Problems of US health care
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Problems of US Health care

Summary
Donald Barlett and James Steele write about their investigations of the major problems afflicting US is the United States of America.   health care as of 2006. 
Critical Condition
In Donald Barlett and James Steele's book 'Critical Condition' they catalog the classes of problem:
Barlett and Steele lament that the US has got a second rate health care network, even as it invests more than any other country in total or per person.  The best health care is available, but only to about two to three percent of Americans. 

They justify their conclusion with distressing examples of failures across the network. 

There is rampant over charging.  Prices are set high and then hugely discounted for the strongest population segments. 

There is no safety net for the weakest segment.  The federal legislation COBRA is the consolidated Omnibus Budget Reconciliation Act of 1985 with amended ERISA to give some employees the ability to continue health care coverage after leaving employment.   is judged too expensive for the poorest people to afford.  For those able to obtain insurance, caps limited the protection that could be obtained.  As of 2006 the lack of a premium base had induced the insurance providers to seek exclusions.  The affordable care act 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 SCOTUS decision. 
  • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
  • Medical home models.  
  • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
  • Qualifications for ACOs.  Organizations must:
    • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
    • Participate in the MSSP for three or more years. 
    • Have a management structure. 
    • Have clinical and administrative systems. 
    • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
    • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
    • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
    • Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
  • CMMI Medicare payment experimentation.  
  • Requirements that pharmaceutical companies must report payments made to physicians. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
aims to address the premium base. 

The billing of treatments is opaque, and both the insurers and billers are encouraged in seeking profits to push the patient to pay.  Time and education are needed to ensure that billing issues are identified, and fixed.  Instead poorly educated, over worked, families with seriously ill members are encouraged to take out high cost loans to settle the billed amounts.  Debt collectors are used to enforce the strategy. 

Barlett and Steele judge the US to be spending more for health care than other nations while getting less.  For a while the enterprises that many Americans work for subsidized the increasing cost of their employees' health care.  Eventually, they passed the cost increases along to their employees. 

Barlett and Steele argue that the costs are rising because of rampant 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. 
, increasing malpractice costs, increased treatment of chronic ailments, market orientation, manipulation and inefficiency within the network.  Hospitals offer costly centralized services whatever the patient's need.  Profit seeking behavior is unconstrained.  The highest price increases occur in prescription drugs.  US prices are 30 - 60% higher than in other health services.  Success in reducing death from acute disease has increased the numbers of patients with chronic problems which are treated with a life time drug prescription. 

Treatment processes are made ineffective, by a focus on improved efficiency.  Barlett and Steele describe how departmental cost management in hospitals has reduced the available spare beds.  This appears to reduce direct costs, but the lack of bed capacity generates queues all the way to the ER 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). 
where costly beds cannot be freed, and so ambulances are forced to hunt for hospitals with available ER beds.  They show how this impacts the matching of patient insurance coverage to hospital ER and impacts patients' health and financial situation. 

Barlett and Steele discuss the modeling of problems in the health care network.  It is likely that the system under-reports problems.  Reporting errors is discouraged by the potential for malpractice law suits and the cost of malpractice insurance.  They conclude that the health care network has many issues which are dangerous and very costly.  There are many complex transactions 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. 
where handovers fail.  Conflicts of interest exist.  Financial incentives, provided to doctors from manufacturers, have criminally distorted the interpretation of data and decision making processes. 

Barlett and Steele describe how the pressure on manufacturers to extend their product's markets encourages them to pay doctors to recommend off-label uses to other doctors. 

