The complexity, M. Mitchell Waldrop describes a vision of complexity via:

• Rich interactions that allow a system to undergo spontaneous self-organization
• Systems that are adaptive
  
• More predictability than chaotic systems by bringing order and chaos into
  
• Balance at the edge of chaos 

of the health care network

Summary

• Is deeply embedded in the US nation state. It reflects the conflict between two opposing visions for the US.  The emergence of a parasitic elite further constrains the choices. 
  
• Is incented to focus on localized competition generating massive & costly duplication of services within a historically ineffective physician based health care instead of proven public health strategies.  This process drives increasing research & treatment complexity and promotes hope for each new technological breakthrough. 
  
• Is amplified by the legislatively structured separation and indirection of service development is a phase during the operation of a CAS agent.  It allows for schematic strategies to be iteratively blended with environmental signals to solve the logistical issues of migrating newly built and transformed sub-agents.  That is needed to achieve the adult configuration of the agent and optimize it for the proximate environment.  Smiley includes examples of the developmental phase agents required in an emergent CAS.  In situations where parents invest in the growth and memetic learning of their offspring the schematic grab bag can support optimizations to develop models, structures and actions to construct an adept adult.  In humans, adolescence leverages neural plasticity, elder sibling advice and adult coaching to help prepare the deploying neuronal network and body to successfully compete. 
  , provision, reimbursement and payment. 
  
• Is impacted by the different political strategies for managing the increasing cost of health care for retirees.  
• Is presented with acute and chronic problems to respond to.  As currently setup the network is tuned to handle acute problems.  The interactions with patients tend to be transactional. 
  
• Includes a legislated health insurance infrastructure which is:
• Costly and inefficient
• Structured around yearly contracts which undermine long-term health goals and strategies.  
• Is supported by increasingly regulated HCIT which offers to improve data sharing and quality but has entrenched commercial EHR refers to electronic health records which are a synonym of EMR.  EHRs have strengths and weaknesses:
  • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
  • The EHR does not necessarily reflect the patient's situation accurately. 
    
  • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    
  • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patent setting. 
    
  • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  
  products deep within the hospital systems. 
  

Introduction

• Prices vary tenfold!  They depend on who you work for.  The poorest pay the highest prices. 
  
• Medical decisions are taken by for-profit business employees. Medical assessments are made by clerical staff.  Hospital patients are discharged - have costly handoff problems reviewed by project BOOST.  When discharge takes too long it ties up acute bed space which can result in adding up to 30% more (unnecessary) capacity when improved discharge would translate into additional revenue.  Various interventions aim to improve the execution of the process including: CTI, TCN and RED for discharge to outpatient; InterAct for discharge to SNFs and BPIP to HHAs.  Discharge information can include:
  • Patient info
    
  • Behavioral summary
  • Treatment history
  • Medical history
  • Treatment objectives
  • Insurance policy
  • Discharge plans
  early overriding the judgments of doctors.  
• Preventative care is discouraged.  Overtreatment is the application of unnecessary health care.  It is a complex problem:
  • Overtreatment needs to be adaptive.  As people age their medicine levels typically need to be changed.  Often, as in the case of blood pressure, and blood sugar reduction, they should be reduced to avoid inducing falls (Nov 2015).  
  • Patients with chronic diseases, such as type 2 diabetes, often require different treatment settings.  And again these vary with age. 
    
  • Patients who have learned a regime, and been told it was successful, may resist instructions to change it.  Some worry that they will impact their health care provider's treatment performance measures. 
    
  is encouraged.  Huge numbers of people die from medical mistakes. 
  
• More than 48 million Americans don't have health insurance.  18,000 die each year.  Many have to be treated in expensive emergency wards is emergency department.  Pain is the main reason (75%) patients go to an E.D.  It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital.  The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals.  Unreimbursed care is supported from federal government funds.  The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics.  Commercial nature of care requires walk-ins to register to gain access to care.  With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). 
  .  
• More than 10 million Americans are under insured.  They risk bankruptcy is a legal status for an entity that cannot repay its creditor's loans.  It holds creditor lawsuits in abeyance while the restructuring process proceeds to allow the entity to continue operations.  It also has legal tools for forcing holdout creditors to accept repayments that are lower than the bond sale initially promised.   when treated by the health care network. 
  
• Thirty years of government policy has pushed for cost reductions within the health care network.  Each strategy has failed to reduce costs, while creating distortions.  A huge, costly billing and administrative infrastructure has developed.  Doctors are encouraged to overtreat is the application of unnecessary health care.  It is a complex problem:
  • Overtreatment needs to be adaptive.  As people age their medicine levels typically need to be changed.  Often, as in the case of blood pressure, and blood sugar reduction, they should be reduced to avoid inducing falls (Nov 2015).  
  • Patients with chronic diseases, such as type 2 diabetes, often require different treatment settings.  And again these vary with age. 
    
  • Patients who have learned a regime, and been told it was successful, may resist instructions to change it.  Some worry that they will impact their health care provider's treatment performance measures. 
    
  and focus on profitable specialties. 
  This presentation reviews just-in-time manufacturing with analysis based on complex adaptive system (CAS) theory. 
  
  Just-in-time manufacturing methodologies, misapplied to hospitals, starved the network of resources, inducing chaos provides an explanation for the apparently random period between water droplets falling from a tap.  Typically the model of the system is poor and so the data captured about the system looks unpredictable - chaotic.  With a better model the system's operation can be explained with standard physical principles.  Hence chaos as defined here is different from complexity.   within the complex operations. 
  

• The overall US economy and its main food production network is based on the fossil fuels that empowered Rockefeller, Senator Aldrich & the oil companies and subsequently
  This page reviews the catalytic impact of infrastructure on the expression of phenotypic effects by an agent.  The infrastructure reduces the cost the agent must pay to perform the selected action.  The catalysis is enhanced by positive returns. 
  
  amplified the
  Through the operation of three different food chains Michael Pollan explores their relative merits.  The application of complex adaptive system (CAS) theory highlights the value of evolutionary testing of the food chain. 
  
  food production network: Finance: Conglomerates, Private Equity; Agri-business, Processed food companies: Beverages (Coca-Cola), Fast-food (McDonalds), Sugar; Farmers, Supermarkets; powerful
  Plans are interpreted and implemented by agents.  This page discusses the properties of agents in a complex adaptive system (CAS). 
  It then presents examples of agents in different CAS.  The examples include a computer program where modeling and actions are performed by software agents.  These software agents are aggregates. 
  The participation of agents in flows is introduced and some implications of this are outlined. 
  
  agents.  With food-processing adding fat, sugar & salt, food is very stimulating and plentiful.  This has allowed the total human population to rise geometrically until it is running up against the carrying capacity of the planet:
  E. O. Wilson reviews the effect of man on the natural world to date and explains how the two systems can coexist most effectively. 
  
