access |
Reading and writing present a conundrum. The reader's
brain contains neural networks tuned to reading. With
imaging a written word can be followed as it progresses from the
retina through a functional chain that asks: Are these letters?
What do they look like? Are they a word? What does it sound
like? How is it pronounced? What does it mean? Dehaene
explains the importance of
education in tuning the brain's networks for reading as
well as good strategies for teaching reading and countering dyslexia. But
he notes the reading
networks developed far too recently to have directly evolved.
And Dehaene asks why humans are unique in developing
reading and culture.
He explains the cultural
engineering that shaped writing to human vision and the exaptations and neuronal structures that
enable and constrain reading and culture.
Dehaene's arguments show how cellular, whole animal and cultural
complex adaptive system (CAS) are
related. We review his explanations in CAS terms and use
his insights to link cultural CAS that emerged based on reading
and writing with other levels of CAS from which they emerge.
Evolved reading |
Read Montague explores how brains make decisions. In
particular he explains how:
- Evolution can create indirect abstract models, such as the dopamine system, that
allow
- Life changing real-time
decisions to be made, and how
- Schematic structures provide
encodings of computable control
structures which operate through and on incomputable,
schematically encoded, physically active structures and
operationally associated production
functions.
Receptor indirection |
Daniel Goleman and Richard Davidson describe a scientific
investigation of meditation's
impact on the brain. They introduce
the book by describing their experiences with meditation,
science and the research establishment, their friendship, how
meditation is now used in two distinct ways: deep - leading to altered
traits & wide - that can reach the multitudes; which
the book reviews as it critiques the claims and research used to
back them up.
Goleman and Davidson describe meeting as Harvard psychology
graduate students, interested in consciousness, and how minds
work. They rebel against the behavioral orthodoxy, visit Asia and discover the Eastern
tradition of exploring and altering the mind.
Goleman had travelled to Sri Lanka to understand an Asian model
of the mind, which he presented to the undergraduates at
Harvard. Goleman and Davidson developed it into a shared vision of
consciousness. It took over twenty years for
scientific theory and experimental data to catch up and align
with this model. Much of the prior
experimental data had to be abandoned.
They introduce meditation's
impact on the amygdala
responding to pain and stress.
They look at the changes in:
- Stress
- Compassion
- Attention
- Self-awareness; and the
potential for use of mediation
in psychiatry.
And they warn of the occurrence of dark
nights.
They detail how scientists were able to study the brains of Tibetan meditation masters,
starting with Mingyur Rinpoche,
and detect meditation altering
traits.
Finally they discuss the potential
benefits of meditation and strategies to distribute it
broadly to a busy America.
Meditating neurons |
Tara Brach was worried from
a young age that there was something terribly wrong with
her: she like many others felt unworthy. She responded
by developing Radical
Acceptance. Brach then explains the steps in
applying it: pause,
greet what happens next with unconditional
friendliness; allowing us to:
- Initially attend to the sensations
of our body,
- Accept the
wanting self and discover its source of boundless
love.
- Welcome
fear with a widening
attention, accept the pain of death and become
free.
- Use adversity as a gateway to limitless compassion for ourselves
and others.
- Focus on
our basic goodness to counter Western culture turning anger, at being betrayed,
towards ourselves. Extend observing this goodness in
everyone. This enables the use of loving-kindness.
- Leverage
friendships to understand more about our shared nature
and strengthen Radical Acceptance.
- Realize our Buddha nature.
Complex adaptive system (CAS) theory describes the emergence of
the dualistic self and the tree of life linked by the genetic
code and machinery. It provides an analog of the Buddhist
presence.
Compassionate CAS |
The influence of childhood on behavior is significant.
Enneagrams define personality
types: Reformer, Helper, Achiever,
Individualist, Investigator, Loyalist, Enthusiast,
Challenger and Peacemaker; based on the impact of
childhood driven wounds.
The Enneagram becomes
a tool to enable interested people to transform from the
emotionally wounded base, hidden within
the armor of the type, to the liberated underlying essence.
Childhood leaves each of us with some environmentally specific Basic Fear. In response each
of us adopts an induced Basic Desire
of the type. But as we develop the inner observer, it will
support presence and
undermine the identification
that supports the armor of the type.
The Enneagram reveals three sets of relations about our type
armor:
- Triadic self
revealing: Instinctive,
feeling, thinking; childhood needs
that became significant wounds
- Social style
groupings: Assertive, compliant, withdrawn; strategies for
managing inner conflict
- Coping styles: Positive outlook, competency, reactive; strategies for
defending childhood wounds
Riso and Hudson augment the Enneagram with instinctual
distortions reflected in the interests of the variants.
The Enneagram also offers tools for understanding a person's level of development:
unhealthy, average, healthy,
liberation; including their
current center of gravity,
steriotypical social role,
wake-up call, leaden rule, red
flag, and direction
of integration and disintegration.
Complex adaptive system (CAS) theory associates the models
presented by the Enneagram with evolved behaviors and structures
in the mind: feelings, emotions, social behaviors, ideas; driven
by genetic and cultural evolution and the constraints of family
and social life. Emergent evolved amplifers can be
constrained by Riso and Hudson's awareness strategies.
Enneagram strategies |
Antonio Damasio argues
that ancient
& fundamental homeostatic processes,
built into
behaviors and updated by evolution
have resulted in the emergence
of nervous systems and feelings. These
feelings, representing the state of the viscera, and represented with general
systems supporting enteric
operation, are later ubiquitously
integrated into the 'images'
built by the minds of higher animals
including humans.
Damasio highlights the separate
development of the body frame in the building of
minds.
Damasio explains that this integration of feelings by minds
supports the development of subjectivity and consciousness. His chain of
emergence suggests the 'order of things.' He stresses the
end-to-end
integration of the organism which undermines dualism. And he reviews Chalmers
hard problem of consciousness.
Damasio reviews the emergence of cultures
and sees feelings, integrated with reason, as the judges of the
cultural creative process, linking culture to
homeostasis. He sees cultures as supporting the
development of tools
to improve our lives. But the results of the
creative process have added
stresses to our lives.
Following our summary of his arguments RSS frames his arguments from
the perspective of complex adaptive system (CAS) theory.
Each of the [super]organisms
discussed is a CAS reflecting the theory of such systems:
- Damasio's proposals about homeostasis routed signalling, aligns
well with CAS theory.
- Damasio's ideas on cultural stresses are elaborated by CAS
examples.
Emergence of feelings |
Robert Coram highlights the noble life of John Boyd. John
spent a lot of time alone
during his childhood.
He: excelled at swimming and was a lifeguard, enlisted in the
Army Air Corp while at school which rejected him for pilot
training, was part of the Japan occupation force where he swam;
so the US paid for him to attend University
of Iowa, where he: joined the Air Force Officers' training
corps, was accepted to be an Air Force pilot, and got engaged to
Mary Bruce.
Boyd trained at Nellis AFB to become a
combat ready pilot in
the Korean War.
While the US Air Force focused on
Strategic bombing, Boyd loved
dogfights. His exceptional tactical ability was
rewarded with becoming an instructor. Boyd created new
ways to think about dogfighting and beat all-comers
by using them in the F-100.
He was noticed and enabled by Spradling. As he trained, and defeated the top
pilots from around the US and allied base network, his
reputation spread. But he needed to get
nearer to the hot spring in Georgia, and when his move to
Tyndall AFB was blocked he used the AFIT to train in engineering at
Georgia tech. While preparing to move he documented his FWS training
and mentored Ronald Catton.
While there he first realized the
link between energy
and maneuverability.
At Eglin, in partnership with Tom Christie,
he developed tools to model the link. They developed
comparisons of US and Soviet aircraft which showed the US
aircraft performing poorly. Eventually General Sweeney
was briefed on
the theory and issues with the F-105, F-4, and F-111.
Sent to the Pentagon
to help save the F-X budget, Boyd joined forces with Pierre Sprey to
pressure procurement into designing and
building tactically exceptional aircraft: a CAS tank killer and a
lightweight maneuverable
fighter. The navy aligned with
Senators of states with navy bases, prepared to sink the
F-X and force the F-14 on
the Air Force. Boyd saved
the plane from the Navy and the budget from Congress, ensuring
the Air Force executive and its career focused hierarchy had the
freedom to compromise
on a budget expanding over-stuffed F-X (F-15). Boyd requested to
retire, in disgust.
Amid mounting hostility from the organizational hierarchy Boyd
and Sprey secretly
developed specifications for building prototype lightweight
fighters with General Dynamics: YF-16;
and Northrop: YF-17; and enabled by Everest Riccioni.
David Packard
announced a budget of $200 million for the services to spend on
prototypes. Pierre Sprey's friend Lyle Cameron picked a
short takeoff and landing transport aircraft and Boyd's lightweight fighter to
prototype.
Boyd was transferred to Thailand
as Vice Commander of Task
Force Alpha, inspector general and equal opportunity
training officer; roles in which he excelled. And he
started working on his analysis of creativity: Destruction
and Creation. But on completion of the tour Boyd was
apparently abandoned and sent to run
a dead end office at the Pentagon.