They show how the politicians, who are in the best position to define and enforce regulations to limit corruption, and improve transparency, have encouraged the health care network to seek profits.  This has resulted in integration of the political network, financial services network and the health care network.  The health care industry has become a big lobbyist and political donor.  Regulation shaped with the help of industry representatives, has blocked low cost drugs from Canada, and proved very beneficial to the industry (F.D.A. Food and Drug Administration. 
, MMA is the Medicare Modernization Act of 2003.  It includes Medicare part D the Medicare prescription drug benefit which constrains Medicare from negotiation its drug prices and created MAC and RAC.  IT was sponsored by Senator Bill Tauzin and implemented by Tom Scully. 
).  Prior to, and subsequent to being Presidential administration officials and congressmen some public officials were health care executives and lobbyists.  The leading companies have a record of defrauding 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 
  • 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. 
, and TRICARE is the DOD civilian health care program for military personnel, retirees and their dependents.  It is the civilian component of the Military Health System managed by the DHA.  Congress goal was to allow military personnel increased access to health care resources available in the civilian economy. 
Barlett and Steele lament. 
Wall Street medicine
Barlett and Steele describe how Wall Street supplied 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). 
enabling financiers to purchase multiple health care businesses, integrate them with promises of improved operating performance, and then benefit from the salaries and stock appreciation.  But they lament that more than once fraudulent accounting was used to make the results attractive to investors.  Often, improved profits depended on leverage of a government funded, or induced, niche.  Still for Wall Street each restructuring generated profitable fees. 

Nixon's administration invested $350 million in HMO is a health maintenance organization.  Originally HMOs were fashioned after Dr. Paul Ellwood's admiration for group practices such as: Kaiser Permanente, Mayo Clinic; which employed salaried physicians and charged fixed fees rather than FFS.  Ellwood argued that this architecture helped keep subscribers healthy which he termed a health maintenance organization.  President Nixon was convinced by Ellwood signing the HMO Act.  But the legislated HMO did not have to conform to Ellwood's group practice architecture.  Instead by 1997 for-profit commercial insurance companies operated two-thirds of the HMO business.  The legislated HMO:
  • Provides or arranges managed care for:
    • Health insurance
    • Self-funded health care benefit plans
    • Individuals
  • Acts as a liaison with health care providers
  • Covers care rendered by those doctors and others who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in return for access to patients.  Treatment choices were often driven by insurance company rules.  Financial incentives often based the contracted physician income on success in reducing expenses rather than health outcomes.  There are a variety of contracts with physicians:
    • Closed panel plan
    • Open panel plan
    • Network model plan
  • Covers emergency care regardless of the providers contracted status. 
s copying the non-profit Kaiser group practice is an integrated health care organization with salaried physicians and bundled pricing.   Early examples included Kaiser Permanente and the Mayo Clinic. 
in California.  By 1980 the investment had created 300 such non-profits.  The Reagan administration adopted a Stanford university economic model which suggested making the HMO's profit seeking to finance the application of computer enhanced processes, improve efficiency and reduce costs.  The goal was to induce insurers, doctors and hospitals to organize into rival health care delivery groups which would compete on price and quality of service.  Barlett and Steele wonder how patients were going to be able to choose among these groups.  While costs continued to escalate this initial financial restructuring generated millions for the owners, and initial shareholders (Wall Street bankers), from the IPO is initial public offering. 
s. 

After the HMOs Wall Street restructured US is the United States of America.   Hospitals, and then in 1995 the physician practices.  As usual capital was judged as enabling a restructuring that would allow doctors to become as powerful as the HMOs and Hospitals.  But while dubious accounting could present investors with reasons to raise the share price of the physician practice management (PPM is physician practice management.  This consolidation of PCP practices was partly a response to Wall Street's capitalization of HMOs and hospitals in early 1990s.  As Wall Street switched to financing PPMs, enabling Medpartners's purchase of Mullikin Inc., hospitals responded by buying up the PPMs.  Most PPMs struggled to control costs in the capitated care framework of the 1990s.  Some of these PPMs shifted to become PBMs. 
) companies the power really shifted to the financiers and administrators.  Doctors operating practices did not drastically improve from the restructuring, but overheads increased. 