  Land area per human, Atmospheric carbon.  Humans did not evolve to manage food excess - with dopamine is a synaptic signal.  Its significance is that the receptors that detect the signal are of the slow acting type and are used to alter (modulate) the response of fast acting dopaminergic neural circuits in which the receptors are deployed (LTP).  The signal detects significant changes including predictions of models and actual results which differ unexpectedly.  The dopamine network architecture is designed to signal the possibility of any type of reward: Norm violation punishment, Winning a lottery, & Misfortune of an envied competitor.  Dopamine signalling:
  
  • Rescales continuously to accommodate the range of intensity offered by different stimuli.  So dopamine's responses to any reward habituate.  GABA is released by some tegmental neurons to induce habituation. 
    
  • Reflects the anticipation of reward.  It supports establishment of a relationship between a signal, working for a reward and obtaining the reward, but subsequently dopamine is mainly released encouraging the work, right after the signal supporting anticipation of the reward.  Anticipation requires learning and is reflected in hippocampus activity.  That explains context dependent cravings.  And the learning architecture means reliable cues become rewarding.  The accumbens supports willpower.  And dopamine
    
  • Promotes goal-oriented behavior needed to obtain & likely to achieve the reward - through the dopamine projections to the prefrontal cortex.  That makes dopamine central to:
    
  • Motivation.  This binding fails in depression - due to stress and in anxiety - due to signals from the amygdala.  
  • The prefrontal cortex's mesocortically stimulated support for willpower to act to delay rewards.  To sustain work for delayed rewards additional dopamine is released based on the length of the delay and the rewards uncertainty (modelled in the dorsolateral prefrontal cortex - which promotes the long term and the ventromedial prefrontal cortex - which promotes the short term) and the anticipated size of the reward (modelled in the accumbens).  Impulsiveness in ADHD is reflected in abnormal dopamine processing.  Addictive drugs bias the dopamine network towards impulsiveness. 
    
  habituation ensuring the more we consume the hungrier we get, and we have struggled with the induced health issues.  
• The increasing ability for producers and channel managers to manipulate the food web has transformed the relationship between humanity and its prey animals and edible plants.  They may still look similar but they are easier to obtain, more plentiful and modified: cleaner, less fresh - meat is transported for longer once killed and thus has many vitamins and volatiles denatured, fruit picked unripe, most everything reconstituted to appear fresh.  These foods are ample but do not return us to the ideal rural situation.  Powerful toxins and endocrine disrupters: pesticides and herbicides are deployed to limit pest infestations.  Milk is a mammalian adaptation.  It provides highly effective nutrition, signalling, protection & controls for newborns, constructed by mothers during 200 million years of evolution.  It includes: Lactose, Fats, Over 200 oligosaccharides, Antibodies, Bacteriophages, & Peptidoglycans; which support the initial adaptations of the mammalian newborn, including its microbiome. 
  is separated, heated, homogenized and reconstituted. 
  
• Cars and the supporting infrastructure increased personal freedom but massively reduced the amount the US population is walking while increasing deadly accidents from driving errors and distractions: cell phone and texting. 
  
• Large scale passenger aircraft allowed for global passenger flows.  This has removed barriers to infectious disease transmission enabling networked epidemics is the rapid spread of infectious disease: AIDS (Oct 2016), Cholera (2010), Clostridium difficile (May 2015), Ebola, Influenza, Polio, SARS, Tuberculosis, Typhoid, Malaria, Yellow fever, Zika; to large numbers of people in a population within a short period of time -- two weeks or less.  Epidemics are studied and monitored by: NIAID, CDC, WHO; but are managed by states in the US.  Infection control escalation is supported by biocontainment units: Emory, Nebraska.  Once memes are included in the set of infectious schematic materials, human addictions can present as epidemics concludes Dr. Nora Volkow of the NIDA.  CEPI aims to ensure public health networks are effectively prepared for epidemics.  PHCPI aims to strengthen PCPs globally to improve responsiveness to epidemics.  GAVI helps catalyze the development and deployment of vaccines.  Sporadic investment in public health enables development of conditions for vector development: Mosquitos.  The increasing demands of the global population are altering the planet: Climate change is shifting mosquito bases, Forests are being invaded bringing wildlife and their diseases in contact with human networks.  Globalized travel acts as an infection amplifier: Ebola to Texas.  Health clinics have also acted as amplifiers: AIDS in Haiti, C. diff & MRSA infections enabled & amplified by hospitals.  Haiti earthquake support from the UN similarly introduced Cholera. 
  and pandemics stressing the public health network: CDC is the HHS's center for disease control and prevention based in Atlanta Georgia.  
  , WHO is World Health Organization a United Nations organization.  ; and health care networks: Texas Health Presbyterian. 
  
• The gun manufacturers and their political lobby, the NRA is national rifle association.  , have a single focus lobby of government which ensures the US population has relatively high levels of: Access to guns, Deadly accidents from their use. 
  
• Power of the elites is increasing and trapping capital is the sum total nonhuman assets that can be owned and exchanged on some market according to Piketty.  Capital includes: real property, financial capital and professional capital.  It is not immutable instead depending on the state of the society within which it exists.  It can be owned by governments (public capital) and private individuals (private capital). 
  .  Since the 1980s tax adjustments have driven income and capital to the elites.  This encourages focusing capital on whims and allows many poor areas to collapse.  
• Various states and Puerto Rico have built up huge public debt burdens and are verging on collapse.  These problems will make funding Social Security, Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare includes:
  
  • Benefits
  • Part A: Hospital insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. 
    
  • Part B: Medical insurance
    
  • Part C: Medicare Advantage 
  • Part D: Prescription drug coverage 
  • Eligibility
    
  • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. 
    
  • Persons under 65 with disabilities who receive SSDI. 
    
  • Persons with specific medical conditions:
  • Have end stage renal disease or need a kidney transplant. 
    