The power hierarchy moved to protect the F-15, but: Boyd,
Christie, Schlesinger,
and the Air Force chief of staff; kept the
lightweight fighter budgeted and aligned with Boyd's
requirements in a covert campaign. The Air Force
threw a phalanx of developers at the F-16, distorting Boyd's
concept. He accepted he had lost the fight and retired
from the Air Force.
Shifting to scholarship Boyd reflects on how rigidity must be destroyed to enable
creative new assemblies. He uses the idea to explain
the operational success of the YF16 and F-86 fighters, and then
highlights how the pilot can take advantage of their
infrastructure advantage with rapid decision making he
explains with the O-O-D-A Loop.
Boyd encouraged Chuck Spinney
to expose the systemic cost overruns
of the military procurement process. The military
hierarchy moved to undermine the
Spinney Report and understand the
nature of the reformers. Boyd acted as a progressive
mentor to Michael
Wyly, who taught the
Marine Corps about maneuver
warfare, and Jim Burton.
Finally, after the military hierarchy appears to have
beaten him, Boyd's ideas are tested during
the First Gulf War.
Following our summary of his main points, RSS frames the details from the
perspective of complex adaptive system (CAS) theory. Boyd was Darwinesque, placing the art of
air-to-air combat within a CAS framework.
Air warrior |
Alfred Nemeczek reveals the chaotic, stressful life of Vincent
van Gogh in Arles.
Nemeczek shows that Vincent was driven
to create, and successfully
invented new methods of representing feeling in paintings, and
especially portraits. Vincent
worked hard to allow artists like him-self
to innovate. But
Vincent failed in this goal, collapsing into psychosis.
Nemeczek also provides a brief history of
Vincent's life.
Following our summary of his main points, RSS frames the details from the
perspective of complex adaptive system (CAS) theory.
Vincent creates |
Reginald Dwight, better known as Elton John, writes a hilarious
memoir, full of anecdotal and sometimes morbid humor and gossip, which describes his
immediate family, upbringing, development as a singer
songwriter, stardom and its support for his problems, collapse
and eventual recovery.
Elton stresses the serendipitous nature
of his emergence as a musician. He describes
the contributions of his parents, Stanley & Sheila, mother's
sister, and her mother Ivy;
who formed his early
childhood proximate environment which prepared
him for a job in entertainment: he
developed his performance in the club circuits, setup a
commercial partnership with Bernie Taupin to write songs;
entering a network based around Dick James Music.
And he almost got married.
DJM focused Elton and Bernie's initial song writing
while they studied the songs they admired and Elton did session
work, tightening his performance skills and paying for the
food. A first album supported touring and the formation of
a band. A second one sent them to the US where Elton became an
overnight sensation. And during this period of time
Elton's testosterone
level ramped. Life changed
dramatically.
Stardom provided many rewards but there
were still life's problems to deal with. Elton was
befriended by his idol, John Lennon; he achieved new heights of
success but, sensitive to any hint of failure and fraud, suicidally disassociated.
His career crested, he struggled with loneliness and drugs, and
foresaw a fearful vision of his future, as fame caged him idly
in hotels between concerts. His hair abandoned him.
But he was saved by the challenge of
transforming the collapsed Watford football club. He
retired from touring which allowed him the time to reconstruct his life.
Empowered by success, supported by the removal of constraints,
Elton dominates - limiting feedback, doing whatever he
hopes will bring him happiness:
trying new options, expanding the range and increasing the
quantity of mind altering substances; eventually hitting John Reid and marrying
Renata.
He allows his drug use to enter the recording studio. Problems stress him. He is
frightened by a cancer
scare, AIDS, inspired by
Ryan White, angered by the
Sun, and saddened at
breaking Renata's heart. But he was there for Ryan White's
final days. And his lover Hugh Williams confronted Elton
about his string of addictions.
Elton finally agreed he had a problem.
He went to rehab, stopped hating himself,
gave up his current addictions, accepted the influence of a
higher force, and began admiring the everyday world and other
people.
It seemed the higher force was
supporting Elton's progress: he wrote the music for the
Lion King, met David Furnish who accepted Elton warts and all;
they both enjoyed a friendship with Gianni Versace; until Gianni
was murdered. Princess Diana
died soon after, and Elton performed at the funeral.
He toured with Billy Joel and aimed to do the same with Tina
Turner. While his new records sold well he found
himself in debt and terminated the management relationship
with John Reid
Enterprises.
Elton and Bernie improved their
situations: Elton started writing film scores, he helped
turn the film Billy Elliot into a musical, Bernie lobbied Elton
to improve the way they were making records, Elton and David
entered into a civil partnership, and Elton made a record with
his seminal influence: Leon
Russell.
Elton and David became parents of
two boys: Zachary and Elijah; using their sperm a surrogate
mother and network in California. They quietly get married
when the UK allows.
Elton's mum remains
difficult and cruel to him, but he is sad when she dies, and many
at the funeral recall her fun side with him. Being parents
increases the long-term
stresses on their lives, forcing them to adjust, so they can be there for their boys.
But Elton needs to go out with a bang!
And everyone helps.
Following our summary of his main points, RSS frames the details
of the creative process from the perspective of complex
adaptive system (CAS) theory.
My song |
Richard Feynman
outlines a series of amusing vignettes, as he reviews his life story.
Richard's personality
encouraged him to patiently
seek out fun: performing Shewhart cycles
with electricity, in his childhood laboratory, and aligning theory, and
practice through building and fixing radios.
Leonardo's life inspired him to try
innovation, which he
concluded was hard. He played
with the emotion
in communications, a skill
which he used later at
Caltech. And he made a game of avoiding following
orders at MIT. Working during
the holidays revealed the benefit of joining theory and
practice.
Feynman enrolled as a graduate
student at Princeton, where the successful
approach to science was just like his.
His approach was based on
patience and fun: he used his home lab and other tools for
qualitative exploration. Overtime he added experimental
techniques. He would test
the assertions in articles with amusing investigations;
with his mind aligned by
feelings of joy. Everyone at Princeton heard he would want to be hypnotized.
He was driven to compare the challenges of complex subjects being
taught at Princeton to his current pick. In his summer
recess he explored biology.
Gathering problems in challenging areas of science, and then picking one to solve, supported his
creativity. And his practical
orientation and situation when growing up in Far Rockaway,
supported his desire for choices
and adolescent dislike for purely intellectual and cultural
pursuits. Being mostly self-taught, he
developed different approaches to problems than the
standard strategies provided by mass education.
Richard saw his skill set as very different to that exhibited by his father. But are they very
different?
While Richard was at Princeton, America became concerned about
the implications of the European war. After a friend
enlisted he decided to dedicate his
summer holiday to helping the war effort. Feynman got involved in the
Manhattan Project, and went to Los Alamos where he
experienced constraints, applied by: the military, the
physics of the project, him on Niels
Bohr; but was
freed from them by Von
Neumann. The records & reports of the project
were kept in filing cabinets. Richard explored the weaknesses of
the locks and safes deployed to secure these
secrets. Just after the war he was called up by the draft
board for a medical but was rejected for being mentally
unfit.
After the war, Richard was asked to become a professor at Cornell.
He initially struggled in this role: Too young to match
expectations, stressed by the demands of his new job and his
recent experiences; until he adopted an approach that focused on
fun. He enjoyed knowing
about numbers: using, learning about them and the tools to
use them, and competing with others; to calculate, interpolate
and approximate a value the fastest.
Traveling to Buffalo in a light plane once a week to give a
physics lecture before flying back the next morning wasn't much
fun for Richard. So he used
the stipend to visit a bar after each lecture to meet
beautiful women. Richard liked bars and nightclubs, spending a summer in Albuquerque
frequenting one, and later
ones in Las Vegas, as he explored how to get the girls he
drank with to sleep with him.
Richard reflects on various times when he made government
officials obey their parts of contracts: patent fees, limits on red tape;
Richard became frustrated with his life at Cornell, seeing more
things that interested him on the sunny west coast at Caltech. Both
institutions, and Chicago, offered him incentives to help his decision making,
but Richard began to find reevaluating the alternatives a waste
of time and he saw risks in
a really high salary, deciding he would move to Caltech
and stay there.
Richard is invited to attend a scientific symposium in
Japan. Each of the US attendees is asked to learn a little
Japanese. Richard takes lessons, persists, can converse
effectively, but stops when he
finds the cultural parts of the language conflict with his
individualism.
Richard was unhappy with his achievements in physics. He
felt: slower than his peers, not keeping up or understanding the
latest details, fearful that
he could not cope; as the community
worked to understand the laws of beta decay. But
Martin Block pushed him to question the troubling parity
premise. Encouraged by Oppenheimer the community focused
on parity and failures were discovered in a cascade of
reports. Richard attended a meeting where Lee & Yang
discussed a failure and a theory to explain it. Richard
felt terrified and could not understand what they said.
