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This web frame explores very
significant example real world complex
adaptive systems (CAS). It explains how the examples
relate to each other, why we all have trouble effectively
comprehending these systems and outlines the items we see as key
to the system and why. By understanding these summaries
you can better frame the interdependencies of important events
such as war in Iraq, new iPhone releases or a cancer diagnosis and see how
they are impacting you.
Example systems frame |
Dietrich Dorner argues complex adaptive systems (CAS) are hard to understand and
manage. He provides examples of how this feature of these
systems can have disastrous consequences for their human
managers. Dorner suggests this is due to CAS properties
psychological impact on our otherwise successful mental
strategic toolkit. To prepare to more effectively manage
CAS, Dorner recommends use of:
- Effective iterative planning and
- Practice with complex scenario simulations; tools which he
reviews.
Complexity catastrophes |
E. O. Wilson reviews the effect of man on the natural world to
date and explains how the two systems can coexist most
effectively.
Adaptive ecology |
Barton Gellman details the strategies used by Vice President
Cheney to align the global system with his economics, defense, and
energy goals.
US vds alignment |
Kevin Kruse argues that from 1930 onwards the corporate elite
and the Republican party have developed and relentlessly
executed strategies to undermine Franklin Roosevelt and the New Deal. Their
successful strategy used the credibility of conservative
religious leaders to:
- Demonstrate religious issues
with the New Deal.
- Integrate the corporate
elite and evangelicals.
- Use the power of corporate
advertising and Hollywood to reeducate the American
people to view the US as historically religious and
the New Deal and liberalism as anti-religious
socialism.
- Focus the message through evangelicals including Vereide and Graham.
- Centralize the strategy through President Eisenhower.
- Add religious elements to
mainstream American symbols: money, pledge;
- Push for prayer in
public school
- Push Congress to promote prayer
- Make elections more
about religious positions.
Following our summary of his arguments RSS frames them from the
perspective of complex adaptive system (CAS) theory.
Strategy is the art of the possible. But it also depends
on persistence.
Inventing Christian America |
Charles Ferguson argues that the US power structure has become
highly corrupt.
Ferguson identifies key events which contributed to the
transformation:
- Junk bonds,
- Derivative
deregulation,
- CMOs,
ABS and analyst fraud,
- Financial network deregulation,
- Financial network consolidation,
- Short term incentives
Subsequently the George W. Bush administration used the
situation to build
a global bubble, which Wall Street
leveraged. The bursting of the
bubble: managed
by the Bush Administration and Bernanke Federal Reserve;
was advantageous to some.
Ferguson concludes that the restructured and deregulated
financial services industry is damaging to
the American economy. And it is supported by powerful, incentive aligned academics.
He sees the result being a rigged system.
Ferguson offers his proposals
for change and offers hope that a charismatic young FDR will appear.
Following our summary of his arguments, RSS comments on them framed by
complex adaptive system (CAS)
theory. Once the constraints are removed from CAS
amplifiers, it becomes advantageous to leverage the increased flows. And it is often
relatively damaging not to participate. Corruption and parasitism can become
entrenched.
Financial WMD |
Matt Taibbi describes the phenotypic
alignment of the American justice system. The result
he explains relentlessly grinds the poor and undocumented into
resources to be constrained, consumed and ejected. Even as
it supports and aligns the financial infrastructure into a
potent weapon capable of targeting any company or nation to
extract profits and leave the victim deflated.
Taibbi uses five scenarios to provide a broad picture of the:
activities, crimes, policing, prosecutions, court processes,
prisons and deportation network. The scenarios are:
Undocumented people's neighborhoods, Poor neighborhoods, Welfare
recipients, Credit card debtors and Financial institutions.
Following our summary of his arguments, RSS comments on them framed by
complex adaptive system (CAS) theory. The alignment of the
justice system reflects a set of long term strategies and
responses to a powerful global arms race that the US leadership intends to
win.
Aligned justice |
Jonathan Powell describes how the government of, the former UK Prime Minister, Tony Blair,
actually operated. Powell was Blair's only chief of
staff.
Mechanics of power |
H. A. Hayek compares and contrasts collectivism and
libertarianism.
Libertarianism |
David Bodanis illustrates how disruptive effects can take
hold. While the French revolution had many driving forces
including famine and
oppression the emergence of a new philosophical vision ensured
that thoughtful leaders
were constrained and conflicted in their responses to the
crisis.
Voltaire's disruptive network |
An epistatic meme suppressed for a thousand years reemerges
during the enlightenment.
It was a poem
encapsulating the ideas of Epicurus rediscovered by a
humanist book hunter.
Greenblatt describes the process of suppression and
reemergence. He argues that the rediscovery was the
foundation of the modern world.
Complex adaptive system (CAS) models of the memetic mechanisms
are discussed.
Constraining happiness |
Isaacson uses the historic development of the global cloud of
web services to explore Ada
Lovelace's ideas about thinking
machines and poetic
science. He highlights the value of computer
augmented human creativity and the need for liberal arts to
fulfill the process.
Complex adaptive system (CAS) models of agent networks and
collaboration are discussed.
Arts technology & intelligence |
Haikonen juxtaposes the philosophy and psychology of
consciousness with engineering practice to refine the debate on
the hard problem of consciousness. During the journey he
describes the architecture of a robot that highlights the
potential and challenges of associative neural
networks.
Complex adaptive system (CAS) theory is then used to illustrate the
additional requirements and constraints of self-assembling
evolved conscious animals. It will be seen that
Haikonen's neural
architecture, Smiley's Copycat
architecture and molecular biology's intracellular
architecture leverage the same associative properties.
Associatively integrated robots |
Good ideas are successful because they build upon prior
developments that have been successfully implemented.
Johnson demonstrates that they are phenotypic expressions of
memetic plans subject to the laws of complex adaptive systems (CAS).
Developing ideas |
A government sanctioned monopoly
supported the construction of a superorganism
American Telephone and Telegraph (AT&T). Within this
Bell Labs was at the center of three networks:
- The evolving global scientific
network.
- The Bell telephone network. And
- The military
industrial network deploying 'fire and missile
control' systems.
Bell Labs strategically leveraged each network to create an innovation
engine.
They monitored the opportunities to leverage the developing
ideas, reorganizing to replace incumbent
opposition and enable the creation and growth of new
ideas.
Once the monopoly was dismantled AT&T disrupted.
Complex adaptive system (CAS) models of the innovation mechanisms are
discussed.
Strategic innovation |
Roger Cohen's New York Times opinion about the implications of
BREXIT is summarized. His ideas are then framed by complex
adaptive system (CAS) theory and
reviewed.
BREXIT |
Scott Galloway argues that Apple, Amazon, Facebook and Google
are monopolists that trade workers for technology.
Monopolies that he argues should be broken up to ensure the
return of a middle class.
Following our summary of his arguments, RSS comments on these arguments
assuming they relate to a complex adaptive system (CAS).
While Scott's issue is highly significant his analysis conflicts
with relevant CAS history and theory.
Monopoly job killers |
The IPO of Netscape is
defined as the key emergent event of
the New Economy by Michael Mandel. Following the summary
of Mandel's key points the complex adaptive system (CAS) aspects are highlighted.
New economy |
Ed Conway argues that Bretton Woods produced a unique set of
rules and infrastructure for supporting the global economy. It was
enabled by the experience of Keynes
and White during and after the First World War, their dislike of the Gold Standard,
the necessity of improving
the situation between the wars and the opportunity created
by the catastrophe of the Second
World War.
He describes how it was planned
and developed. How it
emerged from the summit.
And he shows how the opportunity inevitably allowed the US to replace the UK at the center of the global economy.
Like all plans there are
mistakes and Conway takes us through them and how the US recovered the situation as
best it could.
And then Conway describes the period after
Bretton Woods collapsed. He explains what followed
and also compares the relative performance of the various
periods before during and after Bretton Woods.
Following our summary of his arguments RSS comments from the
perspective of Complex Adaptive System (CAS)
theory. Conway's book illustrates the rule making and
infrastructure that together build an evolved amplifier.
He shows the strategies at play of agents that were for and
against the development
and deployment of the system. And The Summit provides a
key piece of the history of our global economic CAS.
Bretton woods |
A key agent in the 1990 - 2008
housing expansion Countrywide is linked into the residential
mortgage value delivery system (VDS)
by Paul Muolo and Mathew Padilla. But they show the VDS
was full of amplifiers and control points. With no one
incented to apply the brakes the bubble grew and burst.
Following the summary of Muolo and Padilla's key points the
complex adaptive system (CAS)
aspects are highlighted.
Housing amplifiers |
Satyajit Das uses an Indonesian company's derivative trades to
introduce us to the workings of the international derivatives
system. Das describes the components of the value delivery
system and the key
transactions. He demonstrates how the system
interacted with emerging economies
expanding them, extracting profits and then moving on as the
induced bubbles burst. Following Das's key points the
complex adaptive system (CAS)
aspects are highlighted.
Derivative systems |
Johnson & Kwak argue that expanding the national debt
provides a hedge against unforeseen future problems, as long as
creditors are willing to continue lending. They illustrate
different approaches to managing the debt within the US over its history and of the
eighteenth century administrations of England and France.
The US embodies two different political and economic systems which
approach the national debt differently:
- Taxes to support a sinking
fund to ensure credit to leverage fiscal power in:
Wars, Pandemics, Trade disputes, Hurricanes, Social
programs; Starting with Hamilton,
Lincoln & Chase, Wilson, FDR;
- Low taxes, limited infrastructure, with risk assumed by
individuals: Advocated by President's Jefferson & Madison,
Reagan, George W. Bush
(Gingrich);
Johnson & Kwak develop a model of what the US
government does. They argue that the conflicting
sinking fund and low tax approaches leaves the nation 'stuck in
the middle' with a future problem.
And they offer their list of 'first principles' to help
assess the best approach for moving from 2012 into the
future.
They conclude the question is still political. They hope
it can be resolved with an awareness of their detailed
explanations. They ask who is willing to
push all the coming risk onto individuals.
Following our summary of their arguments RSS frames them from the
perspective of complex adaptive system (CAS) theory.
Historically developing within the global cotton value delivery
system, key CAS features are highlighted.