  • They have ALS. 
    
  • Some beneficiaries are dual eligible.  
  • Premiums
  • Part A premium
  • Part B insurance premium
    
  • Part C & D premiums are set by the commercial insurer. 
    
  and Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program made state optional by the SCOTUS decision was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
  more complex.  
• The middle class are continuously stressed is a multi-faceted condition reflecting high cortisol levels.  Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight.  As these actions occur the levels of cortisol return to the baseline rate.  A stressor is anything that disrupts the regular homeostatic balance.  The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis. 
  
  • The short term response to the stressor
    
  • activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response.  The brain's acuity and cognition are stimulated.  The immune system is stimulated with beta-endorphin and repair activities curtail.  But when the stressor is
    
  • long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues.  Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in.  Sustained stress provides an evolved amplifier of a position of dominance and status.  It is a strategy in female aggression used to limit reproductive competition.  Sustained stress:
    
  • Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment! 
    
  • Activates the integration between the thalamus and amygdala. 
    
  • Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful. 
    
  • BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning. 
    
  • Makes it easier to learn a fear association and to consolidate it into long-term memory.  Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala.  And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces.  Accuracy of assessing emotions from faces suffers.  A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand.  The activation of the amygdala seems to determine how the hippocampus responds. 
    
  • Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression. 
    
  • Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive.  It also desynchronizes activation in different frontal lobe regions impacting shifting of attention. 
    
  • During depression, stress inhibits dopamine signalling. 
    
  • Strategies for stress reduction include: Mindfulness. 
    
  worrying about their financial situation.  The fight and flight responses are switched on and left running resulting in stress induced medical problems. 
  
• The poor struggle with collapse, finding no way out and increasingly being at risk of lethal violence.  Evolved responses focus the desperate on shifting resources to the next generation using suicide as a strategy. 
  
• Globalization has increased the power of financed: 3G Capital with Berkshire Hathaway; global food and drink production: Kraft Heinz; and distribution enterprises & the political significance of local jobs: Health care, Teaching;
• E-commerce is disrupting local commerce and encouraging consumers to shop while sitting. 
  
• Contragrade teleodynamic
  Flows of different kinds are essential to the operation of complex adaptive systems (CAS). 
  Example flows are outlined.  Constraints on flows support the emergence of the systems.  Examples of constraints are discussed. 
  
  flows of political agents' conflicting democratic ideas 
• Being the only super power allows the elites to focus on overpowering one another, and limits their dependence on the rapidly aging majority. 
  
• Wealthy 'New Democrats' accept the benefits and costs of globalization. 
  This page reviews Christensen's disruption of a complex adaptive system (CAS).  The mechanism is discussed with examples from biology and business. 
  
  Disintermediation of the poor is the unfortunate cost of leveraging a global workforce.  Health care investments offer a way to improve the health of the gross population as long as cost inflation can be contained.  But the local jobs associated with health care and education and the voter hostility to cost management signals, is an emergent capability which is used by cooperating agents to support coordination & rival agents to support control and dominance.  In eukaryotic cells signalling is used extensively.  A signal interacts with the exposed region of a receptor molecule inducing it to change shape to an activated form.  Chains of enzymes interact with the activated receptor relaying, amplifying and responding to the signal to change the state of the cell.  Many of the signalling pathways pass through the nuclear membrane and interact with the DNA to change its state.  Enzymes sensitive to the changes induced in the DNA then start to operate generating actions including sending further signals.  Cell signalling is reviewed by Helmreich.  Signalling is a fundamental aspect of CAS theory and is discussed from the abstract CAS perspective in signals and sensors.  In AWF the eukaryotic signalling architecture has been abstracted in a codelet based implementation.  To be credible signals must be hard to fake.  To be effective they must be easily detected by the target recipient.  To be efficient they are low cost to produce and destroy. 
  : premiums, copayments 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);
  , deductibles; limits the effectiveness of the cost management strategy. 
  
• Powerful Republicans counter the problematic demographic trends with a focus on using the justice system to remove poor voters from the rolls.  Removing state funded health care shifts the burden from getting sick to the individual and limits the direct pressure on the
  Johnson & Kwak argue that expanding the national debt provides a hedge against unforeseen future problems, as long as creditors are willing to continue lending.  They illustrate different approaches to managing the debt within the US over its history and of the eighteenth century administrations of England and France. 
  
  The US embodies two different political and economic systems which approach the national debt differently:
  

  • Taxes to support a sinking fund to ensure credit to leverage fiscal power in: Wars, Pandemics, Trade disputes, Hurricanes, Social programs; Starting with Hamilton, Lincoln & Chase, Wilson, FDR;
    
  • Low taxes, limited infrastructure, with risk assumed by individuals: Advocated by President's Jefferson & Madison, Reagan, George W. Bush (Gingrich); 

  Johnson & Kwak develop a model of what the US government does.  They argue that the conflicting sinking fund and low tax approaches leaves the nation 'stuck in the middle' with a future problem.  And they offer their list of 'first principles' to help assess the best approach for moving from 2012 into the future.  
  
  They conclude the question is still political.  They hope it can be resolved with an awareness of their detailed explanations.  They ask who is willing to push all the coming risk onto individuals. 
  
  Following our summary of their arguments RSS frames them from the perspective of complex adaptive system (CAS) theory.  Historically developing within the global cotton value delivery system, key CAS features are highlighted. 
  
  
  national debt.  Additionally these actions indirectly constrain access to: Education, Quality food, 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, 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.  
  • Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.  
  • Development, deployment and maintenance of vaccination strategies. 
    
  • Regulation and constraint of foods, drugs and devices by agencies including the FDA. 
    
  , Health care; which supports the over-all strategy by weakening the social fabric needed for defense against these attacks, while energizing poor Republicans with a stigmatized outgroup to focus anger upon and stabilizing a three tier structure. 
  
• Regulation to enforce a competitive market in health care has repeatedly failed. 
  
• 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 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 SCOTUS decision. 
    
  • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
  • Medical home models.  
  • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    
  • Qualifications for ACOs.  Organizations must:
    
  • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
    
  • Participate in the MSSP for three or more years. 
    
  • Have a management structure. 
    
  • Have clinical and administrative systems. 
    
  • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
    
  • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
    
  • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
  • Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
  • CMMI Medicare payment experimentation.  
  • Requirements that pharmaceutical companies must report payments made to physicians. 
    