His sister pushed him to change his attitude: act like a student
having fun, read every
line and equation of their paper; he would understand it.
And he did, as well as developing additional insights about what
was happening and what still seemed conflicted. He
reported his ideas back to the community. After Richard
returned from Brazil he reviewed the confusion of facts with
Caltech's experimental physicists who made him aware of
Gell-mann abandoning another former premise of Beta decay.
Feynman realized his ideas were consistent: fully and simply
describing the details of beta decay. He had identified
the workings of a fundamental law. Years later he was awarded the Nobel
prize for physics. He was conflicted about the prize
and attending the ceremony, but eventually enjoyed the trip,
where he discussed cultural achievement with the Japanese
ambassador.
Richard was interested in the operation of the brain, modeling
it on a digital computer. He explored hallucinations and the reality of
experiences.
Richard lobbies for integrity
in science.
In aspects of his life that weren't focused directly on science,
Richard was quirky. He would tease those who asked for his
help: pushing bargains to their logical conclusion; insisting on everyone keeping to
their part of the agreement. And he paid no attention to the
logistical details of planning. He loved percussion,
playing: drums, bongos, baskets, tables, Frigideira; and became quite a success. He
eventually discovered art could be
fun, and tried to express his joy at the underlying
mathematical beauty of the physical world. He had a great
art teacher. But he discovered although he could
eventually draw well he did not understand art.
Many of the artists he met were fakers, and even the powerful,
who were interested in integrating art and science, did not
understand either subject. He found the situation was
similar in other complex adaptive systems: philosophy, religion and
economics; which he dabbled in for a while but found the
strategies of other people practicing the study of such subjects
made him angry and
disturbed, so he avoided participating in them. It seemed
ironic that he was eventually asked to help in bringing
culture to the physicists!
He discusses issues in teaching creative physics in Brazil. He gets
involved in the California public school text
book selection process which he concluded was totally
broken, but also reveals how his father
provided him with a vision of how our world works,
inspiring his interest in experimentation and physical
theory.
Following our summary of his main points, RSS reviews how his personality, family and cultural history supported
his creative development from the perspective of complex
adaptive system (CAS) theory.
Richard draws |
Desmond & Moore paint a picture of Charles Darwin's life,
expanded from his own highlights:
- His naughty
childhood,
- Wasted
schooldays,
- Apprenticeship with Grant,
- His extramural
activities at Cambridge, walks with Henslow,
life with FitzRoy on the
Beagle,
- His growing
love for science,
- London: geology, journal and Lyell.
- Moving from
Gower Street to Down and writing Origin and other
books.
- He reviewed his position on
religion: the long
dispute with Emma, his
slow collapse of belief
- damnation for unbelievers like his father and brother, inward conviction
being evolved and unreliable, regretting he had ignored his father's
advice; while describing Emma's side of the
argument. He felt happy with his decision to dedicate
his life to science. He closed by asserting after Self &
Cross-fertilization his strength will be
exhausted.
Following our summary of their main points, RSS frames the details from the
perspective of complex adaptive system (CAS) theory. Darwin placed
evolution within a CAS framework, and built a network of supporters whose
complementary skills helped drive the innovation.
Darwin emerges |
Richard Dawkin's explores how nature has created implementations
of designs, without any need for planning or design, through the
accumulation of small advantageous changes.
Accumulating small changes |
Russ Abbott explores the impact on science of epiphenomena and
the emergence of agents.
Autonomous emergence |
Terrence Deacon explores how constraints on dynamic flows can
induce emergent phenomena
which can do real work. He shows how these phenomena are
sustained. The mechanism enables
the development of Darwinian competition.
Constraint based phenomena |
|
|
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 is the economic realization of invention and combinatorial exaptation. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy. 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 structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Globalization connects disparate environments in a network. At the edges,
humans are drastically altering the biosphere. That
is reducing the proximate natural environment's
connectedness, and leaving its end-nodes disconnected and
far less diverse. This disconnects predators from
their prey, often resulting in local booms and busts that
transform the local parasite
network and their reservoir and amplifier
hosts. The situation is setup so that man is
introduced to spillover
from the local parasites' hosts. Occasionally, but
increasingly, the spillover results in humanity becoming
broadly infected. The evolved
specialization of the immune system
to the proximate environment during development
becomes undermined as the environment transforms.
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
health
care. It supports Geisinger's innovative is the economic realization of invention and combinatorial exaptation. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy. approach to
providing health care. They illustrate this with examples
from:
- Acute care where they first developed ProvenCare,
so as to ensure standardization on quality, cost-efficient
care, resulting in the right care at the right time while
treating everyone as though they were family.
- The 10 ProvenCare acute and chronic services where
successful value reengineering means a flat fee is used,
providing a warranty to cover complications 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.
for
90 days:
- Anticoagulation
therapy management service illustrating community
based integrated coordinated
care aims to transfer information between the patient and each care participant as required and establish accountability by defining who is responsible for each care delivery activity, the extent of that responsibility and when that responsibility will be transferred to other care participants or the patient and family. Successful care coordination requires face-to-face interactions. It also requires aligned incentives (ACO, Bundled payments). AHRQ defines quality measures for care coordination. The situation is usually complex and adaptive due to the interactions of all the providers, settings, the patients' preferences, and the number of physical health problems, treatments, and the patients' social situation. The potentially exponential increase in complexity as the number of these factors present increases leads to patient hot spots requiring explicit proactive coordination of care. It is argued that care coordination must include six specific activities:
- Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history. It needs to be updated periodically and after new diagnosis and other changes in health or functional status.
- Creation and updating of proactive plan of care
- Communication
- Facilitation of transitions: typical transition problems are detailed by Project Boost. A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff.
- Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness.
- Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.
by a distributed team, with specialists at the
central
medical center's central radiology &
anticoagulation clinic, supported by EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
. Patients are
rapidly diagnosed and treated in the community where they
live, some even with deep
vein is deep vein thrombosis. After major peripheral joint surgery DVTs may form in the legs and then fragment inducing PEs in the lungs. clots or coagulation is formation of a clot: - Platlets become activated, adhere and aggregate supported by
- Fibrin polymerization, deposition and maturation.
in their legs, successfully returning home from the local
clinic within hours, to be closely monitored by a health navigator is: - A nurse case manager (TCN) at Geisinger focused on the patient's transition of care from the health system to their home or nursing home.
- An advisor who helps people obtain insurance on the ACA individual exchanges.
and local 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. .
- 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
process transformation resulting in a:
- 67% decrease in mortality,
- 4.8% decrease in cost per case,
- 17.6% increase in contribution margin
- ProvenCare Perinatal:
- ProvenCare Knee:
- Decrease in average acute plus rehabilitation time
from 16 to 9.9 days
Steele & Feinberg attribute Geisinger's growth and
reengineering success to providing better care at lower cost,
enabled by:
- A system wide culture is how we do and think about things, transmitted by non-genetic means as defined by Frans de Waal. CAS theory views cultures as operating via memetic schemata evolved by memetic operators to support a cultural superorganism. Evolutionary psychology asserts that human culture reflects adaptations generated while hunting and gathering. Dehaene views culture as essentially human, shaped by exaptations and reading, transmitted with support of the neuronal workspace and stabilized by neuronal recycling. Damasio notes prokaryotes and social insects have developed cultural social behaviors. Sapolsky argues that parents must show children how to transform their genetically derived capabilities into a culturally effective toolset. He is interested in the broad differences across cultures of: Life expectancy, GDP, Death in childbirth, Violence, Chronic bullying, Gender equality, Happiness, Response to cheating, Individualist or collectivist, Enforcing honor, Approach to hierarchy; illustrating how different a person's life will be depending on the culture where they are raised. Culture:
- Is deployed during pregnancy & childhood, with parental mediation. Nutrients, immune messages and hormones all affect the prenatal brain. Hormones: Testosterone with anti-Mullerian hormone masculinizes the brain by entering target cells and after conversion to estrogen binding to intracellular estrogen receptors; have organizational effects producing lifelong changes. Parenting style typically produces adults who adopt the same approach. And mothering style can alter gene regulation in the fetus in ways that transfer epigenetically to future generations! PMS symptoms vary by culture.
- Is also significantly transmitted to children by their peers during play. So parents try to control their children's peer group.
- Is transmitted to children by their neighborhoods, tribes, nations etc.
- Influences the parenting style that is considered appropriate.
- Can transform dominance into honor. There are ecological correlates of adopting honor cultures. Parents in honor cultures are typically authoritarian.
- Is strongly adapted across a meta-ethnic frontier according to Turchin.
- Across Europe was shaped by the Carolingian empire.
- Can provide varying levels of support for innovation. Damasio suggests culture is influenced by feelings:
- As motives for intellectual creation: prompting
detection and diagnosis of homeostatic
deficiencies, identifying
desirable states worthy of creative effort.
- As monitors of the success and failure of cultural
instruments and practices
- As participants in the negotiation of adjustments
required by the cultural process over time
- Produces consciousness according to Dennet.
of innovation and early adoption of best practices:
- From its beginning it employed its physicians building a
group practice and interdisciplinary approach, and strived
to minimize its costs and prices.