National debt |
Robert Gordon argues that the inventions of the second
industrial revolution were the foundation for
American economic growth. Gordon shows how flows of people
into difficult rural America built a population base
which then took the opportunity to move on to urban settings: Houses, Food in supermarkets,
Clothes in
department stores;
that supported increasing productivity and standard of living.
The deployment of nationwide networks: Rail, Road, Utilities;
terminating in the urban housing and work places allowing the workers to
leverage time saving goods and services, which helped grow
the economy.
Gordon describes the concomitant transformation of:
- Communications
and advertising
- Credit
and finance
- Public
health and the health
care network
- Health insurance
- Education
- Social
and welfare services
Counter intuitively the constraints
introduced before and in the Great Depression and the demands of World War 2
provide the amplifiers that drive the inventions deeply and
fully into every aspect of the economy between 1940 and 1970
creating the exceptional growth and standard of living of post
war America.
Subsequently the
rate of growth was limited until the shift of women
into the workplace and the full networking of
voice and data supported the Internet and World Wide Web
completed the third industrial revolution, but the effects were
muted by the narrow reach of the technologies.
The development of Big Data, Robots,
and Artificial Intelligence may support additional growth,
but Gordon is unconvinced because of the collapse of
the middle class.
Following our summary of Gordon's book RSS frames his arguments from
the perspective of complex adaptive system (CAS) theory.
American growth |
Carl Menger argues that the market induced the emergence of
money based on the attractive features of precious metals.
He compares the potential for government edicts to create money
but sees them as lacking.
Following our summary of his arguments RSS frames his arguments from
the perspective of complex adaptive system (CAS) theory.
With two hundred years of additional knowledge we conclude that
precious metals are not as attractive as Menger asserts.
Government backed promissory notes are analogous to:
- Other evolved CAS forms of ubiquitous high energy
transaction intermediates and
- Schematic strategies that are proving optimal in
supporting survival and replication in the currently
accessible niches.
Emergence of money |
Eric Beinhocker sets out to answer a question Adam Smith
developed in the Wealth of Nations: what is wealth? To do
this he replaces traditional
economic theory, which is based on the assumption that an
economy is a system in equilibrium, with complexity economics in which
the economy is modeled as a complex adaptive system (CAS).
He introduces Sugerscape
to illustrate an economic CAS model in action. And then he
explains the major features of a CAS economy: Dynamics,
Agents, Networks, Emergence, and
Evolution.
Building on complexity economics Beinhocker reviews how evolution applies to
the economy to build wealth. He explains how design spaces
map strategies to instances of physical and
social
technologies. And he identifies the interactors and
selection mechanism of economic
evolution.
This allows Beinhocker to develop a new definition
of wealth.
In the rest of the book Beinhocker looks at the consequences of
adopting complexity economics for business and society: Strategy, Organization, Finance,
& Politics
& Policy.
Following our summary of his arguments, RSS explores his conclusions
and aligns Beinhocker's model of CAS with the CAS theory and evidence we
leverage.
Economic complexity |
Sven Beckert describes the historic transformation of the
growing, spinning, weaving, manufacture of cotton goods and
their trade over time. He describes the rise of a first global
commodity, its dependence on increasing: military power, returns for
the control points in the value delivery system(VDS), availability of land
and labor to work it including slaves.
He explains how cotton offered the opportunity for
industrialization further amplifying the productive capacity of
the VDS and the power of the control points. This VDS was quickly
copied. The increased capacity of the industrialized
cotton complex adaptive system (CAS) required more labor to
operate the machines. Beckert describes the innovative introduction of wages
and the ways found to
mobilize industrial labor.
Beckert describes the characteristics of the industrial cotton
CAS which made it flexible enough to become globally interconnected.
Slavery made the production system so cost effective that all
prior structures collapsed as they interconnected. So when
the US civil war
blocked access to the major production nodes in the
American Deep South the CAS began adapting.
Beckert describes the global
reconstruction that occurred and the resulting destruction of the traditional ways
of life in the global countryside. This colonial expansion
further enriched and empowered the 'western' nation
states. Beckert explains how other countries responded
by copying the colonial strategies and creating the
opportunities for future armed conflict among the original
colonialists and the new upstarts.
Completing the adaptive shifts Beckert describes the advocates
for industrialization
in the colonized global south and how over time they
joined the global cotton CAS disrupting the early western
manufacturing nodes and creating the current global CAS
dominated by merchants like Wal-Mart
pulling goods through a network of clothing manufacturers,
spinning and weaving factories, and growers competing with each
other on cost.
Following our summary of Beckert's book, RSS comments from the
perspective of CAS theory. The transformation of
disconnected peasant farmers, pastoral warriors and their lands
into a supply chain for a highly profitable industrial CAS
required the development over time: of military force, global
transportation and communication networks, perception and
representation control networks, capital stores and flows,
models, rules, standards and markets; along with the support at
key points of: barriers, disruption, and infrastructure and
evolved amplifiers. The emergent system demonstrates the
powerful constraining influence of extended phenotypic
alignment.
Globalization from cotton |
Health care |
Deaton describes the wellbeing
of people around the world today. He explains the powerful benefit of public
health strategies and the effect of growth in
material wellbeing but also the corrosive effects of
aid.
Following our summary of Deaton's arguments RSS comments from the
perspective of complex adaptive system (CAS)
theory. The situation he describes is complex including
powerful amplifiers, alignment and incentives that overlap
broadly with other RSS summaries of adaptations of: The
biosphere, Politics, Economics,
Philosophy and Health care.
Improving wellbeing |
Donald Barlett and James Steele write about their investigations
of the major problems afflicting US
health care as of 2006.
Problems of US health care |
Glenn Steele & David Feinberg review the development of the
modern Geisinger healthcare business after its near collapse
following the abandoned merger with Penn State AMC. After an overview of the
business, they describe how a calamity
unfolding around them supported building a vision of a
better US health care network. And they explain:
- 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.
Following our summary of their arguments RSS comments on them. We
frame their ideas with complex adaptive system (CAS)
theory.
E2E insured quality care |
Robert Pearl explains the perspectives of a health care leader
and son who know that the current health care network interacts
with human behavior to induce a poorly performing system that
caused his father's death. But he is confident that these
problem perceptions can be changed. Once that occurs he
asserts the network will become more integrated, coordinated,
collaborative, better led, and empathetic to their
patients. The supporting technology infrastructure will be
made highly interoperable. All that will reduce medical
errors and make care more cost effective.
Following our summary of his arguments RSS comments on them. We
frame his ideas with complex adaptive system (CAS) theory
including synergistic examples of these systems in
operation. The health care network is built out of
emergent human agents. All agents must model the signals
they perceive to represent and respond to them. Pinker
explains how this occurs. Sapolsky explains why fear and
hierarchy are so significant. He includes details of Josh
Green's research on morality and death. Charles Ferguson
highlights the pernicious nature of financial incentives.
Bad medical models |
US healthcare is ripe for
disruption. Christensen, Grossman and Hwang argue that
technologies are emerging which will support low cost business
models that will undermine the current network. Applying
complex adaptive system (CAS)
theory to these arguments suggests that the current power hierarchy can effectively resist
these progressive forces.
Disrupting health care |
Atul Gawande writes about the opportunity for a thirty per cent
improvement in quality in medicine by organizing
to deploy as agent based teams using shared schematic
plans and distributed signalling or as he puts it the use of checklists.
With vivid examples from a variety of situations including construction, air crew support and global health care Gawande illustrates
the effects of
complexity and how to organize to cope with it.
Following the short review RSS
additionally relates Gawande's arguments to its models of
complex adaptive systems (CAS) positioning his discussion within
the network of US health care,
contrasting our view of complexity, comparing the forces shaping
his various examples and reviewing facets of complex
failures.
Complexity checklists |
Friedman and Martin leverage the lifelong data collected on
1,528 bright individuals selected by Dr. Lewis Terman starting
in 1921, to understand what aspects of the subjects' lives
significantly affected their longevity. Looking broadly
across each subject's: Personality,
Education, Parental impacts,
Energy
levels, Partnering,
Careers, Religion,
Social networks,
Gender, Impact from war and
trauma; Friedman and Martin are able to develop a set of model pathways,
which each individual could be seen to select and travel
along. Some paths led to the traveler having a long
life. Others were problematic. The models imply that
the US approach to health and
wellness should focus
more on supporting
the development and selection of beneficial pathways.
Following our summary of their arguments RSS comments from the
perspective of CAS theory. The pathways are most
applicable to bright individuals with the resources and support
necessary to make and leverage choices they make. Striving
to enter and follow a beneficial pathway seems sensible but may
be impossible for individuals trapped in a collapsing network,
starved of resources.
Promoting longevity |
Gawande uses his personal experience, analytic skills and lots
of stories of innovators to demonstrate better ways of coping
with aging and death. He introduces the lack of focus on
aging and death in traditional medicine. And goes on to
show how technology has amplified
this stress point. He illustrates the traditional possibility of the
independent self, living fully while aging with the
support of the extended family. Central
planning responded to the technological and societal changes
with poorly designed infrastructure and funding. But
Gawande then contrasts the power of
bottom up innovations created by experts responding to
their own family situations and belief
systems.
Gawande then explores in depth the challenges
that unfold currently as we age and become infirm.
He notes that the world is following the US path. As such it will
have to understand the dilemma of
integrating medical treatment and hospice
strategies. He notes that all parties
involved need courage to cope.
He proposes medicine must aim to assure
well being. At that point all doctors will practice
palliative care.
Complex adaptive system (CAS) models of agency, death,
evolution, cooperation and adaptations
to new technologies are discussed.
Agent death |
Sonia Shah reviews the millennia old (500,000 years) malarial arms race between Humanity, Anopheles
mosquitoes and Plasmodium. 250 - 500 million people are
infected each year with malaria and one million die.
Malaria |
Peter Medawar writes about key historic events in the evolution
of medical science.
Medical science events |
Using John Holland's theory of adaptation in complex
systems Baldwin and Clark propose an evolutionary theory of
design. They show how this can limit the interdependencies
that generate complexity
within systems. They do this through a focus on
modularity.
Modular designed systems |
Lou Gerstner describes the challenges he faced and the
strategies he used to successfully restructure the computer
company IBM.