  • A requirement that chain restaurants must report calorie counts on their menus. 
    
  competition
• Between new and incumbent insurers
  
• Between insurers and hospitals
  
• Predatory incentives shift political and system focus from low cost highly effective public health strategies to high cost inefficient health care strategies 
• Employment opportunities for health care workers encourage Democratic politicians to support health care based strategies
• Infrastructure development opportunities encourage Democratic and Republican politicians to support health care based strategies
• Doctor & hospital presence removes constraints on business development and community growth.  
• Incentives and increased complexity drive specialization of doctors and hospitals. 
  
• 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 amplification of self-regulatory power awarded to doctors, maintained by lobbying: AMA is the American Medical Association.  , ANA is the American nurses association. 
  ; and subsequent
• This page reviews the inhibiting effect of the value delivery system on the expression of new phenotypic effects within an agent. 
  
  Extended phenotypic alignment of doctors, pharmacists, hospitals, drug companies & their lobbying groups: NCPA is the national community pharmacists associations, a lobby for pharmacists. 
  , AHA is the American_hospital association. 
  , PhRMA;
  
• Some of the profit captured by hospitals has been invested in inefficient projections of status is a publically accepted, signal that one possesses assets: wealth, beauty, talent, expertise, access & trust of powerful people; to be able to help others. 
  with the building of grand edifices.  
• The flows of supplies to hospitals has evolved to maximize power.  Hospital group purchasing and supply/distribution consolidation have resulted in shortages, and gaming.  
• The conflation of science with medical practice and drug development is leveraged to limit government constraints: Outcomes-based contracts require suppliers to return money to the health system if the drugs fail to work as expected.  Typically drug makers pay rebates to insurers based on the number of drugs sold.  The manufacturers gain easier access to insurers' members for their products.  It appears unlikely that outcomes-based contracts reduce prescription drug prices (Jul 2017). 
  ;
  
• The commercialization of each significant stage of life of the US population has both improved wellbeing is described by Angus Deaton as all the things that are good for a person:
  • Material wellbeing includes income and wealth and its measures: GDP, personal income and consumption.  It can be traded for goods and services which recapture time.  Material wellbeing depends on investments in:
  • Infrastructure
    
  • Physical
    
  • Property rights, contracts and dispute resolution
    
  • People and their education
  • Capturing of basic knowledge via science.  
  • Engineering to turn science into goods and services and then continuously improve them. 
    
  • Physical and psychological wellbeing are represented by health and happiness; and education and the ability to participate in civil society through democracy and the rule of law.  Life expectancy as a measure of population health, highly weights reductions in child mortality. 
    
  and gradually increased the
  Barriers are particular types of constraints on flows.  They can enforce separation of a network of agents allowing evolution to build diversity.  Examples of different types of barriers and their effects are described. 
  
  barriers to success.  Education and health care have become essential services and a source of significant debt.  The proximate environment has become more uncertain is when a factor is hard to measure because it is dependent on many interconnected agents and may be affected by infrastructure and evolved amplifiers.  This is different from Risk.   and stressful is a multi-faceted condition reflecting high cortisol levels.  Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight.  As these actions occur the levels of cortisol return to the baseline rate.  A stressor is anything that disrupts the regular homeostatic balance.  The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis. 
  
  • The short term response to the stressor
    
  • activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response.  The brain's acuity and cognition are stimulated.  The immune system is stimulated with beta-endorphin and repair activities curtail.  But when the stressor is
    
  • long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues.  Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in.  Sustained stress provides an evolved amplifier of a position of dominance and status.  It is a strategy in female aggression used to limit reproductive competition.  Sustained stress:
    
  • Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment! 
    
  • Activates the integration between the thalamus and amygdala. 
    
  • Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful. 
    
  • BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning. 
    
  • Makes it easier to learn a fear association and to consolidate it into long-term memory.  Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala.  And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces.  Accuracy of assessing emotions from faces suffers.  A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand.  The activation of the amygdala seems to determine how the hippocampus responds. 
    
  • Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression. 
    
  • Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive.  It also desynchronizes activation in different frontal lobe regions impacting shifting of attention. 
    
  • During depression, stress inhibits dopamine signalling. 
    
  • Strategies for stress reduction include: Mindfulness. 
    
  for the majority. 
  
• The US population now associates health problems with technological solutions provided by the health care network.  Health care agents: Politicians, Academics, NIH is the National Institute of Health, Bethesda Maryland.  It is the primary federal agency for the support and conduct of biomedical and behavioral research.  It is also one of the four US special containment units of the CDC.  , Drug companies, Hospitals, Physicians, Pharmacists; reinforce this view. 
  
• Integration of health products with marketing networks have transformed the populations attitude to cleanliness.  The
  Kevin Kruse argues that from 1930 onwards the corporate elite and the Republican party have developed and relentlessly executed strategies to undermine Franklin Roosevelt and the New Deal.  Their successful strategy used the credibility of conservative religious leaders to:
  

  • Demonstrate religious issues with the New Deal. 
    
  • Integrate the corporate elite and evangelicals. 
    
  • Use the power of corporate advertising and Hollywood to reeducate the American people to view the US as historically religious and the New Deal and liberalism as anti-religious socialism. 
  • Focus the message through evangelicals including Vereide and Graham. 
    
  • Centralize the strategy through President Eisenhower. 
    
  • Add religious elements to mainstream American symbols: money, pledge;
  • Push for prayer in public school
    
  • Push Congress to promote prayer
    
  • Make elections more about religious positions. 
    

  
  Following our summary of his arguments RSS frames them from the perspective of complex adaptive system (CAS) theory.  Strategy is the art of the possible.  But it also depends on persistence. 
  
  
  strategic coordination of: Government, Marketing, News, Entertainment; supports and
  Flows of different kinds are essential to the operation of complex adaptive systems (CAS). 
  Example flows are outlined.  Constraints on flows support the emergence of the systems.  Examples of constraints are discussed. 
  
  controls this flow. 
  
• Supplements can provide concentrated amounts of biologically active chemicals to consumers.  These supplements can interact with pharmaceuticals in complex ways. 
  
• Huge public investments in health, by political leaders, have seen significant returns in control of and response to: Infectious diseases, Cardiovascular disease; but little from the war-on-cancer. 
  