- The trustees agreed with CEO Henry Hood that Geisinger's
board chair would be selected by the board ensuring rapid
forward action.
- Regional expansion, including a rural trauma center,
ensured patient access to Geisinger doctors within 30
minutes from their home. And
- A for profit management corporation helped Geisinger
advise other hospitals
on administration and management.
- Transformative
use of EHR, through a partnership with Epic
deploying it in 1995 for ambulatory
care at 78 sites in 42 counties. Later the two
inpatient hospitals were included and Geisinger now work
with Epic and Cerner.
Geisinger see the EHR as a stabilizer which enabled the productivity is the efficiency with which an agent's selected strategy converts the inputs to an action into the resulting outputs. It is a complex capability of agents. It will depend on the agent having: time, motivation, focus, appropriate skills; the coherence of the participating collaborators, and a beneficial environment including the contribution of: standardization of inputs and outputs, infrastructure and evolutionary amplifiers.
improvements and innovation is the economic realization of invention and combinatorial exaptation. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy.
activities:
- Its histories, test results, and physician notes are
critical success factors for ProvenCare, helping
clinicians interact appropriately with
patients.
- Its best practice reminders ensure standardization of
effective care.
- The patient portal improves patient access to physicians
and information, enhancing their understanding and
participation.
- Stable, loyal patient population which Geisinger leverages
to understand generational effects, build participation and
trust and develop long term care strategies. Primary
care is deployed at 50-plus community sites.
- Accepting and recovering from failure:
- Discipline-based physician care designed around how the
doctors wanted to deliver care was replaced by 28
cross-disciplinary 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.
delivering care how patients and their
families wanted care delivered.
- Accept the
failure of the 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);
merger
and develop a new vision of population based care with
payment for value.
- Building an innovation is the economic realization of invention and combinatorial exaptation. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy.
model that would plan for and fund a 15 to 20% failure
rate. It is dependent on operational recovery &
sustainability that maintain Geisinger's fiduciary
responsibilities.
- Vertically integrated health
insurance operation focused on end-to-end outcomes
that enabled ProvenCare. The cost savings from the
lower cost better care for: diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections.
, 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. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). Treatments include: digoxin; , COPD is chronic obstructive pulmonary disease. It is one of the most common lung diseases. Chronic bronchitis and emphysema are the major forms. ; flowed through a
quality fund back to the insurance company from where the
savings were transferred through to the primary care and
specialist providers who were providing higher value
care.
Steele & Feinberg were looking for better lives for patients
in their care:
- ProvenCare chronic
has treated 30,000 type 2 diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include:
- Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
patients, preventing: 306 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.
, 141
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). , and 166 cases
of retinopathy.
- Refunding all or part of the copay is a fixed payment for a covered service after any deductible has been met. It is a key strategy of the ACA to make subscribers aware of the costs of treatment and to put pressure on high cost health services. As such suppliers and providers are keen to undermine the copayment: value based health insurance, Paying the copayment (Oct 2015), Place on the USPSTF list of preventative services (Sep 2016);
for spine and
bariatric surgery, if patients were dissatisfied with 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. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community. 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. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). 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 episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult;; 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:
- The majority of providers were structured to impede
adoption of best practice and evidence based care, often
providing care that did not benefit patients, and were
rewarded when patients experienced complications needing
more care.
- Insurers through consolidation were becoming more
powerful, benefiting from decreasing payments to providers
per unit of work. Why change from FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment. which was working for
them?
- Geisinger was amongst a handful of 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.
providers. It was
questioned whether this model of health care could scale
& be generalized.
- The ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
transformed
health insurance coverage, but did not solve the core issues
regarding care provision and financing.
In the post-ACA health care environment Steele & Feinberg
argue the needed transformation must include:
- Affordable health insurance coverage for all
- A shift over to FFV from FFS
- Best practice, coordinated care aims to transfer information between the patient and each care participant as required and establish accountability by defining who is responsible for each care delivery activity, the extent of that responsibility and when that responsibility will be transferred to other care participants or the patient and family. Successful care coordination requires face-to-face interactions. It also requires aligned incentives (ACO, Bundled payments). AHRQ defines quality measures for care coordination. The situation is usually complex and adaptive due to the interactions of all the providers, settings, the patients' preferences, and the number of physical health problems, treatments, and the patients' social situation. The potentially exponential increase in complexity as the number of these factors present increases leads to patient hot spots requiring explicit proactive coordination of care. It is argued that care coordination must include six specific activities:
- Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history. It needs to be updated periodically and after new diagnosis and other changes in health or functional status.
- Creation and updating of proactive plan of care
- Communication
- Facilitation of transitions: typical transition problems are detailed by Project Boost. A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff.
- Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness.
- Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.
.
- Continuous innovation is the economic realization of invention and combinatorial exaptation. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy.
- Empowered patients and families
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 is a human SuperOrganism complex adaptive system (CAS) which operates and controls trade flows within a rich niche. Economics models economies. Robert Gordon has described the evolution of the American economy. Like other CAS, economic flows are maintained far from equilibrium by: demand, financial flows and constraints, supply infrastructure constraints, political and military constraints; ensuring wealth, legislative control, legal contracts and power have significant leverage through evolved amplifiers. ,
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. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy. .
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 include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
:
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 is the economic realization of invention and combinatorial exaptation. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy. , 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. Damasio notes prokaryotes and social insects have developed cultural social behaviors. Sapolsky argues that parents must show children how to transform their genetically derived capabilities into a culturally effective toolset. He is interested in the broad differences across cultures of: Life expectancy, GDP, Death in childbirth, Violence, Chronic bullying, Gender equality, Happiness, Response to cheating, Individualist or collectivist, Enforcing honor, Approach to hierarchy; illustrating how different a person's life will be depending on the culture where they are raised. Culture: - Is deployed during pregnancy & childhood, with parental mediation. Nutrients, immune messages and hormones all affect the prenatal brain. Hormones: Testosterone with anti-Mullerian hormone masculinizes the brain by entering target cells and after conversion to estrogen binding to intracellular estrogen receptors; have organizational effects producing lifelong changes. Parenting style typically produces adults who adopt the same approach. And mothering style can alter gene regulation in the fetus in ways that transfer epigenetically to future generations! PMS symptoms vary by culture.
- Is also significantly transmitted to children by their peers during play. So parents try to control their children's peer group.
- Is transmitted to children by their neighborhoods, tribes, nations etc.
- Influences the parenting style that is considered appropriate.
- Can transform dominance into honor. There are ecological correlates of adopting honor cultures. Parents in honor cultures are typically authoritarian.
- Is strongly adapted across a meta-ethnic frontier according to Turchin.
- Across Europe was shaped by the Carolingian empire.
- Can provide varying levels of support for innovation. Damasio suggests culture is influenced by feelings:
- As motives for intellectual creation: prompting
detection and diagnosis of homeostatic
deficiencies, identifying
desirable states worthy of creative effort.
- As monitors of the success and failure of cultural
instruments and practices
- As participants in the negotiation of adjustments
required by the cultural process over time
- Produces consciousness according to Dennet.
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.
- 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.
'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. The MA plans offer a PCP who coordinates care. And the plans have an annual limit on out-of-pocket expenses unlike traditional Medicare. When they obtain treatment they will have to pay a copayment which may be quite high for some specialists. It is the health plan's responsibility to contract the physician network that will provide the care, leaving the risk with the insurer. About 36% of Medicare beneficiaries are enrolled with Medicare Advantage by 2019. The ACA introduced quality outcome and patient satisfaction based differential payments into MA. To measure the performance it added a five-star quality rating scheme. MA plans report their quality and patient satisfaction data to CMS annually and based on the results are awarded one to five stars. The highest rated plans are provided with large additional payments. It was assumed that subscribers would shift to the highest rated plans and the other plans would improve or drop out of MA. And the ACA eliminated subsidies which the federal government used to establish Medicare Advantage. However, the Obama administration has used a $8.5 Billion demonstration project to maintain this funding. It is intended that it will eventually taper off so that the cost of Medicare Advantage coverage will be equivalent to standard Medicare.
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. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy. 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 is the economic realization of invention and combinatorial exaptation. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy. ,
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 is the owner of a set of hospitals and other owned infrastructure and employer of direct staff. '
executives, about the wider applicability of Geisinger's
strategies:
- Merger & acquisitions to drop the integrated payer
provider business model into other hospital systems:
- Wilkes-Barre/Scranton
- Harrisburg, Pennsylvania
- Atlantic
City, New Jersey
- Expand insurance operations:
- Beyond Pennsylvania
- With non-Geisinger providers
- 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. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy.
and well run.