Compartmented systems |
Grady Booch advocates an object oriented approach to computer
software design.
Object based systems |
Bertrand Meyer develops arguments, principles and strategies for
creating modular software. He concludes that abstract data
types and inheritence make object orientation a superior
methodology for software construction. Complex adaptive
system (CAS) theory suggests agents provide an alternative strategy
to the use of objects.
Software construction |
Tools and the businesses that produce them have evolved
dramatically. W Brian Arthur shows how this occurred.
Tools |
Matt Ridley demonstrates the creative effect of man on the
World. He highlights:
- A list of
preconditions resulting in
- Additional niche
capture & more free time
- Building a network
to interconnect memes processes & tools which
- Enabling inter-generational
transfers
- Innovations
that help reduce environmental stress even as they leverage fossil
fuels
Memetic trading networks |
Brynjolfsson and McAfee explore the effects of Moore's law on the
economy. They argue it has generated exponential
growth. This has been due to innovation.
It has created a huge bounty of
additional wealth.
But the wealth is spread unevenly across
society. They look at the short and long term implications of
the innovation bounty and spread
and the possible future of
technology.
Following our summary of their arguments RSS comments from the
perspective of CAS theory.
Brilliant technologies |
Salman Khan argues that the evolved global education system is
inefficient and organized around constraining and corralling
students into accepting dubious ratings that lead to mundane
roles. He highlights a radical and already proven
alternative which offers effective self-paced deep learning
processes supported by technology and freed up attention of
teams of teachers. Building on his personal experience of
helping overcome the unjustified failing grade of a relative
Khan:
- Iteratively learns how to teach: Starting with Nadia, Leveraging
short videos focused on content,
Converging on mastery,
With the help of
neuroscience, and filling
in dependent gaps; resulting in a different approach
to the mainstream method.
- Assesses the broken US education system: Set in its ways, Designed for the 1800s,
Inducing holes that
are hidden by tests, Tests
which ignore creativity.
The resulting teaching process is so inefficient it needs to
be supplemented with homework.
Instead teachers were encouraging their pupils to use his tools at home so
they could mentor them while they attended school, an
inversion that significantly improves the economics.
- Enters the real world: Builds a scalable service,
Working with a
real classroom, Trying stealth
learning, At Khan Academy full time, In the curriculum at
Los Altos, Supporting life-long
learning.
- Develops The One World Schoolhouse: Back to the future with
a one
room school, a robust
teaching team, and creativity enabled;
so with some catalysis
even the poorest can
become educated and earn credentials
for current jobs.
- Wishes he could also correct: Summer holidays, Transcript based
assessments, College
education;
- Concludes it is now possible to provide the infrastructure
for creativity to
emerge and to support risk taking.
Following our summary of his arguments RSS frames them from the
perspective of complex adaptive system (CAS) theory. Disruption is a powerful force for
change but if its force is used to support the current teachers
to adopt new processes can it overcome the extended phenotypic alignment and evolutionary amplifiers sustaining the
current educational network?
Education versus guilds |
Amy Chua and Jed Rubenfeld's New York Times opinion based on The
Triple Package is summarized. Their ideas are then framed
by CAS theory and reviewed.
What drives success |
Peter Turchin describes how major pre-industrial empires
developed due to effects of geographic boundaries constraining
the empires and their neighbors' interactions. Turchin
shows how the asymmetries of breeding rates and resource growth
rates results in dynamic cycles within cycles. After the
summary of Turchin's book complex adaptive system (CAS) theory
is used to augment Turchins findings.
Warrior groups |
Through the operation of three different food chains Michael
Pollan explores their relative merits. The application of
complex adaptive system (CAS)
theory highlights the value of evolutionary
testing of the food chain.
Natural systems |
E. O. Wilson & Bert Holldobler illustrate how bundled cooperative strategies can
take hold. Various social insects have developed
strategies which have allowed them to capture the most valuable
available niches. Like humans they invest in
specialization and cooperate to subdue larger, well equipped
competitors.
Insect superorganisms |
Computational
theory of the mind and evolutionary
psychology provide Steven Pinker with a framework on which
to develop his psychological arguments about the mind and its
relationship to the brain. Humans captured a cognitive niche by
natural selection 'building out'
specialized aspects of their bodies and brains resulting in a system of mental organs
we call the mind.
He garnishes and defends the framework with findings from
psychology regarding: The visual
system - an example of natural
selections solutions to the sensory challenges
of inverse
modeling of our
environment; Intensions - where
he highlights the challenges of hunter gatherers - making sense
of the objects they perceive and predicting what they imply and
natural selections powerful solutions;
Emotions - which Pinker argues are
essential to human prioritizing and decision making; Relationships - natural selection's
strategies for coping with the most dangerous competitors, other
people. He helps us understand marriage, friendships and war.
These conclusions allow him to understand the development and
maintenance of higher callings: Art, Music, Literature, Humor,
Religion, & Philosophy; and develop a position on the meaning of life.
Complex adaptive system (CAS) modeling allows RSS to frame Pinker's arguments
within humanity's current situation, induced by powerful evolved
amplifiers: Globalization,
Cliodynamics, The
green revolution and resource
bottlenecks; melding his powerful predictions of the
drivers of human behavior with system wide constraints.
The implications are discussed.
Computationally adapted mind |
The complexity of behavior is explored through Sapolsky
developing scenarios of our best and worst behaviors across time
spans, and scientific subjects including: anthropology,
psychology, neuroscience, sociology. The rich network of
adaptive flows he outlines provides insights and highlight
challenges for scientific research on behavior.
Complex adaptive system (CAS) theory builds on Sapolsky's
details highlighting the strategies that evolution has captured
to successfully enter niches we now occupy.
CAS behavior |
Consciousness has confounded philosophers and scientists for
centuries. Now it is finally being characterized
scientifically. That required a transformation of
approach.
Realizing that consciousness was ill-defined neuroscientist
Stanislas Dehaene and others characterized and focused on conscious access.
In the book he outlines the limitations of previous
psychological dogma. Instead his use of subjective
assessments opened the
window to contrast totally unconscious
brain activity with those
including consciousness.
He describes the research methods. He explains the
contribution of new sensors and probes that allowed the
psychological findings to be correlated, and causally related to
specific neural activity.
He describes the theory of the brain he uses, the 'global neuronal
workspace' to position all the experimental details into a
whole.
He reviews how both theory and practice support diagnosis and
treatment of real world mental illnesses.
The implications of Dehaene's findings for subsequent
consciousness research are outlined.
Complex adaptive system (CAS) models of the brain's development and
operation introduce constraints which are discussed.
Conscious access |
Reading and writing present a conundrum. The reader's
brain contains neural networks tuned to reading. With
imaging a written word can be followed as it progresses from the
retina through a functional chain that asks: Are these letters?
What do they look like? Are they a word? What does it sound
like? How is it pronounced? What does it mean? Dehaene
explains the importance of
education in tuning the brain's networks for reading as
well as good strategies for teaching reading and countering dyslexia. But
he notes the reading
networks developed far too recently to have directly evolved.
And Dehaene asks why humans are unique in developing
reading and culture.
He explains the cultural
engineering that shaped writing to human vision and the exaptations and neuronal structures that
enable and constrain reading and culture.
Dehaene's arguments show how cellular, whole animal and cultural
complex adaptive system (CAS) are
related. We review his explanations in CAS terms and use
his insights to link cultural CAS that emerged based on reading
and writing with other levels of CAS from which they emerge.
Evolved reading |
Read Montague explores how brains make decisions. In
particular he explains how:
- Evolution can create indirect abstract models, such as the dopamine system, that
allow
- Life changing real-time
decisions to be made, and how
- Schematic structures provide
encodings of computable control
structures which operate through and on incomputable,
schematically encoded, physically active structures and
operationally associated production
functions.
Receptor indirection |
Richard Dawkin's explores how nature has created implementations
of designs, without any need for planning or design, through the
accumulation of small advantageous changes.
Accumulating small changes |
Russ Abbott explores the impact on science of epiphenomena and
the emergence of agents.
Autonomous emergence |
Terrence Deacon explores how constraints on dynamic flows can
induce emergent phenomena
which can do real work. He shows how these phenomena are
sustained. The mechanism enables the development of Darwinian competition.
Constraint based phenomena |
|
|
Summary
The complexity and problems of the US is the United States of America.
Health network is described in terms of complex adaptive system
( This page introduces the complex adaptive system (CAS) theory
frame. The theory is positioned relative to the natural
sciences. It catalogs the laws and strategies which
underpin the operation of systems that are based on the
interaction of emergent agents.
John Holland's framework for representing complexity is
outlined. Links to other key aspects of CAS theory
discussed at the site are presented.
CAS) theory.
The network:
Introduction
The current US is the United States of America. health care network is both costly
and underperforming. There are major systemic issues that
result in proximate problems described in 2006 in Donald Barlett and James Steele write about their investigations
of the major problems afflicting US
health care as of 2006.
Barlett and Steele's Critical Condition:
- 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. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016).
.
- 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.
Since 2006 the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
has
changed the situation but due to the underlying causes the
problems persist.
To understand the nature of the systemic problems and future
trends health is viewed as a large set of Plans are interpreted and implemented by agents. This page
discusses the properties of agents in a complex adaptive system
(CAS).
It then presents examples of agents in different CAS. The
examples include a computer program where modeling and actions
are performed by software agents. These software agents
are aggregates.
The participation of agents in flows is introduced and some
implications of this are outlined.
agents and This page discusses the effect of the network on the agents participating in a complex
adaptive system (CAS). Small
world and scale free networks are considered.
networked
structures within the US
nation state interacting with each other. If one
compares America to the human body, the 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.
system,
health care network and the Matt Taibbi describes the phenotypic
alignment of the American justice system. The result
he explains relentlessly grinds the poor and undocumented into
resources to be constrained, consumed and ejected. Even as
it supports and aligns the financial infrastructure into a
potent weapon capable of targeting any company or nation to
extract profits and leave the victim deflated.
Taibbi uses five scenarios to provide a broad picture of the:
activities, crimes, policing, prosecutions, court processes,
prisons and deportation network. The scenarios are:
Undocumented people's neighborhoods, Poor neighborhoods, Welfare
recipients, Credit card debtors and Financial institutions.