• Public health benefits have
  Deaton describes the wellbeing of people around the world today.  He explains the powerful benefit of public health strategies and the effect of growth in material wellbeing but also the corrosive effects of aid. 
  
  Following our summary of Deaton's arguments RSS comments from the perspective of complex adaptive system (CAS) theory.  The situation he describes is complex including powerful amplifiers, alignment and incentives that overlap broadly with other RSS summaries of adaptations of: The biosphere, Politics, Economics, Philosophy and Health care. 
  
  
  improved wellbeing driving up life expectancy is a measure of the average life time of a new born baby.  Without public health assistance many children die in the first five years of life significantly lowering the life expectancy of the whole group.  There are representational and data capture problems with the model:
  
  • Not knowing the risk of dying in the newborn's future, demographers use the risks present at that time to predict impacts in the future of the person.  No adjustment can be made for increased wellbeing. 
    
  • Saving the lives of children has a far larger effect on increasing life expectancy than extending the lives of the elderly
    
  • Impacts that occur in a particular year, such as a epidemic or pandemic, are treated as permanent effects for that years life expectancy even though they may be handled by public health strategies and hence be transients.  For life expectancy calculations in subsequent years the impact is ignored.  
  • Programs that reduced the impacts of infectious diseases, such as antibiotics and vaccine deployment, have reduced the variability of life expectancy following their introduction.  
  • Vital registration systems gather accurate data for life expectancy.  But most countries do not have the infrastructure and instead estimates are generated from demographic and health surveys. 
    
  .  This shift has encouraged the transformation of the family from extended to nuclear, and reduced the average number of children. 
  
• Smaller families and a shift in environment from farms to sterile urban homes has transformed the proximate environment of infants and their microbiomes, the trillions of bacteria and viruses that live inside higher animals' guts, on their skin etc.  These bacteria and viruses seem to play a role in: immune responses, digesting food, making nutrients, controlling mental health and maintaining a healthy weight.  The signals from the gut microbiota are relayed by major nerve fibers: vagus; to the central nervous system.  The symbiotic relationship must be actively managed.  In the human gut: Barriers are setup: Mucus secretions form a physical constraint and provide sites for bacteriophages to anchor and attack pathogenic bacteria; Symbiont tailored nourishment: Plant-heavy food creates opportunities for fibre specialists like Bacteroides thetaiotaomicron; is provided, Selective binding sites are provided, Poisons are deployed against the unwelcome, and Temperature, acidity and oxygenation are managed.    High throughput sequencing allows the characterization of bacterial populations inside guts.  Beginning at birth, as they pass down the birth canal infants are supplied with a microbiome from their mothers.  If they are borne via cesarean they never receive some of the key bacteria from their mothers.  A variety of diseases may be caused by changes in the microbiome:
  • Eczema can be related to changes in the skin microbiome. 
    
  • Obesity can be induced by changes to the gut microbiome. 
    
  .  
• Antibiotic are compounds which kill bacteria, molds, etc.  The first 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). 
    
  integration in health care and agriculture has supported the development of valuable processes.  But the resulting pressure on microbes has selected for resistant variants results from plasmids and R factors: NDN1; which encode resistance properties for otherwise lethal antibiotics.  World leaders hope cooperation can preserve the power of last resort antibiotics: Carbapenems, Colistin (Oct 2016).  Worrying trends include: CRE (May 2016), C. diff. (May 2015), MDR & XDR TB; resulting in increased risk of sepsis and death.  The World Bank estimates full resistance would reduce the global economy in 2050 by between 1.1 and 3.8%. 
  : C. diff, MRSA is methicillin-resistant Staphylococcus aureus
  , XDR TB is extensively drug-resistant tuberculosis.  It requires very toxic and costly drugs to treat.  Most patients die. 
  ; that now threaten the business models and patient's lives. 
  
• Technological development continues to provide health care with powerful, but mostly unrealizable, marketing signals. 
  
• Pharmaceutical innovation is constrained by niche strategies & strong regulation. 
  
• To scale personalized medicine will need broad support from hospital networks accepting
  This page reviews Christensen's disruption of a complex adaptive system (CAS).  The mechanism is discussed with examples from biology and business. 
  
  disruption, molecular imaging allows the visualization of cellular function and molecular processes, allowing more precise and earlier diagnosis of disease.  It extends traditional imaging by:
  
  • Using biomarkers including nano sensors, which interact chemically with their surroundings, to image particular targets and pathways.  
  • Providing quantitative data on the imaged process or function enabling nanomedicine.  
  • Extending mass spectrometry with MALDI to allow rapid (relative to sequencing or x-ray crystallography), low cost analysis of proteins, bacteria and viruses. 
    
  and Big Data encompasses the IT systems and processes necessary to do population based data collection, management and analysis.  For the analysis to be useful it requires a hierarchy of supporting BI infrastructure:
  • Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature. 
    
  • Analytics tools (BI) for PHM will be hard to develop.  
  • Complex data models must include clinical aspects of the patient specific data, including disease state population wide.  
  • A key aspect is providing clear signals about the nature of the data using data visualization. 
    
  • Data communication with the ability to exchange and transact.  HIEs and EMPI alliance approaches are all struggling to provide effective exchange. 
    
  • Data labeling and secure access and retreival.  While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool.  Silos imply that the security architecture will need to be robust. 
    
  • Raw data scrubbing, restructuring and standardization.  Even financial data is having to be restandarized shifting from ICD-9 to -10.  The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process. 
    
  • Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data. 
    
  • Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure.  The integration of the EHR into a big data collection tool is key. 
    
  .  Its applicability also depends on two
  This page introduces the complex adaptive system (CAS) theory frame.  The theory is positioned relative to the natural sciences.  It catalogs the laws and strategies which underpin the operation of systems that are based on the interaction of emergent agents. 
  John Holland's framework for representing complexity is outlined.  Links to other key aspects of CAS theory discussed at the site are presented. 
  