The strategy
for achieving success in reengineering clinical practice was:
- Eliminating unjustified or ambiguous indications of
treatment: test duplications, long stays, admissions &
readmissions. And then
- Applying identified evidence-based or consensus-based best
practice recommendations to identify and minimize
unjustified variation in each component of care. At
that time this was only available for cardiology and
cardiothoracic surgery. Geisinger's initial success
encouraged other disciplines: orthopedics is the treatment of the musculoskeletal system which supports multi-cell higher animals and allows them to move about: including correcting deformities, breaks, tears, compression, tendonitis, disc failures, misalignment, fusion to treat damaged discs.
(HfSS);
to build similar processes and registries. Together
these two bullet items removed unnecessary or hurtful units
of work.
- Learning from failures:
- Autism is a major hereditary mental disorder that starts before age three when it features: a strong preference to be alone, a desire for things to stay the same, and areas of creative ability - they see the ordinary as beautiful and have special talents for: poetry, foreign languages, music, art, and calculations. They generate less but more original ideas. It occurs as a spectrum of symptoms, from mild to severe, across the population of sufferers (ASD). Before age two the circumference of an autistic child's head is larger than typical and regions: amygdala, frontal lobe; develop prematurely, altering activity in other regions. Autism highlights aspects of the brain's specialized regions and processes for interacting with other people. Autistic's interests are restricted. They struggle with social interactions & verbal and nonverbal communications. Autistics do not attribute minds to other people: attributing mental states to others allows us to predict their behavior; a critical skill for social learning and interaction. While their visual area MT detects motion, the superior temporal sulcus does not respond to biological motion in autistics, undermining the understanding of intention. And they gaze at mouths rather than eyes when looking at faces. The default mode network is disrupted. Autistic adolescents have unusually large numbers of synapses, because of a failure of synaptic pruning. Autistics almost never pretend. They can't explain the difference between an instance of an object and a memory of it. Mild autism still maintains some pressure to conform socially and often results in depression and anxiety. Autism occurs in every country and social class. It lasts a lifetime. It has genetic and neurological causes. Identical twins are 90% likely to both have autism if one of them does. With 50% of genes active in the brain, mutations are likely to impact the development and operation of the brain. The genes: SHANK3, CDH10; are involved but account for a very small percentage of the risk. Facial gaze studies indicate a high genetic influence and an opportunity to identify more genes associated with autism (Jul 2017). Copy number variations: an extra copy of a segment of 25 genes of chromosome 7 increases the risk of ASD, while deletion of the segment causes Williams syndrome; and de novo mutations which drive up the number of autism cases as paternal age has increased in the US. ASD is associated with a reduced fusiform face area response. Tests [in development] for autism include: SynapDx's blood test.
care
reengineering aimed to ameliorate the year-and-a-half wait
time for an appointment by providing a remote application
to capture information earlier. But the clinical
leaders weren't involved and did not accept the redesign.
- Cataract surgery reengineering did not alter the near
perfect outcomes achieved prior to the
redesign.
- Leverage the structure, culture, payer/provider overlap in
deriving benefits for the patients and
subscribers.
- Utilize the reduced
waste: fewer complications, less test duplications,
shorter lengths of stay; 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.
for
chronic ambulatory care; less 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). , 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.
, eye are major sensors in primates, based on opsins deployed in the retina & especially fovea, signalling the visual system: Superior colliculi, Thalamus (LGN), Primary visual cortex; and indirectly the amygdala. They also signal [social] emotional state to other people. And they have implicit censorious power with pictures of eyes encouraging people within their view to act more honorably. Eyes are poor scanners and use a saccade to present detail slowly to the fovea. The eye's optical structures and retina are supported by RPE. Eyes do not connect to the brain through the brain stem and so still operate in locked-in syndrome. Evo-devo shows eyes have deep homology. High pressure within the eye can result in glaucoma. Genetic inheritance can result in retinoblastoma. Age is associated with AMD. and kidney disease is chronic kidney disease - Where there is permanent damage to the Kidneys. Diabetes and high blood pressure are the leading causes of CKD. This has driven up the percentage of American's suffering from CKD.
- CKD is diagnosed via a GFR of less than 60, or another marker such as protein in the urine, for atleast three months.
- The disease, classed as having five stages, causes no symptoms until the later stages. The fifth stage of CKD is ESRD. CKD is associated with: Atherosclerosis, Cardiovascular disease, Iron deficiency anemia from reduced EPO synthesis, Fluid volume overload, Hyperphosphatemia, Hypertension, Metabolic acidosis, Mineral bone disorder, Potassium accumulation, & Urea accumulation.
for diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
sufferers; to support a
more effective compensation
plan. Steele & Feinberg note that the
benefits to the patients were even more influential
enhancing professional pride.
- Undermining criticisms of reengineering: Cookbook
medicine, Discovery is undermining best practice; by
allowing exceptions whenever they could be justified and had
been broadly socialized.
- Insisted that strategic activities had the potential to create national
excitement. Academic and press reviews generated
significant momentum. Other providers came to visit
and understand the process. Subsequent evidence of
scalability and generalizability from non-Geisinger markets
was highlighted by Geisinger.
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 patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
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 is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
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. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births.
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:
- Capture the
heart in Buckner's fMRI based analysis, supports using past experiences to plan for the future, navigate social interactions and maximize the utility of moments when attention is not focused on external events. It includes the: Medial prefrontal cortex, Medial temporal cortex, Posterior cingulate cortex. It is disrupted in autism, schizophrenia, Alzheimer's disease. It becomes quiet under the influence of psychedelics that bind to the serotonin receptor. , then the
head, with improved results of reengineered patient
care, and then capture their wallet with the redesigned
compensation.
- Leverage the external
reputation to hire great clinical leaders into the
remaining problematic critical positions, where they can
help champion the reengineering.
- Build an effective service line care reengineering
leadership team, from a team capable clinical leader, along
with a financial and operational partner.
- Push back on operationally
induced chaos with the creation of Geisinger
Innovations, which can provide the operational care
teams with strategic focus and analysis in identifying
reengineering opportunities for them to leverage.
- Additionally control cost creep with the creation of Geisinger
Transformation.
- Maintain strategic focus, by hiring a strategy
and strategic program development EVP, who with the
chief of innovation, head of Geisinger Innovations, built an
innovation engine analogous to
A government sanctioned monopoly
supported the construction of a superorganism
American Telephone and
Telegraph
(AT&T). Within this Bell Labs was at the center of
three networks:
- The evolving global scientific
network.
- The Bell telephone network. And
- The military
industrial network deploying 'fire and missile
control' systems.
Bell Labs strategically leveraged each network to create an innovation
engine.
They monitored the opportunities to leverage the developing
ideas, reorganizing to replace incumbent
opposition and enable the creation and growth of new
ideas.
Once the monopoly was
dismantled, AT&T disrupted.
Complex adaptive system (CAS) models of the innovation mechanisms are
discussed.
AT&T's
Bell Labs & Lockheed Martin's Skunk Works.
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:
- Sustained leadership commited to the reengineering goals
was required. If these champions left, former 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. hospitals would
revert.
- When a partner CFO is chief financial officer
experienced a volume decrease due to better care for chronic
cases, they would push up unit prices.
- System leaders would abandon the partnership with
Geisinger, when their leading payer include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
pressed them by
threatening their FFS 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.
.
- Geisinger's costly reengineering infrastructure did not
need to be recreated in the partner's markets.
And Geisinger struggled to convince leaders of other hospital systems is the owner of a set of hospitals and other owned infrastructure and employer of direct staff. ,
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 patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
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:
- Asking about determinants of good outcome: Antibiotic are compounds which kill bacteria, molds, etc. Sulfur dye stuffs were found to be effective antibiotics. The first evolved antibiotic discovered was penicillin. Antibiotics are central to modern health care supporting the processes of: Surgery, Wound management, Infection control; which makes the development of antibiotic resistance worrying. Antibiotics are:
- Economically problematic to develop and sell.
- Congress enacted GAIN to encourage development of new antibiotics. But it has not developed any market-entry award scheme, which seems necessary to encourage new antibiotic R&D.
- Medicare has required hospitals and SNFs to execute plans to ensure correct use of antibiotics & prevent the spread of drug-resistant infections.
- C.D.C. is acting to stop the spread of resistant infections and reduce unnecessary use of antibiotics.
- F.D.A. has simplified approval standards. It is working with industry to limit use of antibiotics in livestock.
- BARDA is promoting public-private partnerships to support promising research.
- Impacting the microbiome of the recipient. Stool banking is a solution (Sloan-Kettering stool banking).
- Associated with obesity, although evidence suggests childhood obesity relates to the infections not the antibiotic treatments (Nov 2016).
- Monitored globally by W.H.O.
- Regulated in the US by the F.D.A. who promote voluntary labeling by industry to discourage livestock fattening (Dec 2013).
- Customer demands have more effect - Perdue shifts to no antibiotics in premier chickens (Aug 2015).
protocol, Blood-clot or coagulation is formation of a clot: - Platlets become activated, adhere and aggregate supported by
- Fibrin polymerization, deposition and maturation.
prevention protocol; at the key site of care: Recovery room
for inpatient interventions; to get an indication of
standardization across care teams. If it varies by
surgeon, Steele & Feinberg assert, there is: No
consensus on best practice, Seat of the pants care
giving.