Following our summary of his arguments, RSS comments on them framed by
complex adaptive system (CAS) theory. The alignment of the
justice system reflects a set of long term strategies and
responses to a powerful global arms race that the US leadership intends to
win.
justice
system together seem analogous to our extensive immune system has to support and protect an inventory of host cell types, detect and respond to invaders and maintain the symbiont equilibrium within the microbiome. It detects microbes which have breached the secreted mucus barrier, driving them back and fortifying the barrier. It culls species within the microbiome that are expanding beyond requirements. It destroys invaders who make it into the internal transport networks. As part of its initialization it has immune cells which suppress the main system to allow the microbiome to bootstrap. The initial microbiome is tailored by the antibodies supplied from the mother's milk while breastfeeding. The immune system consists of two main parts the older non-adaptive part and the newer adaptive part. The adaptive part achieves this property by being schematically specified by DNA which is highly variable. By rapid reproduction the system recombines the DNA variable regions in vast numbers of offspring cells which once they have been shown not to attack the host cell lines are used as templates for interacting with any foreign body (antigen). When the immune cell's DNA hyper-variable regions are expressed as y-shaped antibody proteins they typically include some receptor like structures which match the surfaces of the typical antigen. Once the antibody becomes bound to the antigen the immune system cells can destroy the invader. .
Just as a deficient or over active immune system is dangerous to
the complete body's health the same is true of the health care
network's impacts on the nation.
The significant
feedback This page discusses the effect of the network on the agents participating in a complex
adaptive system (CAS). Small
world and scale free networks are considered.
networks and 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 affecting the US is the United States of America. health care CAS include:
- The overall US is the United States of America. economy is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics. and its main
food network is based on augmentation with fossil
fuels which (initially empowered Rockefeller, Senator
Aldrich & the oil companies and subsequently)
- Finance: Conglomerates,
Private Equity is the pooling of money from partners to: buy companies, improve their acquisition's value and sell them again. They gain competitive advantage from being lightly regulated. Private equity companies were initially corporate raiders.
;
- Agri-business,
- Processed
food companies: Beverages (Coca-Cola),
Fast-food
(McDonalds),
Sugar,
COC
lobbied capital
enabled global
alcohol;
- Retail;
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 supported by
WTO is the World Trade Organization. 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.
trade agreements. 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 supporting generalized goal-directed behavior & anticipation of reward. 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.
- Is lowered by certain gene variants which induce: less dopamine in the synapse, fewer receptors, lower responsiveness of receptors; associated with (as tiny effects in hugely varying social scenarios): sensation seeking, risk taking, attentional problems, extroversion; where:
- The receptor D4's gene shows high variability. The D47R form is relatively unresponsive to dopamine.
- Dopamine is degraded by COMT. The COMT gene includes a variant which is highly efficient reducing dopamine signalling but with complicating gene/environment interactions.
- Dopamine is removed from the synapse by a reuptake transporter DAT.
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.
- From 1800
to 1980 the average calories consumed by Americans
remained constant but after 1980 calorie consumption
grew contributing to obesity is a disorder where the brain is induced to require more eating, often because of limits to the number of fat cells available to report satiation (Jul 2016). It is associated with: metabolic syndrome including inflammation, cancer (Aug 2016), high cholesterol, hypertension, type-2-diabetes and heart disease. It is suspected that this is contributing to the increase in maternal deaths in the US (Sep 2016). Obesity is a complex condition best viewed as representing many different diseases, which is affected by the: Amount of brown adipose tissue (Oct 2016), Asprosin signalling by white adipose tissue (Nov 2016), Genetic alleles including 25 which guarantee an obese outcome, side effects of some pharmaceuticals for: Psychiatric disorders, Diabetes, Seizure, Hypertension, Auto-immunity; Acute diseases: Hypothyroidism, Cushing's syndrome, Hypothalamus disorders; State of the gut microbiome. Infections, but not antibiotics, appear associated with childhood obesity (Nov 2016).
and type 2
diabetes is the leading cause of blindness, limb amputations and kidney failure. Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat. Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system. Increased fat levels in obesity demand more insulin overloading the pancreas. Persistent high glucose levels are also toxic to the pancreas beta cells. High glucocorticoid levels have been associated with type 2 diabetes. There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic). The inheritance is polygenic. More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified. Of those identified so far many are associated with the beta cells. The one with the strongest relative risk is TCF7L2. The disease can be effectively controlled through a diligent application of treatments and regular checkups. Doctors are monitored for how under control their patients' diabetes is (Sep 2015). Treatments include: - Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken.
- Diet
- Exercise
.
- 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 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. 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 (Apr 2018), 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 and during the New Deal was the National Recovery Administration which required a minimum wage and eight hour work day. The National Recovery Administration was found unconstitutional by the Supreme Court in 1935. , 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.
- Electric light & central heating safely extend the
waking hours. But they encourage habits that result in
lack
of sleep. Sleep facilitates salient memory formation and removal of non-salient memories. The five different stages of the nightly sleep cycles support different aspects of memory formation. The sleep stages follow Pre-sleep and include: Stage one characterized by light sleep and lasting 10 minutes, Stage two where theta waves and sleep spindles occur, Stage three and Stage four together represent deep slow-wave sleep (SWS) with delta waves, Stage five is REM sleep; sleep cycles last between 90-110 minutes each and as the night progresses SWS times reduce and REM times increase. Sleep includes the operation of synapse synthesis and maintenance through DNA based activity including membrane trafficking, synaptic vesicle recycling, myelin structural protein formation and cholesterol and protein synthesis.
is a complex operation which takes time to complete
successfully. The time required will depend on the
level and significance of the proximate stimulus, the
current state and the developmental phase of the
person.
- Smart-phone 'app'
This page discusses the effect of the network on the agents participating in a complex
adaptive system (CAS). Small
world and scale free networks are considered.
network effects
have been hugely successful in capturing users. This
has been augmented with 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
amplifiers based on dopamine is a synaptic signal supporting generalized goal-directed behavior & anticipation of reward. 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.
- Is lowered by certain gene variants which induce: less dopamine in the synapse, fewer receptors, lower responsiveness of receptors; associated with (as tiny effects in hugely varying social scenarios): sensation seeking, risk taking, attentional problems, extroversion; where:
- The receptor D4's gene shows high variability. The D47R form is relatively unresponsive to dopamine.
- Dopamine is degraded by COMT. The COMT gene includes a variant which is highly efficient reducing dopamine signalling but with complicating gene/environment interactions.
- Dopamine is removed from the synapse by a reuptake transporter DAT.
habituation
ensuring the more we use the apps the more we want to check
for updates. For children
and adolescents in humans supports the transition from a juvenile configuration, dependent on parents and structured to learn & logistically transform, to adult optimized to the proximate environment. And it is staged encouraging the adolescents to escape the hierarchy they grew up in and enter other groups where they may bring in: fresh ideas, risk taking; and alter the existing hierarchy: Steve Jobs & Steve Wozniak, Bill Gates & Paul Allen. It marks the beginning of Piaget's formal operational stage of cognitive development. The limbic, autonomic and hormone networks are already deployed and functioning effectively. The frontal cortex has to be pruned: winning neurons move to their final highly connected positions, and are myelinated over time. The rest dissolve. So the frontal lobe does not obtain its adult configuration and networked integration until the mid-twenties when prefrontal cortex control becomes optimal. The evolutionarily oldest areas of the frontal cortex mature first. The PFC must be iteratively customized by experience to do the right thing as an adult. Adolescents: - Don't detect irony effectively. They depend on the DMPFC to do this, unlike adults who leverage the fusiform face area.
- Regulate emotions with the ventral striatum while the prefrontal cortex is still being setup. Dopamine projection density and signalling increase from the ventral tegmentum catalyzing increased interest in dopamine based rewards. Novelty seeking allows for creative exploration which was necessary to move beyond the familial pack. Criticisms do not get incorporated into learning models by adolescents leaving their risk assessments very poor. The target of the dopamine networks, the adolescent accumbens, responds to rewards like a gyrating top - hugely to large rewards, and negatively to small rewards. Eventually as the frontal regions increase in contribution there are steady improvements in: working memory, flexible rule use, executive organization and task shifting. And adolescents start to see other people's perspective.
- Drive the cellular transformations with post-pubescent high levels of testosterone in males, and high but fluctuating estrogen & progesterone levels in females. Blood flow to the frontal cortex is also diverted on occasion to the groin.
- Peer pressure is exceptionally influential in adolescents. Admired peer comments reduce vmPFC activity and enhance ventral striatal activity. Adults modulate the mental impact of socially mean treatment: the initial activation of the PAG, anterior cingulate, amygdala, insula cortex; which generate feelings of pain, anger, and disgust, with the VLPFC but that does not occur in adolescents.
- Feel empathy intensely, supported by their rampant emotions, interest in novelty, ego. But feeling the pain of others can induce self-oriented avoidance of the situations.
this induced addiction is associated with reduced IQ and
other developmental issues.
- The culture is how we do and think about things, transmitted by non-genetic means as defined by Frans de Waal. CAS theory views cultures as operating via memetic schemata evolved by memetic operators to support a cultural superorganism. Evolutionary psychology asserts that human culture reflects adaptations generated while hunting and gathering. Dehaene views culture as essentially human, shaped by exaptations and reading, transmitted with support of the neuronal workspace and stabilized by neuronal recycling. Sapolsky argues that parents must show children how to transform their genetically derived capabilities into a culturally effective toolset. He is interested in the broad differences across cultures of: Life expectancy, GDP, Death in childbirth, Violence, Chronic bullying, Gender equality, Happiness, Response to cheating, Individualist or collectivist, Enforcing honor, Approach to hierarchy; illustrating how different a person's life will be depending on the culture where they are raised. Culture:
- Is deployed during pregnancy & childhood, with parental mediation. Nutrients, immune messages and hormones all affect the prenatal brain. Hormones: Testosterone with anti-Mullerian hormone masculinizes the brain by entering target cells and after conversion to estrogen binding to intracellular estrogen receptors; have organizational effects producing lifelong changes. Parenting style typically produces adults who adopt the same approach. And mothering style can alter gene regulation in the fetus in ways that transfer epigenetically to future generations! PMS symptoms vary by culture.