  CAS-questionable assumptions being true:
1. An
   This page reviews the implications of selection, variation and heredity in a complex adaptive system (CAS).  The mechanism and its emergence are discussed. 
   
   evolved process is
   This page discusses the strategy of modularity in a complex adaptive system (CAS).  The benefits, mechanism and its emergence are discussed. 
   
   modular enough that treatments can be specific.  But that is unlikely since evolved innovations leverage addressable templates for a grab bag of strategic tools which may be broadly used.  
2. Genomics combines recombinant DNA, DNA sequencing and bioinformatics  to sequence, assemble and analyse genomes.   provides an easily understood description of phenotypic implementation.  But the understanding of control networks for genes and their products is still limited and probably requires understanding complex adaptive dynamic factors.  
• HCIT is health care information technology.  The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets.  Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.; 
  offers health care:
• Additional ways to understand the patient base
  
• New access & delivery models
• Patient portals provides web and or application based access to a patient's EHR based health care information and services.  Specific portal services are mandated by meaningful use.  They include at a minimum lab test results, problem list, medication list, and medication allergy list.   
• M-health - mobile health applications running on smart phones and other mobile devices.  It is viewed as key to improving clinical efficiency, access and cost effectiveness of treatments.  Applications will be integrated into bidirectional flows, enhancing team collaboration, as well as providing clinical information.  Both should improve decision making and reduce errors.  Hope for access at inpatient bed side, exam room.  As usual with mobility the light weight devices, extended access to confidential data and wireless connectivity work in opposition to the desire for zero latency, video streaming and conferencing, large image access, offline operation with synchronization, and strong security.  Privacy has been a major drag on adoption.  
  
• Better integration, coordination and control 
• EHR refers to electronic health records which are a synonym of EMR.  EHRs have strengths and weaknesses:
  • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
  • The EHR does not necessarily reflect the patient's situation accurately. 
    
  • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    
  • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patent setting. 
    
  • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  
  systems are developed by commercial software developers, to conform to legislation and CMS is the centers for Medicare and Medicaid services.   regulations, providing standardized patient data to NIH is the National Institute of Health, Bethesda Maryland.  It is the primary federal agency for the support and conduct of biomedical and behavioral research.  It is also one of the four US special containment units of the CDC.   & CDC is the HHS's center for disease control and prevention based in Atlanta Georgia.  
  .  
• Transfers supported by Direct messaging is a secure messaging technology used by HIEs (& Blue Button+) to directly interoperate.  It uses SMIME body in a SMTP protocol and X.509 certification. 
  or possibly through an HIE a Health Information Exchange is responsible for the transmission of healthcare-related data among facilities, health information organizations and government agencies according to national standards.  They are designed to address legal, organizational and technical challenges that would otherwise impede the sustainability of health information interchange.  An HIE is a component of the HIT.  It must enable reliable and secure transfer of data among diverse systems and facilitate access and retrieval.  The two main types are private and public exchanges.  Private exchanges may be able to leverage homogeneous IT infrastructure to facilitate data sharing.  Public exchanges are likely to be heterogeneous.  RHIO provide the regional organizations to support such HIE.  They are there to ensure that infrastructure amplification initiates.  The government will ensure that low healthcare density areas are served by public HIE infrastructure.  Both centralized and federated technical solutions were initially considered for implementation by the RHIOs for deploying HIE as specified in the Markle Foundation's NHIN common framework.  Common framework clients such as appropriately architected HIE use SOAP messaging to interact with their local SNO's ISB and RLS.  The HIE SOAP query transactions follow the HL7 Query Model.  Alternatively some HIE's are now using direct messaging to support interoperation.  HIE deployment goals have been phased (1 - supporting care transitions, 2 - Quality and care management, 3 - Population health).  Some HIEs will support "EHR-lite" as part of their functionality.  HIE does not yet solve some difficult challenges:
  • Safeguarding the security of health information.  Currently HIEs conforming to the common framework only provide locations of clinical data held remotely.  
  • Providing effective life cycle management.  The HIE is dependent on the local set of entities to provide updates that match the current state of the entity data. 
    
  network. 
  
• RCM is either:
  
  • Restrictive cardiomyopathy, a rare disease where scar tissue makes the heart muscle rigid and reduces the efficiency.  Or
    
  • Revenue Cycle Management aligns treatment with reimbursement.  Customer service will be involved.  IT will architect the core billing, decision support and ad-hoc services, constructed by RCM vendors, into systems to support RCM.  The Hospital's central business office will aim to maximize cash recoveries.  As per Deming mistakes in the RCM pipeline result in rework and lost cash flow and revenue of between 4 - 12%.  The staff must be trained and fully engaged in the design and operation of the pipeline.  The front end processes are best placed to capture all the information needed to make the cycle successful.  The activities include:
  • Scheduling and Appointments - where visits and procedures are booked and demographic and insurance information is collected.  If this information is incorrect it is likely the claims will not forward to third party payers.  When resources and their states are accurately known an optimal set of plans can be constructed to efficiently and effectively flow patients through the system.  But that is difficult to guarantee because of a number of interrelated problems:
  • Scale - as the number of resources increases the ability of a central scheduling system to represent all of them accurately and reliably becomes impossible. 
    
  • Ubiquity - a CAS strategy for ensuring availability is to have an over-abundance of equivalent resource that can be used for schedule allocation.  But often these resource levels are set by local decision makers who all respond at about the same time to imposed funding changes.  The effect is to suddenly and unpredictably undermine the guarantee of over-abundance.  Sometimes the assumption of equivalence also fails as in the desire of a patient to see only a specific surgeon. 
    
  • Changes can ripple through the plans requiring coordination meetings and notifications or guaranteed receipt of status updates. 
    
  • Verification checks for:
    
  • Referral - Is there PCP authorization?  Is the PCP referred service covered by the patient's plan,
    
  • Authorization - obtain Insurance authorization if required, and
    
  • Pre-certification - is there 'need' for inpatient care or other care before admission by the MCO.  Otherwise could introduce problems including not obtaining/verifying the insurance name, number and eligibility, not securing pre-certification and pre-authorization with time limits, not copying the insurance card, not checking for secondary coverage, not detecting expired referral or authorization,
    
  • Pre-registration - provide advice about their financial obligations and what documents to bring to the procedure.  If there is a copay or an outstanding payment to be paid these should be processed,
    
  • Registration - some patients are scheduled outside of the main admitting process (by OP clinic or E.D.) and this must be detected and the scheduling verification and pre-registration process be performed,
    
  • Time of service payments - co pays and self pays,
    
  • Coding - identify diagnosis (ICD 9 -> ICD-10 codes) and treatment (CPT) activities and charges for the episode.  More than 80% of hospital cases are coded in error. 
    