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:
- Documenting the appropriateness of care
- Establishing all key elements of EBM or consensus-based
best practices
- Socializing and making routine the complex clinical
systems that embed default best practices into new provider
behaviors for everyday patient flow
- Activating patients and families so they are fully engaged
in the care process redesign and implementation
- 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 include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
or
actual buyer
- 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 (Sep 2018) to allow the value delivery system to optimize around low cost high quality long term health care. With one bundled payment physicians & hospitals must coordinate care and reduce the unit costs to remain profitable. And to avoid taking on risk of expensive complications physicians & hospitals are incented to standardize and focus on quality. This optimization is dependent on quantifying the value of the outcome of the episode of care. Previously FFS payments induced excessive treatment activity. Bundled payment is included in CMS ACE demonstrations and BPCI initiatives. There are significant impacts on IT. - It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.
- Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments.
- Care delivery must be re-architected to reduce costs and improve quality.
- Monitoring sensors can be used to feed reports to ensure re-architected operations conform.
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 include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
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. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy.
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:
- High-volume hip surgery; into the reengineering activity:
ProvenCare Hip, ProvenCare Fragile Hip. Common aspects
recur: eliminating waste, automating as much work as
possible, focusing physicians on patient care by delegating
other work to non-physicians, incorporating new work flows,
represented in the EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses:
- The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
/bolt
on This page reviews the strategy of setting up an arms race. At its
core this strategy depends on being able to alter, or take
advantage of an alteration in, the genome
or equivalent. The situation is illustrated with examples
from biology, high tech and politics.
evolved amplifier. For
hip surgery the challenges were different:
- Breaking incentives that encourage use of particular
devices,
- Less robust consensus best practices,
- No national registries of success metrics; requiring
more committed clinical and administrative
leadership. Once again the reengineering generated
improved cost outcomes and quality for the patients.
- 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.
offered the opportunity to standardize a national regime
with huge variation and noncompliance with staging and
preoperative requirements. The Commission
on Cancer Collaborative supported pilots of ProvenCare
Lung Cancer with 2,000 patients. The reengineering
initially identified 38 standardized elements. Results
indicated compliance went from 40% to 90%. Steele
& Feinberg stress this shows reengineering:
- Going far beyond a single institution.
- Driven by professional pride of purpose and clinical
leadership
- Does not depend on integration of the payer and provider
operations.
- Autism is a major hereditary mental disorder that starts before age three when it features: a strong preference to be alone, a desire for things to stay the same, and areas of creative ability - they see the ordinary as beautiful and have special talents for: poetry, foreign languages, music, art, and calculations. They generate less but more original ideas. It occurs as a spectrum of symptoms, from mild to severe, across the population of sufferers (ASD). Before age two the circumference of an autistic child's head is larger than typical and regions: amygdala, frontal lobe; develop prematurely, altering activity in other regions. Autism highlights aspects of the brain's specialized regions and processes for interacting with other people. Autistic's interests are restricted. They struggle with social interactions & verbal and nonverbal communications. Autistics do not attribute minds to other people: attributing mental states to others allows us to predict their behavior; a critical skill for social learning and interaction. While their visual area MT detects motion, the superior temporal sulcus does not respond to biological motion in autistics, undermining the understanding of intention. And they gaze at mouths rather than eyes when looking at faces. The default mode network is disrupted. Autistic adolescents have unusually large numbers of synapses, because of a failure of synaptic pruning. Autistics almost never pretend. They can't explain the difference between an instance of an object and a memory of it. Mild autism still maintains some pressure to conform socially and often results in depression and anxiety. Autism occurs in every country and social class. It lasts a lifetime. It has genetic and neurological causes. Identical twins are 90% likely to both have autism if one of them does. With 50% of genes active in the brain, mutations are likely to impact the development and operation of the brain. The genes: SHANK3, CDH10; are involved but account for a very small percentage of the risk. Facial gaze studies indicate a high genetic influence and an opportunity to identify more genes associated with autism (Jul 2017). Copy number variations: an extra copy of a segment of 25 genes of chromosome 7 increases the risk of ASD, while deletion of the segment causes Williams syndrome; and de novo mutations which drive up the number of autism cases as paternal age has increased in the US. ASD is associated with a reduced fusiform face area response. Tests [in development] for autism include: SynapDx's blood test.
, Bariatric
surgery, Cellulitis, COPD is chronic obstructive pulmonary disease. It is one of the most common lung diseases. Chronic bronchitis and emphysema are the major forms. ,
CNS Mets, Epilepsy, Heart
Failure 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. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). Treatments include: digoxin; , Hepatitis
C is a virus which destroys the liver during infection. In 2016 it affects 185 million people worldwide. Once the virus genome was sequenced in 1989 Dr. Bartenschlager and Dr. Rice worked to replicate the virus in the laboratory. Rice realized the genome sequence was missing details that stopped the lab replication. Bartenschlager was then successful at replicating the virus in cells in his laboratory. The replication technique allowed Pharmasset's Dr. Sofia to develop a new hepatitis C drug, by enhancing an RNA-polymerase inhibitor with a coat that allowed the drug to enter the liver, where the coat was destroyed and the polymerase inhibitor was activated. With high concentrations of the drug, sofosbuvir, in the liver it could eradicate the hepatitis C virus. Sovaldi was the first sofosbuvir approved by the F.D.A. , Hysterectomy, Inflammatory
Bowel is inflammatory bowel disease, which is a chronic inflammation of part of the digestive tract. It includes Crohn's disease and Ulcerative colitis. Johns Hopkins's Bayless noted it differs from irritable bowel syndrome - they require different treatments. Symptoms include: Severe diarrhea, Pain, Fatigue & weight loss. It typically begins in the teens or twenties. Incidence has increased exponentially since 1945 in developed countries. 160 genes have been associated with IBD. These genes all relate to: Producing mucus, solidifying the lining of the gut, or regulating the immune system. The rapid increase in the incidence of IBD can be explained by societal impacts on the gut microbiome which interacts with these genes and their products. No particular culprit has been found. It is probably an ecological shift away from symbiosis. There is a shift from fibre-fermenters: Faecalibaterium prausnitzii, Bacteroides fragilis; to: Fusobacterium nucleatum, Escherichia coli; which are more inflammatory. The trigger for disease appears complex: Less early infections with tapeworms, bacteria & viruses, Smaller families - which are typically cleaner, More urban environments - resulting in less contact with higher animals, Less pets, Antibiotics, Endocrine disrupters, Caeserean births, Formula fed babies - rather than breast milk; all potentially contributing to the altered setup and operation of the immune system and microbiome. , Lumbar Spine, Migraine, Multiple Sclerosis is multiple sclerosis. ,
Percutaneous Coronary Intervention, Perinatal, Psoriasis,
Rectal Cancer, Rheumatoid
Arthritis is an autoimmune disorder where the immune system attacks the joints and can generate inflammation around the lungs and heart. It can be treated with: Enbrel, Humira, Ilaris, Xeljanz; , and Total Knee.
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 include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
.
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. It is a risk factor for Alzheimer's disease. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
.
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. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). 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
Carlo Rovelli resolves the paradox of time.
Rovelli initially explains that low level physics does not
include time:
- A present that is common throughout the universe does not exist
- Events are only partially ordered. The present is
localized
- The difference between past and future is not foundational.
It occurs because of state that through our blurring appears
particular to us
- Time passes at different speeds dependent on where we are and how fast we travel
- Time's rhythms are due to
the gravitational field
- Our quantized physics shows neither
space nor time, just processes transforming physical
variables.
- Fundamentally there is no time. The basic equations
evolve together with events, not things
Then he
explains how in a physical world without time its perception can
emerge:
- Our familiar time emerges
- Our interaction with the world is partial, blurred,
quantum indeterminate
- The ignorance determines the existence of thermal time
and entropy that quantifies our uncertainty
- Directionality of time is real
but perspectival. The entropy of the world in
relation to us increases with our thermal time. The
growth of entropy distinguishes past from future: resulting in
traces and memories
- Each human is a
unified being because: we reflect the world, we
formed an image of a unified entity by
interacting with our kind, and because of the perspective
of memory
- The variable time: is one
of the variables of the gravitational field.
With our scale we don't
register quantum fluctuations, making space-time
appear determined. At our speed we don't perceive
differences in time of different clocks, so we experience
a single time: universal, uniform, ordered; which is
helpful to our decisions
time. 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. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community. 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. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). 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:
- Nurse care managers monitor CHF patients'
Bluetooth-enabled bathroom scales, understanding the
significance of any fluctuation from goal weight. And
responding with a call to the patient, as necessary.
They also facilitated smooth data flow between the provider
and payer.
- Patients are grouped by payer data, to ensure focus by the
nurse care manager on the sickest.