- Is also significantly transmitted to children by their peers during play. So parents try to control their children's peer group.
- Is transmitted to children by their neighborhoods, tribes, nations etc.
- Influences the parenting style that is considered appropriate.
- Can transform dominance into honor. There are ecological correlates of adopting honor cultures. Parents in honor cultures are typically authoritarian.
- Is strongly adapted across a meta-ethnic frontier according to Turchin.
- Across Europe was shaped by the Carolingian empire.
- Can provide varying levels of support for innovation.
- Produces consciousness according to Dennet.
of the
US has become oriented towards the support of powerful
enterprises. Children, adolescents and adults are told
that life long learning allows them to reinvent
themselves. The impact of this shift is:
- 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 (Dec
2017). 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 (Dec
2017). These problems will make funding Social Security is the social securities act of 1935 was part of the second New Deal. It attempted to limit risks of old age, poverty and unemployment. It is funded through payroll taxes via FICA and SECA into the social security trust funds. Title IV of the original SSA created what became the AFDC. The Social Security Administration controls the OASI and DI trust funds. The funds are administered by the trustees. The SSA was amended in 1965 to include:
- Title V is Maternal and child health services.
- Title XVIII is Medicare.
, Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hosptial.
- Part B: Medical insurance
- Part C: Medicare Advantage
- Part D: Prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
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.
- Positive return
economics, W. Brian Arthur's conception of how high tech products have positive economic feedback as they deploy. Classical products such as foods have negative returns to scale since they take increasing amounts of land, and distribution infrastructure to support getting them to market. High tech products typically become easier to produce or gain from network effects of being connected together overcoming the negative effects of scale.
has driven resources and monopoly power to
the leaders aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group. John Adair developed a leadership methodology based on the three-circles model. of
networked high technology companies. These companies
are pushing to enter the medical and Salman Khan argues that the evolved global education system is
inefficient and organized around constraining and corralling
students into accepting dubious ratings that lead to mundane
roles. He highlights a radical and already proven
alternative which offers effective self-paced deep learning
processes supported by technology and freed up attention of
teams of teachers. Building on his personal experience of
helping overcome the unjustified failing grade of a relative
Khan:
- Iteratively learns how to teach: Starting with Nadia, Leveraging
short videos focused on content,
Converging on mastery,
With the help of
neuroscience, and filling
in dependent gaps; resulting in a different approach
to the mainstream method.
- Assesses the broken US education system: Set in its ways, Designed for the 1800s,
Inducing holes that
are hidden by tests, Tests
which ignore creativity.
The resulting teaching process is so inefficient it needs to
be supplemented with homework.
Instead teachers were encouraging their pupils to use his tools at home so
they could mentor them while they attended school, an
inversion that significantly improves the economics.
- Enters the real world: Builds a scalable service,
Working with a
real classroom, Trying stealth
learning, At Khan Academy full time, In the curriculum at
Los Altos, Supporting life-long
learning.
- Develops The One World Schoolhouse: Back to the future with
a one
room school, a robust
teaching team, and creativity enabled;
so with some catalysis
even the poorest can
become educated and earn credentials
for current jobs.
- Wishes he could also correct: Summer holidays, Transcript based
assessments, College
education;
- Concludes it is now possible to provide the infrastructure
for creativity to
emerge and to support risk taking.
Following our summary of his arguments RSS frames them from the
perspective of complex adaptive system (CAS) theory. Disruption is a powerful force for
change but if its force is used to support the current teachers
to adopt new processes can it overcome the extended phenotypic alignment and evolutionary amplifiers sustaining the
current educational network?
educational networks:
- Incentives to teachers are increasing the complexity of
the educational network (Sep
2017).
- 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 is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker. It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche. '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:
- Shifting wealth from the
public to the private citizens
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.
with
tax law (Dec
2017).
- 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 is an emotion which protects a person who has been cheated by a supposed friend. When the exploitation of the altruism is discovered, Steven Pinker explains, the result is a drive for moralistic aggression to hurt the cheater. upon and
stabilizing a three
tier structure.
- The power to nominate: President;
and subsequently appoint:
- Members of the judiciary, instantiates the contragrade
flows of judiciary influences subsequent interpretation
of the constitution.
- Appointees to the executive
branch regulators.
- 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 follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
competition
- Predatory incentives shift
political and system focus from low cost highly
effective public health strategies to high cost inefficient
health care strategies
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.
- Infrastructure focused hospitals, offering platforms for
independent doctors to utilize, compete by offering the
most advanced and costly technologies. With little
price constraint, this results in rampant
over-building and too
much infrastructure deployment. Integrated
payer-provider configurations:
Glenn Steele & David Feinberg review the development of the
modern Geisinger healthcare business after its near collapse
following the abandoned merger with Penn State AMC. After an overview of the
business, they describe how a calamity
unfolding around them supported building a vision of a
better US health care network. And they explain:
- 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.
Following our summary of their arguments RSS comments on them. We
frame their ideas with complex adaptive system (CAS)
theory.
Geisinger,
Kaiser;
offer an alternative where This page reviews the strategy of architecting an end-to-end
solution in a complex adaptive system (CAS).
The mechanism and its costs and benefits are discussed.
end-to-end
architecting can develop with the support of 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.; capabilities.
The ACA & MACRA is Medicare Access and CHIP Reauthorization Act of 2015 is designed to encourage physicians to move to FFV and to link Medicare payment to quality & value. It alters the way Medicare pays for part B physician services encouraging physicians and other ECs to conform to one of two value based payment schemes: Advanced APMs (where the EC can become a QP) or MIPS. MACRA does not apply to hospitals which have their own meaningful use. MACRA is designed to promote transformation and includes: Data reporting by ECs, New practice models, Changing clinical standards, and Physician evaluations; with hundreds of millions of dollars in penalties and bonuses. It authorizes CMS to develop and deploy new rules. It provides for PCPs in PCMHs to qualify as advanced APMs via a special lower risk pathway. It replaced the problematic physician SGR formula.
attempt to 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.
institutionalize
this end-to-end 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.
framework through Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hosptial.
- Part B: Medical insurance
- Part C: Medicare Advantage
- Part D: Prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
payer
data linked ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. - CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
s.
- PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
's business
model is disrupting (Apr
2018)
- The
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 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.
- The
This page reviews the implications of selection, variation and
heredity in a complex adaptive system (CAS).
The mechanism and its emergence are
discussed.
evolved dopamine is a synaptic signal supporting generalized goal-directed behavior & anticipation of reward. 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.
- Is lowered by certain gene variants which induce: less dopamine in the synapse, fewer receptors, lower responsiveness of receptors; associated with (as tiny effects in hugely varying social scenarios): sensation seeking, risk taking, attentional problems, extroversion; where:
- The receptor D4's gene shows high variability. The D47R form is relatively unresponsive to dopamine.
- Dopamine is degraded by COMT. The COMT gene includes a variant which is highly efficient reducing dopamine signalling but with complicating gene/environment interactions.
- Dopamine is removed from the synapse by a reuptake transporter DAT.
Read Montague explores how brains make decisions. In
particular he explains how:
- Evolution can create indirect abstract models, such as the dopamine system, that
allow
- Life changing real-time
decisions to be made, and how
- Schematic structures provide
encodings of computable control
structures which operate through and on incomputable,
schematically encoded, physically active structures and
operationally associated production
functions.
goal based reward system offers
the health care network a highly profitable,
self-reinforcing product -- opioids
-- with demand which becomes self-reinforcing. Drug
manufacturers have obtained large profits from
over-subscription, but like the triangular opium trade of
prior centuries, the results have been highly destructive
for many patients.
- The addictive
nature of opioids combined with this
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: EPAEDE is the ensuring patient access and effective drug enforcement act of 2016. It allows patients' access to necessary medications including opioid painkillers (Sep 2015). And it constrains the powers of the DEA to intervene (May 2016). It establishes a process for federal agencies to go through before a distribution center can be shut down. Sponsors include Senators Orrin Hatch and Sheldon Whitehouse and Representatives Tom Marino and Peter Welch. ; supports huge
protected profits and 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.
issues.
- The adoption of an authoritarian white uniform:
- About 5% of the patient base generates 50% of the costs
of health care. A focus on these hot spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable.
patients
has had some success in reducing costs.
- Mental illness is still a significant challenge for the
health system. Huge numbers of people suffer from: Depression is a debilitating state which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels; and an accumulation of traumatic events. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. There is an association between depression and particular brain regions: Hippocampal dendrite and spine number reductions, Dorsal raphe nucleus linked to loneliness, Abnormalities of the ACC. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Treatments include: CBT, UMHS depression management. As of 2010 drug treatments take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult;, Anxiety is manifested in the amygdala mediating inhibition of dopamine rewards. Major anxiety results in elevated glucocorticoids and reduces hippocampal dendrite & spine density. Some estrogen receptor variants are associated with anxiety in women.
; with little
progress in effective treatment.
- 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: Finance, 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.
- The addictive
nature of opioids combined with this
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: EPAEDE is the ensuring patient access and effective drug enforcement act of 2016. It allows patients' access to necessary medications including opioid painkillers (Sep 2015). And it constrains the powers of the DEA to intervene (May 2016). It establishes a process for federal agencies to go through before a distribution center can be shut down. Sponsors include Senators Orrin Hatch and Sheldon Whitehouse and Representatives Tom Marino and Peter Welch. ; supports huge
protected profits and 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.
issues.
- 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.
Until recently dementia is a classification of memory impairment, constrained feelings and enfeebled or extinct intellect. The most common form for people under 60 is FTD. Dementia has multiple causes including: vascular disease (inducing VCI) including strokes, head trauma, syphilis and mercury poisoning for treating syphilis, alcoholism, B12 deficiency (Sep 2016), privation, Androgen deprivation therapy (Oct 2016), stress, Parkinson's disease and prion infections such as Alzheimer's disease, CJD and kuru. The condition is typically chronic and treatment long term (Laguna Honda ward) and is predicted by Stanley Prusiner to become a major burden on the health system. It appears to develop faster in women than men.
obtained little investment.
- 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. 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).
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.