  • Demographics and billing data entry - enter charges and adjust capitated charges,
    
  • Patient statements - submit primary and secondary claims (following HIPAA formats) with or without involvement of a clearinghouse, produce patient statements including time of service, outstanding balance, charged amount with codes, insurance details, forms used (UB 92/04 and HCFA 1500).  A paper based claims filing has a rejection rate of 30%.  Duplicate claim payment rates of 1 - 2% of medical expenses are common.  Duplicate claims detection is often not part of the process.  Payer's goals are in conflict with Provider goals.  
    
  • Collections and payment posting - Post all payments and adjustments and deposit money into the bank,
    
  • Denials and appeals - resubmission and appeal of claims, denial analysis and bad debts and write offs.  To reduce denial rates and appeals the reimbursement contracts payer processes and actual denials must be analyzed and understood. 
    
  • Account follow up - Patient inquiries, resubmission of claims and issue refunds. 
    
  • Financial counseling;
  This page reviews the catalytic impact of infrastructure on the expression of phenotypic effects by an agent.  The infrastructure reduces the cost the agent must pay to perform the selected action.  The catalysis is enhanced by positive returns. 
  
  infrastructure amplifiers. 
  
• Additional security capabilities to counter the additional issues introduced by networking and mobile technologies. 
  
• Paying for health care was supported by health insurance from early in the twentieth century: Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments.  Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures.  The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment.  Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. 
  , Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. 
  ; introducing payer driven
  Terrence Deacon explores how constraints on dynamic flows can induce emergent phenomena which can do real work.  He shows how these phenomena are sustained.  The mechanism enables the development of Darwinian competition. 
  
  constraints and
  This page reviews the catalytic impact of infrastructure on the expression of phenotypic effects by an agent.  The infrastructure reduces the cost the agent must pay to perform the selected action.  The catalysis is enhanced by positive returns. 
  
  infrastructure amplifiers.  
• The Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare includes:
  
  • Benefits
  • Part A: Hospital insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. 
    
  • Part B: Medical insurance
    
  • Part C: Medicare Advantage 
  • Part D: Prescription drug coverage 
  • Eligibility
    
  • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. 
    
  • Persons under 65 with disabilities who receive SSDI. 
    
  • Persons with specific medical conditions:
  • Have end stage renal disease or need a kidney transplant. 
    
  • They have ALS. 
    
  • Some beneficiaries are dual eligible.  
  • Premiums
  • Part A premium
  • Part B insurance premium
    
  • Part C & D premiums are set by the commercial insurer. 
    
  /Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program made state optional by the SCOTUS decision was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
  PPS is Prospective payment system a method of CMS reimbursement in which a Medicare payment is made based on a predetermined fixed amount.  The amount is derived based on the classification system of that service (such as a diagnosis related group for an inpatient hospital service).  CMS uses separate PPSs for reimbursement to acute inpatient hospitals, HHAs, hospice, hospital outpatients, inpatient psychiatric facilities, IRF, LTCH and SNFs. 
  legislated integration of tax based funding with hospital based medical procedures enabled
  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. 
  
  evolutionary amplification. 
  
• Deming's Out Of The Crisis highlighted the cost inflation resulting from health care's expanding funding demands: The Seven Deadly Diseases (6) "Excessive medical costs for employee health care, which increase the final costs of goods and services".  This amplifier is still intact, built into large organizations' annual salary plans.  
• The CAS based
  This page reviews the implications of selection, variation and heredity in a complex adaptive system (CAS).  The mechanism and its emergence are discussed. 
  
  evolution of the network to include legislated & regulated flows between subscribers, payers and the supply/provision sub-networks supports additional
  This page discusses the benefits of constraining the flows in a complex adaptive system (CAS) until you are ready to act. 
  
  restrictions on flows: PBM is pharmacy benefit manager.  These companies, such as Caremark, were often originally PPMs.  PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. 
  , Specialty pharmacy dispense specialty medications.  They aim to save health plans money by: teaching patients how to apply their medicines and deal with side effects, ensure they take the full course and limit waste.  These specialized channels can be used by drug companies to limit competition to their drugs since access in constrained.  Generic drugs rebranded as specialty medications may escape competition, remove copayment and formulary exclusion sales inhibitors and obtain considerable pricing power. 
  ; which can be
  This page discusses the strategy of confusing the control system of a complex adaptive system (CAS). 
  
  un-balanced. 
  
• Price constraints are removed by:
• Fixed payments for specific treatments independent of cost enable profit seeking and profit maximization by increasing treatment volume. 
  
• Ancillary constraining patient copayments removed (paid) by producers, distributors and operators of treatments, whose profits are tied to treatment volume.  
• Drug price competition regulated away
  

US health care access transaction

US health care treatment transaction

1. The patient is an
   This page discusses the mechanisms and effects of emergence underpinning any complex adaptive system (CAS).  Key research is reviewed. 
   
   emergent
   This page introduces the complex adaptive system (CAS) theory frame.  The theory is positioned relative to the natural sciences.  It catalogs the laws and strategies which underpin the operation of systems that are based on the interaction of emergent agents. 
   John Holland's framework for representing complexity is outlined.  Links to other key aspects of CAS theory discussed at the site are presented. 
   
   system.  The patient includes the microbiome, the trillions of bacteria and viruses that live inside higher animals' guts, on their skin etc.  These bacteria and viruses seem to play a role in: immune responses, digesting food, making nutrients, controlling mental health and maintaining a healthy weight.  The signals from the gut microbiota are relayed by major nerve fibers: vagus; to the central nervous system.  The symbiotic relationship must be actively managed.  In the human gut: Barriers are setup: Mucus secretions form a physical constraint and provide sites for bacteriophages to anchor and attack pathogenic bacteria; Symbiont tailored nourishment: Plant-heavy food creates opportunities for fibre specialists like Bacteroides thetaiotaomicron; is provided, Selective binding sites are provided, Poisons are deployed against the unwelcome, and Temperature, acidity and oxygenation are managed.    High throughput sequencing allows the characterization of bacterial populations inside guts.  Beginning at birth, as they pass down the birth canal infants are supplied with a microbiome from their mothers.  If they are borne via cesarean they never receive some of the key bacteria from their mothers.  A variety of diseases may be caused by changes in the microbiome:
   • Eczema can be related to changes in the skin microbiome. 
     