- Populations of patients, & insurance plan members,
were identified,
segmented and risk-stratified in "near" real-time aims to segment a patient population by treatment acuity and patient derived impact to raise outcomes efficiently without being rejected like the early HMOs. Small numbers of patients follow life styles which impact themselves and the health care network very significantly. Specialized treatment regimens focused on these high impact patients can improve outcomes and lower costs for these patients and the rest of the geographic patient cluster and the health care network. Population health includes techniques for understanding the health characteristics of a patient population by leveraging analytics, business intelligence etc. so as to determine the patient population's health trends.
based on past utilization. This allowed:
- The shortage of PCPs demanded a reengineering of the
primary care process into a medical
neighborhood 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. . Former responsibilities of the PCP
were:
- Optimized. Best practices were adopted and
systematized through the EHR.
- Distributed to appropriate specialists integrated into
the care team. Team members resolved many issues with a
phone call to a participating hospital specialist.
- Eliminated with reworked workflows to reflect the
easiest path.
- Distributed to patients and their families with support
from all-or-none 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.
bundling.
- Integrated across the health care continuum: ambulatory
care, PAC
providers is a Post-Acute Care provider. A three-day hospital admission and discharge are prerequisite requirements to receiving Medicare PAC services. Acute care hospitals become portals to the PAC business. Referrals are key. PAC includes different types of facility focused on different severity of illness (high to low):
- Long term care Hospital (LTCH),
- Inpatient rehabilitation facility (IRF),
- Skilled nursing facility (SNF),
- Home health agency (HHA) - most acute care hospitals and EMR providers have strategies for integration with home based care,
- Outpatient rehabilitation. SNF and HHA represent 80% of discharges and expenditures. Assisted living is not part of federal Medicaid, but states often include it through a waiver.
, pharmacy, social services. 24/7
communication was encouraged through to Geisinger
specialists when CHF or diabetes patients in the
neighborhood were in crisis.
Non-PCP care team members also provided the PCPs with more Carlo Rovelli resolves the paradox of time.
Rovelli initially explains that low level physics does not
include time:
- A present that is common throughout the universe does not exist
- Events are only partially ordered. The present is
localized
- The difference between past and future is not foundational.
It occurs because of state that through our blurring appears
particular to us
- Time passes at different speeds dependent on where we are and how fast we travel
- Time's rhythms are due to
the gravitational field
- Our quantized physics shows neither
space nor time, just processes transforming physical
variables.
- Fundamentally there is no time. The basic equations
evolve together with events, not things
Then he
explains how in a physical world without time its perception can
emerge:
- Our familiar time emerges
- Our interaction with the world is partial, blurred,
quantum indeterminate
- The ignorance determines the existence of thermal time
and entropy that quantifies our uncertainty
- Directionality of time is real
but perspectival. The entropy of the world in
relation to us increases with our thermal time. The
growth of entropy distinguishes past from future: resulting in
traces and memories
- Each human is a
unified being because: we reflect the world, we
formed an image of a unified entity by
interacting with our kind, and because of the perspective
of memory
- The variable time: is one
of the variables of the gravitational field.
With our scale we don't
register quantum fluctuations, making space-time
appear determined. At our speed we don't perceive
differences in time of different clocks, so we experience
a single time: universal, uniform, ordered; which is
helpful to our decisions
time 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 patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
'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:
- Building a team structure with supporting infrastructure
to optimize the physicians activities & expand the role
of all care team members.
- Leadership had to reflect payer, hospital, community
practices, 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.
, specialists. And the leaders had to
align around the goal of making things better for
patients. That enables distributed planning, change
management, and accountability.
- Transforming ideas into operation flows required shared
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.
tactical planning 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.
iterative collaboration, up
and down the hierarchy, to identify how a network of
goals could be effectively implemented across the ProvenHealth
network. Each clinical strategy had to be reflected
in the EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
by a
full-time IT optimization team. 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. and practice providers at SNF is skilled nursing facility. s ensured the
strategies would network out to the neighborhood 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. .
- Physicians finally have a clear, shared view of great
care, with: data on who to treat, a managed optimized
schedule, defined outcomes, quality metrics to target.
That replaces the prior paradigm of: Doctor totally
responsible, Paper charts or EHR as a type writer, unmanaged
schedule creating a treadmill of patients, no help with
direction, and no tools to assess quality.
- Leveraging design and technology to make all reengineered
care pathways easier for patient and providers, than prior
workflows.
- Improvements for patients motivate physicians.
- Feedback supports continuous improvement.
- A delta team focuses on support for continued innovation is the economic realization of invention and combinatorial exaptation. Keynes noted it provided the unquantifiable beneficial possibility that limits fear of uncertainty. Innovation operates across all CAS, being supported by genetic and cultural means. Creativity provides the mutation and recombination genetic operators for the cultural process. While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity. This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy.
.
Top managers focus on progress towards the vision.
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. Such biologics partially 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 (MABs), 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:
- EPO is Erythropoietin a glycoprotein hormone that controls red blood cell production. It is available as a biologic, which is used to treat anemia, but Geisinger found during their biologic reengineering that 20% of their chronic renal failure based anemia patients were being inappropriately treated with costly EPO, putting the patients at risk of exacerbated central and peripheral vascular disease, inplace of the appropriate oral iron.
for anemia is a decrease in the number of red blood cells or the amount of hemoglobin in the blood. There are various types: Fanconia anemia, Iron-deficiency anemia, Pernicious anemia, Sickle-cell anemia; - where hurtful
outcomes were avoided by applying stringent, standardized
indications for treatment even before:
- Establishing efficient treatment protocols
- Designating centralized sites for biological treatments,
- Tecfidera for MS is multiple sclerosis.
management algorithms & sub-algorithms - Geisinger have
2,600 MS patients. Biologics have only proved
beneficial for relapsing-remitting types of MS.
Specifying which treatments are appropriate for each patient
is a critical initial step in the best
practice protocols. Steele & Feinberg note
the financial benefits and improved health care of patients
have been significant,
- Harvoni
for hepatitis C is a virus which destroys the liver during infection. In 2016 it affects 185 million people worldwide. Once the virus genome was sequenced in 1989 Dr. Bartenschlager and Dr. Rice worked to replicate the virus in the laboratory. Rice realized the genome sequence was missing details that stopped the lab replication. Bartenschlager was then successful at replicating the virus in cells in his laboratory. The replication technique allowed Pharmasset's Dr. Sofia to develop a new hepatitis C drug, by enhancing an RNA-polymerase inhibitor with a coat that allowed the drug to enter the liver, where the coat was destroyed and the polymerase inhibitor was activated. With high concentrations of the drug, sofosbuvir, in the liver it could eradicate the hepatitis C virus. Sovaldi was the first sofosbuvir approved by the F.D.A.
-
reengineering resulted in better treatment effects and lower
costs, with pharmacists supervising the best practice
transactions, along with 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.
and nurse coordinators,
- Humira
for rheumatoid
arthritis is an autoimmune disorder where the immune system attacks the joints and can generate inflammation around the lungs and heart. It can be treated with: Enbrel, Humira, Ilaris, Xeljanz;
and psoriasis - where 15% of GHP
psoriasis patients were switched to a highly effective and
low cost treatment of daily exposure to UV light that
removed the comorbid long-term impacts of the biologics,
and
- Revlimid
for multiple
myeloma is a cancer of B lymphocytes. The cause is unknown, but alcohol and obesity are risk factors. Abnormal antibodies are generated which cause kidney problems and overly thick blood. If the abnormal lymphocytes form a single mass the diagnosis is plasmacytoma. If there are multiple masses the diagnosis is multple myeloma. Treatments include: Revlimid, Velcade;
- Steele & Feinberg note the This page reviews the strategy of setting up an arms race. At its
core this strategy depends on being able to alter, or take
advantage of an alteration in, the genome
or equivalent. The situation is illustrated with examples
from biology, high tech and politics.
evolved amplifier driving: 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). patients to seek
biologics, even in trials, and pharmaceutical companies to
support them with many biologics developed for: 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), colorectal is also called colon cancer. It:
- Follows a slow, many yearlong, progression from a benign
polyp to a localized cancer to an invasive one. Two
bacteria: Bacteroides fragilis, Escherichia coli variant;
from the gut microbiome have
been implicated in the early stages of tumor induction (Feb
2018). It
- Is often associated with Ras
mutations and the high risk allele TCF7L2.
30 to 50% of colon cancers have KRAS
mutations. Intensive medical surveillance and
removal of polyps can be lifesaving for those at high
risk. Types of colon cancer include the single gene
mutation hereditary: FAP, HNPCC;
- Is linked to obesity.
, lung 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.
, prostate 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
, &
skin cancers; and lymphoma is when lymphocytes continue reproducing, and do not die - a blood cancer. ;
demand for unjustified, costly and potentially harmful
treatments. The situation is chaotic and so Geisinger
has delayed productizing a biologic oncology platform.
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:
- Appointed Greg Burke and Susan Robel as chief patient
experience officers.
- Used a steering committee to develop standards for patient
experience - ABIGAIL is Geisinger's patient experience standards, after founder Abigail Geisinger:
- Accountable
- Befriend
- Inform
- Genuine
- Acknowledge
- Involve
- Listen
.