- Purging of the gut microbiome to assist with medical
tests, without
backup and reintroduction, undermines the generally
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 between microbes and human host.
- Medical
errors, misdiagnosis, overdiagnosis is identification of disease when no symptoms or impacts will occur. It typically results from false positives during screening (Aug 2016). It can result in unnecessary and problematic treatment.
,
under-treatment, 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.
,
medication
adherence failures, and insurance to cover the agents
of the health care network from legal actions concerning
these issues generates costs and induces secrecy,
under-reporting of problems and undermines 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.
Shewhart cycle improvements.
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. reimbursement is the payment process for much of US health care. Reimbursement is the centralizing mechanism in the US Health care network. It associates reward flows with central planning requirements such as HITECH. Different payment methods apportion risk differently between the payer and the provider. The payment methods include: - Fee-for-service,
- Per Diem,
- Episode of Care Payment,
- Multi-provider bundled EPC,
- Condition-specific capitation,
- Full capitation.
undermines
system wide analysis and solutions.
- Technological development continues to provide health care
with powerful, but mostly unrealizable, marketing
signals.
- Pharmaceutical
innovation is the economic realization of invention and combinatorial exaptation.
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:
- 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.
- 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. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
systems
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 inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hosptial.
- Part B: Medical insurance
- Part C: Medicare Advantage
- Part D: Prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
/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. But the construction of an
association between the yearly selection from a choice of
plans and the subscriber's health strategies discouraged a
long-term focus on 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.
by the insurer or participant.
- 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:
ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
, MACRA is Medicare Access and CHIP Reauthorization Act of 2015 is designed to encourage physicians to move to FFV and to link Medicare payment to quality & value. It alters the way Medicare pays for part B physician services encouraging physicians and other ECs to conform to one of two value based payment schemes: Advanced APMs (where the EC can become a QP) or MIPS. MACRA does not apply to hospitals which have their own meaningful use. MACRA is designed to promote transformation and includes: Data reporting by ECs, New practice models, Changing clinical standards, and Physician evaluations; with hundreds of millions of dollars in penalties and bonuses. It authorizes CMS to develop and deploy new rules. It provides for PCPs in PCMHs to qualify as advanced APMs via a special lower risk pathway. It replaced the problematic physician SGR formula. ; & regulated:
ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. - CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
; 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 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
America supports two
opposed ideas of democracy: 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.
Hamiltonian
and Jeffersonian. Different states support one or
the other. But where they meet at the federal level an
effect has been to allow health care costs to grow. The
opposing political goals of the Democrats and Republicans have
limited the strategies that can be applied to managing health
care costs, which will grow dramatically as the baby boomers
retire. Without change the growing cost of
health care will significantly impact the US fiscal health with
a massive 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 (Oct
2016).
America has integrated its political, financial and health care
networks. It provides great To benefit from shifts in the environment agents must be flexible. Being
sensitive to environmental signals
agents who adjust strategic priorities can constrain their
competitors.
flexibility,
but also allows the 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.
of 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 and 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 amplifiers with positive returns, W. Brian Arthur's conception of how high tech products have positive economic feedback as they deploy. Classical products such as foods have negative returns to scale since they take increasing amounts of land, and distribution infrastructure to support getting them to market. High tech products typically become easier to produce or gain from network effects of being connected together overcoming the negative effects of scale. .
Hence these need careful 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.
regulation.
But This page discusses the mechanisms and effects of emergence
underpinning any complex adaptive system (CAS). Key research is
reviewed.
emergent This page discusses the strategy of confusing the control system
of a complex adaptive system (CAS).
parasites
can distort the control systems to their advantage. The
result is that a Charles Ferguson argues that the US power structure has become
highly corrupt.
Ferguson identifies key events which contributed to the
transformation:
- Junk bonds,
- Derivative
deregulation,
- CMOs,
ABS and analyst fraud,
- Financial network deregulation,
- Financial network consolidation,
- Short term incentives
Subsequently the George W. Bush administration used the
situation to build
a global bubble, which Wall Street
leveraged. The bursting of the
bubble: managed
by the Bush Administration and Bernanke Federal Reserve;
was advantageous to some.
Ferguson concludes that the restructured and deregulated
financial services industry is damaging to
the American economy. And it is supported by powerful, incentive aligned academics.
He sees the result being a rigged system.
Ferguson offers his proposals
for change and offers hope that a charismatic young FDR will appear.
Following our summary of his arguments, RSS comments on them framed by
complex adaptive system (CAS)
theory. Once the constraints are removed from CAS
amplifiers, it becomes advantageous to leverage the increased flows. And it is often
relatively damaging not to participate. Corruption and parasitism can become
entrenched.
small powerful elite use the
regulations and controls to improve their situation: Academics, Physicians;
while undermining the nation.
The resurgent globalization
strategy results in This page reviews Christensen's disruption
of a complex adaptive system (CAS).
The mechanism is discussed with examples from biology and
business.
disintermediation
of low skill, high wage workers in the US encouraging 'local'
focus strategies leveraging: Salman Khan argues that the evolved global education system is
inefficient and organized around constraining and corralling
students into accepting dubious ratings that lead to mundane
roles. He highlights a radical and already proven
alternative which offers effective self-paced deep learning
processes supported by technology and freed up attention of
teams of teachers. Building on his personal experience of
helping overcome the unjustified failing grade of a relative
Khan:
- Iteratively learns how to teach: Starting with Nadia, Leveraging
short videos focused on content,
Converging on mastery,
With the help of
neuroscience, and filling
in dependent gaps; resulting in a different approach
to the mainstream method.
- Assesses the broken US education system: Set in its ways, Designed for the 1800s,
Inducing holes that
are hidden by tests, Tests
which ignore creativity.
The resulting teaching process is so inefficient it needs to
be supplemented with homework.
Instead teachers were encouraging their pupils to use his tools at home so
they could mentor them while they attended school, an
inversion that significantly improves the economics.
- Enters the real world: Builds a scalable service,
Working with a
real classroom, Trying stealth
learning, At Khan Academy full time, In the curriculum at
Los Altos, Supporting life-long
learning.
- Develops The One World Schoolhouse: Back to the future with
a one
room school, a robust
teaching team, and creativity enabled;
so with some catalysis
even the poorest can
become educated and earn credentials
for current jobs.
- Wishes he could also correct: Summer holidays, Transcript based
assessments, College
education;
- Concludes it is now possible to provide the infrastructure
for creativity to
emerge and to support risk taking.
Following our summary of his arguments RSS frames them from the
perspective of complex adaptive system (CAS) theory. Disruption is a powerful force for
change but if its force is used to support the current teachers
to adopt new processes can it overcome the extended phenotypic alignment and evolutionary amplifiers sustaining the
current educational network?
Education,
Health care; with the side effect of pushing politically
controlled funds from 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.
and towards
health care.
The This page discusses the mechanisms and effects of emergence
underpinning any complex adaptive system (CAS). Key research is
reviewed.
emergence and 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 US is the United States of America. based science oriented
doctors, hospitals
and communities
is Robert Gordon argues that the inventions of the second
industrial revolution were the foundation for
American economic growth. Gordon shows how flows of people
into difficult rural America built a population base
which then took the opportunity to move on to urban settings: Houses, Food in supermarkets,
Clothes in
department stores;
that supported increasing productivity and standard of living.
The deployment of nationwide networks: Rail, Road, Utilities;
terminating in the urban housing and work places allowing the workers to
leverage time saving goods and services, which helped grow
the economy.
Gordon describes the concomitant transformation of:
- Communications
and advertising
- Credit
and finance
- Public
health and the health
care network
- Health insurance
- Education
- Social
and welfare services
Counter intuitively the constraints
introduced before and in the Great Depression and the demands of World War 2
provide the amplifiers that drive the inventions deeply and
fully into every aspect of the economy between 1940 and 1970
creating the exceptional growth and standard of living of post
war America.
Subsequently the
rate of growth was limited until the shift of women
into the workplace and the full networking of
voice and data supported the Internet and World Wide Web
completed the third industrial revolution, but the effects were
muted by the narrow reach of the technologies.
The development of Big Data, Robots,
and Artificial Intelligence may support additional growth,
but Gordon is unconvinced because of the collapse of
the middle class.
Following our summary of Gordon's book RSS frames his arguments from
the perspective of complex adaptive system (CAS) theory.
described by Robert
Gordon. He explains how doctors
obtained self-regulatory
power which aligned the interests of doctors,
pharmacists, hospitals and drug companies. Doctors'
power continued
to expand until the AHA is the American_hospital association.
pushed back. The medical profession was criticized for
being paternalistic. The profits
from hospital
systems' is the owner of a set of hospitals and other owned infrastructure and employer of direct staff. business success were invested
in grand buildings that signalled, 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. 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. .
As health
care has become
more specialized it has been necessary to respond with
additional tools to help with coordination: Complexity
checklists Atul Gawande writes about the opportunity for a thirty per cent
improvement in quality in medicine by organizing
to deploy as agent based teams using shared schematic
plans and distributed signalling or as he puts it the use of checklists.
With vivid examples from a variety of situations including construction, air crew support and global health care Gawande illustrates
the effects of
complexity and how to organize to cope with it.
Following the short review RSS
additionally relates Gawande's arguments to its models of
complex adaptive systems (CAS) positioning his discussion within
the network of US health care,
contrasting our view of complexity, comparing the forces shaping
his various examples and reviewing facets of complex
failures.
described by Atul Gawande,
Treatment protocols specified in EHR refers to electronic health records which are a synonym of EMR. EHRs have strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patent setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
described by Steele
& Feinberg;
America's current health care insurance legislation
and regulations institutionalize
yearlong contracts between the network and the
subscribers. But many national health issues require
longer term strategies. While piecemeal solutions exist: Geisinger,
Intermountain,
Kaiser;
the yearly cycles help drive the health care network towards a
short term focus.
In 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.
The Great Escape Angus
Deaton reveals that most of the critical health issues
should be best handled as 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.
problems. However, they are sustained within our nation
state by the This page introduces the complex adaptive system (CAS) theory
frame. The theory is positioned relative to the natural
sciences. It catalogs the laws and strategies which
underpin the operation of systems that are based on the
interaction of emergent agents.