   • Obesity can be induced by changes to the gut microbiome. 
     
   setup in a symbiotic is a long term situation between two, or more, different agents where the resources of both are shared for mutual benefit.  Some of the relationships have built remarkable dependencies: Tremblaya's partnership with citrus mealybugs and bacterial DNA residing in the mealybug's genome, Aphids with species of secondary symbiont bacteria deployed sexually from a male aphid sperm reservoir and propagated asexually by female aphids only while their local diet induces a dependency.  If the power relations and opportunities change for the participants then they will adapt and the situation may transform into separation, predation or parasitism. 
   relationship during development is a phase during the operation of a CAS agent.  It allows for schematic strategies to be iteratively blended with environmental signals to solve the logistical issues of migrating newly built and transformed sub-agents.  That is needed to achieve the adult configuration of the agent and optimize it for the proximate environment.  Smiley includes examples of the developmental phase agents required in an emergent CAS.  In situations where parents invest in the growth and memetic learning of their offspring the schematic grab bag can support optimizations to develop models, structures and actions to construct an adept adult.  In humans, adolescence leverages neural plasticity, elder sibling advice and adult coaching to help prepare the deploying neuronal network and body to successfully compete. 
   . 
   
2. The disease could be an invasive pathogen, also an emergent system, or a problem with the operation of cellular agents that on aggregate make up the patient. 
   
3. The treatment of a bacterial pathogen may be an evolved bactericide such as penicillin.  Such a treatment can result in destruction of the pathogen with few apparent side effects for the patient.  But
   
• The microbiome is likely to be significantly impacted.  That may transform the relationship between the participants in
  This page introduces the complex adaptive system (CAS) theory frame.  The theory is positioned relative to the natural sciences.  It catalogs the laws and strategies which underpin the operation of systems that are based on the interaction of emergent agents. 
  John Holland's framework for representing complexity is outlined.  Links to other key aspects of CAS theory discussed at the site are presented. 
  
  complex adaptive ways.  Due to the dependence on effective symbiosis to maintain the integrity of the
  Barriers are particular types of constraints on flows.  They can enforce separation of a network of agents allowing evolution to build diversity.  Examples of different types of barriers and their effects are described. 
  
  barriers to the eukaryotic, a relatively large multi-component cell type from which yeast and multi-celled plants and animals, including humans, is constructed.  It contains modules including a nucleus and production functions such as mitochondria.  
  This page reviews the catalytic impact of infrastructure on the expression of phenotypic effects by an agent.  The infrastructure reduces the cost the agent must pay to perform the selected action.  The catalysis is enhanced by positive returns. 
  
  infrastructure even penicillin's long term effects are complex.  Surgery with its dependence on antibiotic are compounds which kill bacteria, molds, etc.  The first 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). 
    
  driven sterile procedure aims to destroy the skin microbiome and massively perturbe the gut microbiome. 
  
• That does not necessarily imply that the mode of action is understood.  The treatment of a well understood metabolic problem such as type I diabetes, with the hormone are signalling molecules: ACTH, TRH, Melanocyte stimulating hormone, Testosterone, Oxytocin, Vasopressin, Insulin, Growth hormone, Estrogen, Progesterone, Angiotensin II, Asprosin, EPO, Irisin, Leptin, FGF21 hormone, Prostaglandins, TSH, Thyroxine, Glococorticoids; that are transported by the circulatory system to interact with target organs having appropriate receptors.  The levels of hormones can fluctuate massively, as in pregnancy. 
  insulin regulates the metabolism of carbohydrates, fats and protein by signalling the absorption of glucose by fat, liver and skeletal muscle cells.  It is a peptide hormone generated in the islets of Langerhans beta cells of the pancreas.  Peter Medawar explains it was an early drug therapy success.  As manufacturers have shifted from products developed by extraction to biologics: Humulin, Lantus, Levemir; safety has improved.  But the US list price has risen steeply (Feb 2016, Jan 2017)
  also depends for its efficacy on the evolved operation of the patient's cellular signalling systems, is an emergent capability which is used by cooperating agents to support coordination & rival agents to support control and dominance.  In eukaryotic cells signalling is used extensively.  A signal interacts with the exposed region of a receptor molecule inducing it to change shape to an activated form.  Chains of enzymes interact with the activated receptor relaying, amplifying and responding to the signal to change the state of the cell.  Many of the signalling pathways pass through the nuclear membrane and interact with the DNA to change its state.  Enzymes sensitive to the changes induced in the DNA then start to operate generating actions including sending further signals.  Cell signalling is reviewed by Helmreich.  Signalling is a fundamental aspect of CAS theory and is discussed from the abstract CAS perspective in signals and sensors.  In AWF the eukaryotic signalling architecture has been abstracted in a codelet based implementation.  To be credible signals must be hard to fake.  To be effective they must be easily detected by the target recipient.  To be efficient they are low cost to produce and destroy. 
  . 
  
4. The doctor may be an independent agent working with support and infrastructure from a
   
5. Health care provider, part of the health care system.  Surgery, with its dependence on antibiotic are compounds which kill bacteria, molds, etc.  The first 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). 
     
   sterile procedure and opioid based pain management is an iterative process, overseen by a doctor, to limit a patient's pain.  The process is doctor prescribed, RN managed, pharmacist validated, and patient administered.  The process may be coordinated by pain management specialists.  Pain management is central to modern surgery where it is supported by hospital infrastructure.  It is central to the perioperative process.  It is a major aspect of ED operations.  It has been extended out to discharged patients with chronic long term pain where it can lead to opioid dependency.  Treatments include: Opioids including: Fentanyl, Morphine, OxyContin, Percocet; NSAIDs, Cannabinoids, Acupuncture, Massage, CBT, and Mindfulness. 
   , has broad side effects which are slowly being characterized. 
   
6. Government administrators and regulators attempt to
   The agents in complex adaptive systems (CAS) must model their environment to respond effectively to it.  Samuel modeling is described as an approach. 
   
   model, influence and constrain the health care system to conform to the current rules and parameters specified by the US is the United States of America.   and state legislatures.  As such businesses, seeking profits, and participating directly and indirectly in the health care system adapt and seek attractive niches.  Parasitic behaviors is a long term relationship between the parasite and its host where the resources of the host are utilized by the parasite without reciprocity.  Often parasites include schematic adaptations allowing the parasite to use the hosts modeling and control systems to divert resources to them.   emerge from the availability of model and control structures that can be influenced. 

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