- Continued the drive when Dr. Feinberg became CEO - he
encouraging the identification of best practices:
- Consistant patient communication via CICARE 'See-I-Care' is a UCLA health acronym (described in Prescription for Excellence) for:
- Connect with the patient or family member using Mr./Ms. or their preffered name.
- Introduce yourself and your role.
- Communicate what you are going to do, how it will affect the patient, and other needed information.
- Ask for and anticipate patient and/or family needs, questions, or concerns.
- Respond to patient and/or family questions and requests with immediacy.
- Exit, courteously explaining what will come next or when you will return.
.
- Transparent quality reporting metrics: Press Ganey
Patient Satisfaction Survey score highlighted.
- Leadership rounding
- A consistent professional appearance - patients
associate clean,
well-pressed white lab coats with
professionalism.
- Nursing best practices including: bedside shift report,
hourly rounding, and white-boards in hospital rooms
- Calls the night before surgery & patient rounding on
demand
- Transition to home care - made less stressful and more
effective for patients and families by focus from health
navigators is:
- A nurse case manager (TCN) at Geisinger focused on the patient's transition of care from the health system to their home or nursing home.
- An advisor who helps people obtain insurance on the ACA individual exchanges.
.
- Same-day appointments with phones answered by humans -
who remind callers of the same-day commitment.
- Notes pushed out to the patients - by Geisinger
codeveloped OpenNotes is a research project, in which 105 doctors shared their notes with more than 19,000 patients in Boston, based at Beth Israel Deconess Medical Center , supported by the Robert Wood Johnson Foundation Pioneer Portfolio. It has been adopted by the VA and Geisinger.
.
- A redesigned, easy to understand bill - that shows what
the patients owe Geisinger.
- Standardized continuous service recovery - by having
every healer trained to notice when a patient has a
problem and ensure its fixed. All these best
practices are to happen every time with every
patient.
- Provides a smartphone app to measure each patient's
experience and offer a refund on part of the copay is a fixed payment for a covered service after any deductible has been met. It is a key strategy of the ACA to make subscribers aware of the costs of treatment and to put pressure on high cost health services. As such suppliers and providers are keen to undermine the copayment: value based health insurance, Paying the copayment (Oct 2015), Place on the USPSTF list of preventative services (Sep 2016);
.
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, enabled by next generation sequencing of DNA, and detailed by the NIH director Francis Collins and includes: - NCCN intensive cell therapies
- Direct to consumer genomic testing
- Direct to consumer diagnostics
- Pharmacogenomics tailored drug treatments reducing the risk and cost of adverse drug reactions.
. But they stress the goal is great healing
based on being the most caring organization anywhere. That
means:
- Taking exceptional care of the communities they serve,
through supporting prevention appropriate for each
community. And providing compassionate indicates an emotional state where resonance with someone else's distress leads one to help them. The Dalai Lama stresses we must feel compassion for ourselves and others. Tara Brach sees compassion as our capacity to relate in a tender and sympathetic way to what we perceive. Meditation focused on feeling love for the suffering, strengthens compassion by activating the neuron networks for parental love for a child: ACC, insula, striatum, PAG, orbitofrontal cortex; and inducing a reduction in areas responsible for negative emotions.
,
kindhearted caring.
- Where possible treat the community at home, at work or in
the classroom, rather than the hospital or clinic.
Travel is just another form of waste.
- Support the family to be effective care givers, with
training where necessary, with improved quality of outcomes
for all.
- Use genomic details combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes. ,
in partnership with Regeneron,
to proactively support people who are at 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 disease.
- Ensuring access to all-in-need even as more people ask for
care because of aging and Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births.
expansion. That includes: Using IT 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.; to ensure each
patient's situation is accurately understood and Geisinger's
response is tailored appropriately, developing buildings
that provide open, social spaces instead of waiting
rooms.
- Ensuring that the cost implications of interacting with
Geisinger are immediately explicit.
- Not performing unnecessary or detrimental procedures and
treatments.
- Removing all unjustified variation in quality, access and
cost. Steele & Feinberg see this as necessitating
a shift from FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment. to FFV is fee-for-value payment. It may be a bundled payment for a set of services provided by a group of doctors and facilities, or full capitation. In each case the risk has shifted from the payer to the providers of care.
.
- More appealing and enjoyable food, and rooms.
- Better relationships with purchasers through partnerships
with the Health
Transformation Alliance and the Pacific Business Group
on Health.
This page introduces the complex adaptive system (CAS) theory
frame. The theory provides an organizing framework that is
used by 'life.' It can be used to evaluate and rank models
that claim to describe our perceived reality. It catalogs
the laws and strategies which underpin the operation of systems
that are based on the interaction of emergent
agents. It highlights the
constraints that shape CAS and so predicts their form. A
proposal that does not conform is wrong.
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 structure and problems of the US
health care network is described in terms of complex adaptive
system (CAS) theory.
The network:
- Is deeply embedded in the US nation state. It reflects the
conflict between two
opposing visions for the US: high tax with safety net
or low tax without. The emergence
of a parasitic elite supported by tax policy, further
constrains the choices available to improve the efficiency
and effectiveness of the network.
- The US is optimized to sell its citizens dangerous
levels of: salt,
sugar, cigarettes,
guns, light, cell phones, opioids,
costly education, global travel,
antibacterials, formula, foods including
endocrine disrupters;
- Accepting the US controlled global supply chain's
offered goods & services results in: debt, chronic stress,
amplified consumption and toxic excess, leading to obesity, addiction, driving instead of
walking, microbiome
collapse;
- Globalization connects disparate environments in a network. At the edges,
humans are drastically altering the biosphere. That
is reducing the proximate natural environment's
connectedness, and leaving its end-nodes disconnected and
far less diverse. This disconnects predators from
their prey, often resulting in local booms and busts that
transform the local parasite
network and their reservoir and amplifier
hosts. The situation is setup so that man is
introduced to spillover
from the local parasites' hosts. Occasionally, but
increasingly, the spillover results in humanity becoming
broadly infected. The evolved
specialization of the immune system
to the proximate environment during development
becomes undermined as the environment transforms.
- Is incented to focus on localized competition generating
massive & costly duplication of services within
physician based health care operations instead of proven
public health strategies. This process drives
increasing research & treatment complexity and promotes hope
for each new technological breakthrough.
- Is amplified by the legislatively structured separation
and indirection of service development,
provision, reimbursement and payment.
- Is impacted by the different political strategies for
managing the increasing
cost of health care for the demographic bulge of retirees.
- Is presented with acute
and chronic
problems to respond to. As currently setup the network
is tuned to handle acute problems. The interactions
with patients tend to be transactional.
- Includes a legislated health insurance infrastructure
which is:
- Costly and inefficient
- Structured around yearly
contracts which undermine long-term health goals and
strategies.
- Is supported by increasingly regulated HCIT
which offers to improve data sharing and quality but has
entrenched commercial EHR
products deep within the hospital systems.
- Is maintained, and kept in
alignment, by massive network
effects across the:
- Hospital platform
based
sub-networks connecting to
- Physician networks
- Health insurance networks - amplified by ACA
narrow network legislation
- Hospital clinical supply and food
production networks
- Medical school and academic research network and NIH
- Global
transportation network
- Public health networks
- Health care IT supply
network
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:
- Geisinger is a major node in the network
- Geisinger must avoid
the
H. A. Hayek compares and contrasts collectivism and
libertarianism.
central planning trap.
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 ways to
limit this risk.
- Geisinger has had considerable success by doing the
product right. But it must also do the right
product. In instantiating its lofty goals it will
intersect, and possibly compete, with 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, reservoir and amplifier hosts, spillover and other 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 that are typically both efficient and
effective.
- The strategic drive
generated by the threat of collapse, induced by the Penn
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);
merger, is also seen
as contributing to the turnaround of Lou Gerstner describes the challenges he faced and the
strategies he used to successfully restructure the computer
company IBM.
IBM
by Gerstner & a Roman
army by Scipio.
- The conflict induced by divergent
US political visions, is driving up health care
costs. But it also supports the creative drive of
Geisinger. Analogous conflicting demands from
Florence's gonfaloniere & King Louis XII of France allow
the creative genius Leonardo da Vince to extricate himself
from an impossible commitment to complete the 'Battle of
Anghiari'. He can thus focus on other realizable
activities, as illustrated in Isaacson's
Leonardo da Vinci.
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 provides an organizing framework that is
used by 'life.' It can be used to evaluate and rank models
that claim to describe our perceived reality. It catalogs
the laws and strategies which underpin the operation of systems
that are based on the interaction of emergent
agents. It highlights the
constraints that shape CAS and so predicts their form. A
proposal that does not conform is wrong.
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.
.
 Politics, Economics & Evolutionary Psychology |
Business Physics Nature and nurture drive the business eco-system Human nature Emerging structure and dynamic forces of adaptation |
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integrating quality appropriate for each market |
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