John Holland's framework for representing complexity is
outlined. Links to other key aspects of CAS theory
discussed at the site are presented.
CAS properties
identified in last three paragraphs and This page reviews the implications of selection, variation and
heredity in a complex adaptive system (CAS).
The mechanism and its emergence are
discussed.
evolved
properties of our brains discussed by Sonia Shah
as they pertain to community responses to our long chronic In this page we summarize the arms race between hosts
and their parasites. The deadly nature and adaptive
pressure of the relationship is introduced. How the
slowly reproducing hosts cope is
described. Cultural
hosts and parasites are discussed.
arms race with malaria.
Evolved properties explained in Thinking Fast and Slow by Daniel
Kahneman. The consequent inadequate public health
response results in these health issues being diagnosed and
treated by the health care network.
Scientific
advances offer the potential for new cheaper, less
invasive, and more effective ways to understand, diagnose and
treat health problems. But Gordon
shows that after defeating
Infectious
diseases and providing some powerful tools
for CVD is cardiovascular disease which refers to:
- Conditions where narrowed and blocked blood vessels
result in angina, hypertension,
CHD and heart
attacks and hemorrhagic/ischemic strokes.
Mutations of the gene PCSK9 have
been implicated in cardiovascular disease. Rare
families with dominant inheritence of the mutations have
an overactive protein, very high levels of blood
cholesterol and cardiac disease. Other rare PCSK9
mutations result in an 88% reduced risk from heart disease.
Inflammation is associated with cardiovascular disease (Aug
2017).
; the other
strategies: Politically
driven war-on-cancer;
and general shift 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.
from public health
to technology driven research and health care, has been: Costly,
Undermined by the revealed chronic issues from living longer; of
apparently limited benefit. And these changes additionally
introduce confidentiality and complexity issues for doctors and
patients. Augmented intelligence enables the achievement of goals in the face of obstacles. The goals are sub-goals of genes' survival and reproduction and include: - Obtaining and eating food
- Sex
- Finding and maintaining shelter
- Fighting for resources - in the preferred hunter gatherer environment loss of resources was critical while possession was often transient.
- Understanding the proximate environment
- Securing the cooperation of others
: Watson;
may help with the increasing complexity if the additional
analysis can be effectively leveraged by the providers.
The 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.; 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
amplifier has been legislated, standardized, regulated and
funded by the government. The result has been to push
proprietary, costly, EHR refers to electronic health records which are a synonym of EMR. EHRs have strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patent setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
vendors'
systems deep into the health care network agent's operations
creating additional silos! Leverage of the Internet has
been constrained by its lacking ubiquitous architected security
and identity facilities.
The US population
associated
antibiotics 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).
with
effective scientific health care. The association has been
supported by health
care driven signalling, 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.
by legisator supported drug industry messages through
advertisers.
The health care
network has signalled, 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.
that technological
innovation will provide the personalized
focus is a medical strategy where decisions, practices, and products are tailored to the individual patient. Research is looking at the impact of providing potentially deleterious genomic testing information to people: The REVEAL study found no increased anxiety induced by hearing that one's genome implied increased risk of developing late onset Alzheimer's disease. The take-up of personalized medicine benefits from the focus on genomics detailed by the NIH director Francis Collins and includes: - NCCN intensive cell therapies
- Direct to consumer genomic testing
- Direct to consumer diagnostics
- Pharmacogenomics tailored drug treatments reducing the risk and cost of adverse drug reactions.
to improve outcomes and drive down costs. Christensen
asserts that the niche
structure of the US
health care network can be leveraged to drive innovation is the economic realization of invention and combinatorial exaptation. up and costs
down via This page reviews Christensen's disruption
of a complex adaptive system (CAS).
The mechanism is discussed with examples from biology and
business.
disruption. Brynjolfsson
and McAfee note
the exponential growth of multiple This page discusses the benefits of bringing agents and resources to the
dynamically best connected region of a complex adaptive system (CAS).
centralized
and This page discusses the effect of the network on the agents participating in a complex
adaptive system (CAS). Small
world and scale free networks are considered.
networked technologies which
makes The agents in complex adaptive
systems (CAS) must model their
environment to respond effectively to it. Samuel
modeling is described as an approach.
modeling the future trends particularly
difficult. The heart
damaging side-effects of Herceptin highlight
a challenge to technology oriented personalized
medicine is a medical strategy where decisions, practices, and products are tailored to the individual patient. Research is looking at the impact of providing potentially deleterious genomic testing information to people: The REVEAL study found no increased anxiety induced by hearing that one's genome implied increased risk of developing late onset Alzheimer's disease. The take-up of personalized medicine benefits from the focus on genomics detailed by the NIH director Francis Collins and includes: - NCCN intensive cell therapies
- Direct to consumer genomic testing
- Direct to consumer diagnostics
- Pharmacogenomics tailored drug treatments reducing the risk and cost of adverse drug reactions.
.
Patients of a health care network suffer from acute and chronic
types of problem. It is helpful to analyze the two problem
types separately.
Acute problems are
critical to define and address immediately. The patient,
if still conscious, is likely to be focused on the problem and
getting well as soon as possible. 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.
&
medicine have been successful at combating many acute
problems. Sometimes the problems are cured. Or they
may become chronic problems.
Chronic problems are
viewed as ever present and of low priority. Our
associative minds reduce the priority of repetitive
issues. Many of these problems are induced by abundance
and toxicity generated by our Sven Beckert describes the historic transformation of the
growing, spinning, weaving, manufacture of cotton goods and
their trade over time. He describes the rise of a first global
commodity, its dependence on increasing: military power, returns for
the control points in the value delivery system(VDS), availability of land
and labor to work it including slaves.
He explains how cotton offered the opportunity for
industrialization further amplifying the productive capacity of
the VDS and the power of the control points. This VDS was quickly
copied. The increased capacity of the industrialized
cotton complex adaptive system (CAS) required more labor to
operate the machines. Beckert describes the innovative introduction of wages
and the ways found to
mobilize industrial labor.
Beckert describes the characteristics of the industrial cotton
CAS which made it flexible enough to become globally interconnected.
Slavery made the production system so cost effective that all
prior structures collapsed as they interconnected. So when
the US civil war
blocked access to the major production nodes in the
American Deep South the CAS began adapting.
Beckert describes the global
reconstruction that occurred and the resulting destruction of the traditional ways
of life in the global countryside. This colonial expansion
further enriched and empowered the 'western' nation
states. Beckert explains how other countries responded
by copying the colonial strategies and creating the
opportunities for future armed conflict among the original
colonialists and the new upstarts.
Completing the adaptive shifts Beckert describes the advocates
for industrialization
in the colonized global south and how over time they
joined the global cotton CAS disrupting the early western
manufacturing nodes and creating the current global CAS
dominated by merchants like Wal-Mart
pulling goods through a network of clothing manufacturers,
spinning and weaving factories, and growers competing with each
other on cost.
Following our summary of Beckert's book, RSS comments from the
perspective of CAS theory. The transformation of
disconnected peasant farmers, pastoral warriors and their lands
into a supply chain for a highly profitable industrial CAS
required the development over time: of military force, global
transportation and communication networks, perception and
representation control networks, capital stores and flows,
models, rules, standards and markets; along with the support at
key points of: barriers, disruption, and infrastructure and
evolved amplifiers. The emergent system demonstrates the
powerful constraining influence of extended phenotypic
alignment.
global
supply chain or our poorly adapted
responses to it. The toxic impact of smoking is an important
example. Some chronic diseases have This page reviews the implications of selection, variation and
heredity in a complex adaptive system (CAS).
The mechanism and its emergence are
discussed.
co-evolved with us. As such our
mental and immune responses are entrenched. But these
responses cannot take into account the effects and requirements
of medical treatment. Sonia Shah reviews the millennia old (500,000 years) malarial arms race between Humanity, Anopheles
mosquitoes and Plasmodium. 250 - 500 million people are
infected each year with malaria and one million die.
Sonia Shah's
study of malaria is illustrative. For most sufferers
malaria is a chronic, intermittent problem. It is just the
sort of issue that people ignore unless they present symptoms at
which point they seek treatment until the symptoms
subside. Like most chronic problems a more rigorous long
term strategy is required but, when it exists, is not judged
significant enough by the sufferer relative to other current
activities.
There are a number
of important transaction is an operation which guarantees to complete a defined set of activities or return to the initial state. For a fee the postal service will ensure that a parcel is delivered to its recipient or will return the parcel to the sender. To provide the service it may have to undo the act of trying to deliver the parcel with a compensating action. Since the parcel could be lost or destroyed the service may have to return an equivalent value to the sender.
types occurring in the health care network. They include:
the access
transaction, the treatment
transaction, the payment transaction
and the off-label
transaction.
US health
care access transaction
The access transaction controls patient access to the costly
health care resources.
There was little
access to health care services in the US during the early
20th century. As the reputation of doctors and
hospitals
improved during the 1920s the cost-of-care began to rise and insurance coverage
became necessary resulting in the This page discusses the mechanisms and effects of emergence
underpinning any complex adaptive system (CAS). Key research is
reviewed.
emergence
of the access transaction.
The shift by Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hosptial.
- Part B: Medical insurance
- Part C: Medicare Advantage
- Part D: Prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
to
reimbursing 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.
for DRG is a diagnosis-related group. It transformed the health care operating model, when 467 DRGs with standard payments were introduced by Medicare in the 1980s, enabling for-profit business strategies to seek ways to cut expenses and hence increase profits. The DRG is a classification, designed by Yale's Robert Fetter and John Thompson, intended to define the products that a hospital provides. It assumes patients within a grouping are clinically similar. Grouping is based on ICDs adjusted for age, sex, discharge status and comorbidities. For Medicare hospital inpatient claims the DRG is used to select the fee that will be reimbursed. coded procedures introduced
a powerful care provision profit amplifier (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 encouraged the
insurers to further constrain access.
The group practice is an integrated health care organization with salaried physicians and bundled pricing. Early examples included Kaiser Permanente and the Mayo Clinic.
counteracted this FFS trend but HMO legislation is the Health Maintenance Organization Act of 1973 which amended the PHSA to provide assistance for the creation of HMOs including: - Money for development
- An override of specific restrictive state laws
- A mandate offered to specific employers to offer an optional HMO plan as part of their employee benefits package.
ignored the
beneficial aspects of group practice while similarly limiting
policy holder access to only specific doctors.
