End-to-end insured quality care

Summary

• How they planned out the transformation,
  
• Leveraging an effective governance structure,
  
• Using a strategy to gain buy in,
  
• Enabling reengineering at the clinician patient interface. 
• Implementing the reengineering for acute, chronic & hot spot care; to help the patients and help the physicians.  
• Geisinger's leverage of biologics.  
• Reengineering healing with ProvenExperience.  
• Where Geisinger is headed next. 
  

ProvenCare How to deliver value-based healthcare the Geisinger way

• 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:
  1. Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history.  It needs to be updated periodically and after new diagnosis and other changes in health or functional status. 
     
  2. Creation and updating of proactive plan of care
     
  3. Communication
  4. Facilitation of transitions: typical transition problems are detailed by Project Boost.  A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff. 
     
  5. Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness. 
     
  6. Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.  
  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:
• Decrease in C-section rates from 28 to 20%,
• Decrease in NICU is neonatal ICU also called an intensive care nursery.   admissions from 9.4% to 5.9% 
• ProvenCare Knee:
• Decrease in average acute plus rehabilitation time from 16 to 9.9 days 

• 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.  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.  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. 
  

• 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. 
  

Building a better health care network driven by a demerger crisis and suboptimal care

• 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. 

• 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. 
  

• 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:
  1. Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history.  It needs to be updated periodically and after new diagnosis and other changes in health or functional status. 
     
  2. Creation and updating of proactive plan of care
     
  3. Communication
  4. Facilitation of transitions: typical transition problems are detailed by Project Boost.  A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff. 
     
  5. Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness. 
     
  6. Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.  
  .  
• Continuous innovation is the economic realization of invention and combinatorial exaptation.  While highly innovative, monopolies: AT&T, IBM; usually have limited economic reach, constraining productivity.  This explains the use of regulation, or even its threat, that can check their power and drive the creations across the economy. 
  
  
• Empowered patients and families
  

• 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
  

Geisinger's five year plans

• 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. 
  

• 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. 
  

• Increased perception of the brand,
  
• Competitive insurance plan offers, as well as
  
• Investment in innovation. 
  
• A partnership of trust with the members and patients supported their participation in the care-delivery reengineering. 
• Payer and provider data made rapidly available at the point of care catalyzed, an infrastructure amplifier.   the reengineering. 
  

1. Merger & acquisitions to drop the integrated payer provider business model into other hospital systems:
   
• Wilkes-Barre/Scranton
  
• Harrisburg, Pennsylvania
  
• Atlantic City, New Jersey
  
2. Expand insurance operations:
   
• Beyond Pennsylvania
• With non-Geisinger providers
  
3. Establish xG Health Solutions joint venture
   

Effective governance of Geisinger

Starting the transformation

• 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. 
  

Catalyzing reengineering at the Geisinger clinician patient interface

• 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:
  

  1. The evolving global scientific network. 
     
  2. The Bell telephone network.  And
     
  3. The military industrial network deploying 'fire and missile control' systems. 

  Bell Labs strategically leveraged each network to create an innovation engine. 
  They monitored the opportunities to leverage the developing ideas, reorganizing to replace incumbent opposition and enable the creation and growth of new ideas. 
  Once the monopoly was dismantled, AT&T disrupted. 
  Complex adaptive system (CAS) models of the innovation mechanisms are discussed. 
  
  
  AT&T's Bell Labs & Lockheed Martin's Skunk Works. 
  

• 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. 
  

• 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. 
  

ProvenCare Acute: Implementing the reengineering

• Acute hospital-based surgical procedures
  
• Select chronic diseases treated in out-patient settings
  

• 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. 
  

1. Documenting the appropriateness of care
2. Establishing all key elements of EBM or consensus-based best practices
3. Socializing and making routine the complex clinical systems that embed default best practices into new provider behaviors for everyday patient flow
   
4. Activating patients and families so they are fully engaged in the care process redesign and implementation
5. Negotiating a single bundled price for the entire episode of care - An episode of care is the treatment of a specific medical condition during a set period of time.  After MedPac recommended episode based payment bundling for inpatient hospital care it has become a key focus of Medicare incentive strategies. 
   with the payer 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
6. Transferring risk, is an assessment of the likelihood of an independent problem occurring.  It can be assigned an accurate probability since it is independent of other variables in the system.  As such it is different from uncertainty. 
   for the financial effects of preventable complications to the provider and the health system via a bundled payment is where the purchaser disburses a single predefined payment to cover certain combinations of hospital, physician, post-acute, or other services performed during an episode of care relating to a particular condition (unlike capitation).  This bundling is assumed (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. 
   
   1. It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.  
   2. Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments. 
      
   3. Care delivery must be re-architected to reduce costs and improve quality. 
      
   4. Monitoring sensors can be used to feed reports to ensure re-architected operations conform.  
   
   

• 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.  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. 
  

• 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

Responding to hot spot patients with ProvenHealth Navigator

• 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:
• Chronic disease & preventative care to be 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!
    
  based clinical decision support. 
  
• Care gaps and interventions to be communicated to the care teams
• Team results were compared and used to support feedback & optimizations.  
• Payer side data analysis mapped provider's resource usage and outcomes
  
• 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-Geisinger community practices could leverage the PHN reengineering as long as they had a significant volume of GHP members.  When there was no dominant payer encouraging 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. 
  it was found they would collapse back to 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 limit recidivism PHN required:

• Paying attention to the data flows between the payer and provider
• Looking at variations in care in 'near' real-time. 
  

• 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.  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

• 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

• 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

• Taking exceptional care of the communities they serve, through supporting prevention appropriate for each community.  And providing compassionate, 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. 
  

• 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, 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. 
  

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