Consumers typically request access Rather than oppose the direct thrust of some environmental flow agents
can improve their effectiveness with indirect responses.
This page explains how agents are architected to do this and
discusses some examples of how it can be done.
indirectly
during visits with PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. s and
subsequent referrals. The access transaction is validated
during appointment scheduling and
registration 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;
, from health
insurance companies. The company's profits improve
if they can limit access, so they deploy 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
amplifiers which encourage their clerical staff to limit
access. The cost savings for the insurer may not balance
the additional costs to the overall network of complications of
delayed or missed treatment. Consumers of health care
vary. Some are part of an E. O. Wilson & Bert Holldobler illustrate how bundled cooperative strategies can
take hold. Various social insects have developed
strategies which have allowed them to capture the most valuable
available niches. Like humans they invest in
specialization and cooperate to subdue larger, well equipped
competitors.
enterprise
and use bundling to leverage health care benefits.
Others are individuals who get costly and limited
coverage. Some consumers do not have insurance
coverage. They are forced to use costly treatment
transactions and risk financial ruin.
The ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). regulations provide a
partial relaxation of the access transaction constraints.
Unfortunately, the patient being emergently complex makes the
access transaction difficult to get correct, even though its
setup by a skilled doctor.
The ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
expanded patient
access to health care services by mandating insurance
coverage. But with the law's conflicting goals of
increasing access while reducing overall costs, cost sharing is the requirement for patients to pay a portion of the cost of their health care services. Such out-of-pocket payments include: copayments, deductibles and coinsurance.
constraints were consequently added to the access transaction: 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,
Network limitations - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans. This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans. By limiting the number of providers/doctors offered in the plans the few that are included should get more business. Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers). In large cities narrow networks are even more common. Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills. There are problems induced by narrow network constraints: - Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts. Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running. If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016).
;
which remains complex and compromised. And the
transaction's constraints can
be gamed by service
developers, distributors,
doctors,
providers
or pharmacies,
who remove the patient's cost constraints so as, to gain access
to more treatment and payment transactions.
US
health care treatment transaction
The diagnosis/treatment transaction is more complex than a
typical product
transaction since there are potentially six interacting
complex systems participating.
- 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. .
- 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.
- 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. 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).
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. .
- The doctor may be an independent agent working with
support and infrastructure from a
- Health care provider, part of the health care
system. Surgery, with its dependence on 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).
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.
- 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.
Historically the diagnosis/treatment transaction was between a
patient suffering from a disease, and a doctor who proposed to
help 'manage' the disease, as described by Peter
Medawar. The financial power was limited. The
ability of the doctor to affect the disease outcome was minimal,
but the patient probably didn't fully understand that.
There was little financial opportunity to encourage legal
action. Early
treatment regimes were best avoided! And even today
some treatments deliver more harm than good! Patients
vary, diagnosis is not perfect, and treatments may be costly, or
have unfortunate side effects. Health care leverages hope
for new treatments which can cause dilemmas for doctor and
patient. As ever, the benefit to the doctor and the
patient is only related through an 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.
The This page discusses the effect of the network on the agents participating in a complex
adaptive system (CAS). Small
world and scale free networks are considered.
network of Plans are interpreted and implemented by agents. This page
discusses the properties of agents in a complex adaptive system
(CAS).
It then presents examples of agents in different CAS. The
examples include a computer program where modeling and actions
are performed by software agents. These software agents
are aggregates.
The participation of agents in flows is introduced and some
implications of this are outlined.
agents that participate in a treatment
transaction has evolved and reflects the history, including This page discusses the impact of random events which once they
occur encourage a particular direction forward for a complex
adaptive system (CAS).
frozen accidents that occurred along
the way. Doctors and nurses have self-regulated positions
in the value chain.
The evolved nature of the agents includes typical memetic
operator exploration of the adjacent possible.
Improved models of medical science, diagnosis, and treatment and
associated actions have added to agent fitness.
The comparison between a historical treatment transaction and a
product sales transaction only
becomes legitimate once the product characteristics become
unique and complex. A house sale has some of the
flavor. But still the components of the house are
typically commoditized and replaceable. The house has a
design. An old building that has been remodeled repeatedly
seems a closer analogy. Particularly one with parts that
are mostly unique, or at most are only similar to todays
functionally equivalent replaceable commodity components.
An over-the-counter
foreign currency derivative trade seems an even closer
analog. As such a commercial treatment transaction should
be expected to be potentially costly, and of high uncertainty 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. for the
participants. The transaction
costs can be economized by integrating the components
within an iterative social structure, much like iterative
enterprise transactions can have reduced transaction
costs.
US health
care payment transaction
The payment transaction issues payments for services provided by
agents in the health care network. The transaction is
subject to alterations by the insurance provider issuing the
payments, so as to improve profits. But the decoupling of
the payment transaction from the cost of the treatment has
promoted 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.
.
Only politicians can constrain overtreatment and they are not
rewarded for doing so. Our analysis of
the health care network describes
the evolution of the payment transaction, the Plans emerge in complex adaptive
systems (CAS) to provide the
instructions that agents use to
perform actions. The component architecture and structure
of the plans is reviewed.
schematic constraints involved and key
hub agents leveraging the distortions.
US
health care off-label transaction
The off-label transaction disconnects medical product
development and testing from where the products can be
deployed. The markets for block-buster products can be
expanded without the huge costs of testing. However, this
disconnect removes the 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.
Shewhart cycle
that supports the quality improvement process.
US healthcare is ripe for
disruption. Christensen, Grossman and Hwang argue that
technologies are emerging which will support low cost business
models that will undermine the current network. Applying
complex adaptive system (CAS)
theory to these arguments suggests that the current power hierarchy can effectively resist
these progressive forces.
Christensen, Grossman and Hwang argue
that health care has now reached a point where 'precision'
medicine is a medical strategy where decisions, practices, and products are tailored to the individual patient. Research is looking at the impact of providing potentially deleterious genomic testing information to people: The REVEAL study found no increased anxiety induced by hearing that one's genome implied increased risk of developing late onset Alzheimer's disease. The take-up of personalized medicine benefits from the focus on genomics detailed by the NIH director Francis Collins and includes: - NCCN intensive cell therapies
- Direct to consumer genomic testing
- Direct to consumer diagnostics
- Pharmacogenomics tailored drug treatments reducing the risk and cost of adverse drug reactions.
, delivered by an aligned network of agents, can This page reviews Christensen's disruption
of a complex adaptive system (CAS).
The mechanism is discussed with examples from biology and
business.
disrupt the current US is the United States of America. health care network.
The nature of the treatment transaction is far more complex than
an engineered product transaction. It is likely that the
disruption will be initially significant for the problems and
treatments which turn out to be non-adaptive.
Christensen, Grossman and Hwang argue that the presence of
conflicting business models within the hospital
and physician businesses limits their overall efficiency and
effectiveness generating waste and other costs. Separation
of the 'job-shop',
'chain' and 'network' businesses should be enabled by
improved understanding of the disease mechanisms.
As the market shifts to precision diagnostics uses genomic analysis to diagnose genetic disorders - for example Genomic Health's Oncotype DX & Agendia's MammaPrint. The desire to see the genetic risk factors identified by such tests should depend on the risk * burden * Possibility of intervention. Early tests look at only single gene mutations. Genomic testing can be performed direct-to-consumer. Data is being collated on the genetic components of most diseases to enable more sophisticated diagnosis in the future such as the OPHG (EGAPP initiative), USPSTF recommendations and NCBI (Genetic test registry). While there is only limited identification of the significant mutations and limited patient bases misdiagnosis is a problem (Aug 2016).
and medicines, the target markets of specific products are
likely to shrink and off-label strategies will be less valuable
to product developers.
Major disruptions will have to gain market share without
encountering regulatory constraints. But the integrated
nature of the health care, financial and political networks
reduces the likelihood of this. Powerful agents are
moving to control new niches: point-of-care
diagnostics (PoCT) allows: - Immediate diagnosis in the PCP office, an ambulance, the home, the field or in hospital rather than waiting for the lab. It includes over the counter: glucose monitoring and pregnancy testing and professional: critical care, infectious disease (HIV, Chlamydia), cardiac monitors, diabetes, lipids, coagulation and hematology; with 'over the counter' providing the largest market and infectious disease PoCT the fastest growth. Devices range from: sticks and small hand-helds, to bench top versions of laboratory devices. Timely diagnosis allows rapid treatment. Predictive personalized and preemptive medicine can be designed based on PoCT. It is difficult to deliver a: timely - within 5 minutes - flexible, cost effective - $20 for infectious disease, accurate, easy to use, safe; PoCT device. PoCT patients require tests to be free or appropriate while clinicians want to maximize simplicity and coverage. Diagnostics [will] include:
- Operator interface
- Bar code identification
- Chemical reactors (large sample diagnostics: Early LOC, LFS; and molecular diagnostics: LOC, Paper-based;) which only require a small amount of blood. Preparation of the sample avoiding contamination have been major challenges often requiring a laboratory-like facility.
- Molecular diagnostic sample amplification: PCR, LAMP, RCA;
- Optical or electochemical probes
- Low cost imaging devices
- Reagent storage
- Networking and storage
.
The pervasive influence of parasites 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.
leveraged through the political control system on the health
care network amplifiers limits the potential of other actions to
reduce the growth of problems: Maternal
deaths; and costs. The possibility of political
reform seems remote. While popular movements demand change
most of the influential actors are benefiting from the current
distortions. Even the undermining of national
competitiveness relative to the cost structure of China, India,
Japan and Europe would not necessarily impact the financiers and
other elites. But when the majority of the population is
required to align to ensure national survival the political
landscape may need/have to accommodate their expectations.
CAS modeling of the US health care system reveals the
opportunities and uncertainties 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.
inherent in such an extensive network. It also cautions
against assuming the system can be equated with adaptive systems
which contain fully architected components.
 Politics, Economics & Evolutionary Psychology |
Business Physics Nature and nurture drive the business eco-system Human nature Emerging structure and dynamic forces of adaptation |
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integrating quality appropriate for each market |
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