Barlett and Steele note that Wall Street proposed to leverage Just-in-time manufacturing practices into hospital practice is the application of the Toyota quality improvement process.  This focuses on:
  • Removing the seven critical wastes:
    1. Excessive motion
    2. Waiting time
    3. Over production
    4. Unnecessary processing time
    5. Defects
    6. Excessive resources
    7. Unnecessary/ineffective handoffs
  • The result should be improved processes and outcomes, reduced cost and increasing patient and staff satisfaction. 
  • It is typical to use metric collection and analysis to understand where the issues are and if they are being corrected.  
.  But the strategy was not based on an end-to-end architectural reengineering of medical operations.  Instead inventories were limited so that operations would have to be interrupted while resources were transferred to the requesting surgeon.  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.   ensued.  Barlett and Steele note that salaries are the largest costs in hospitals so the strategy increased overall costs

To control escalating treatment costs PPMs were required to apply capitation is a global payment for all care for a patient during a specified time period.  It forces the provider of care to take a high risk.  Managing the risk implies successful population health management. 
.  HMOs agreed to pay a yearly fixed fee per patient to the PPM.  The PPM would be profitable as long as the patients' treatments cost less than the capitation amount.  Some capitation fees were too little to even cover preventative medicine.  PPMs went bankrupt.  Patients avoided health care systems requiring capitation.  Costs continued to escalate. 

Barlett and Steele note that profit oriented HMOs actually became huge costly, inefficient bureaucracies.  They specialize in limiting payments and delaying payments, to shift expense to the patients.  Greater than a thousand health plans, with overlap and duplication are administered individually with discrete call centers, claims operations and 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.  
formulas.  But each of the 1000 is essentially doing the same thing!

Barlett and Steele describe how actuarial models are developed, at a cost of $100 million a year, which are used by insurers to define guidelines on treatments proposed by doctors.  They note that the models tend towards the low end of treatment times and have resulted in increased deaths from lack of treatment. 

In general US Health care administration costs three times as much as the equivalent administration in Canada.  They attribute the difference to Canada's single insurance and billing system. 

In the US the American Medical Association (AMA is the American Medical Association. 
) has developed a $70million a year business defining CPT codes the AMA specified procedure treatment codes for medical and psychiatric procedures performed by physicians and surgeons used when billing for procedures.  The AMA operates a $70M business which develops the classifications in secret.  Doctors are not informed of changes.  Insurers 'bundle' and 'downcode' treatments that have been performed.  Potentially doctors may lose money on the overall treatment.   which doctors must specify to obtain payment for services provided during treatment.  Doctors are not told about changes to the codes which the AMA performs secretly.  Insurers use software to bundle (pay for only one of the services which are deemed equivalent) and downcode is where a cheaper 'equivalent treatment' is payed for in response to an insurers being charged for a provided treatment.   (substitute a cheaper equivalent treatment payment) treatments, so doctors can find that only part of the services they provided are reimbursed.  Doctor's lose money, and chaos increases the costs of billing. 

Call centers are being used to limit patient's access to costly doctors and nurses.  First in the line of treatment are call center operators who use computer coordinated scripts to decide when a patient can gain access to medically trained staff.  Incentives are used which encourage the operators to limit access.  But mistakes result in patient's problems escalating resulting in more costly and serious treatments. 
Madison Avenue medicine
For-profit health care benefits from 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. 
.  Barlett and Steele explain how advertising has been focused on raising awareness of potential illnesses that viewers may be suffering from. 

In 1997 the drug industry lobbied congress to allow advertising on TV of drug ads direct to consumers - including offers of trails and free samples.  Congress also increased the notification time the F.D.A. Food and Drug Administration. 
must wait before acting on misleading advertising.  The industry also benefit from congress restricting the budget the F.D.A. is provided for monitoring the ads.  With limited resources, problematic ads have had their effect and been withdrawn before the F.D.A. has been able to act. 

The value of the advertising is in adding consumer pressure for doctors to prescribe drugs 'off-label'.  Doctors are allowed to prescribe drugs as they see fit, not just in the area where the drug has been tested and verified as useful and safe.  However, it is illegal for the industry to encourage the doctors to prescribe off-label.  Drug companies gain if their drugs expand their area of treatment without costly additional trials. 
Proposed remedy
Barlett and Steele argued that the US is the United States of America.   could leverage 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 
  • 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. 
infrastructure to provide universal coverage and a standardized infrastructure for administration.  But they concede that the for-profit health care industry has been very successful in arguing that this strategy is unacceptable 'big government'. 

The application of
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
represents the US health care network as a set of
This page discusses the mechanisms and effects of emergence underpinning any complex adaptive system (CAS).  Key research is reviewed. 
emergent
niches as categorized by
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
.  But to frame the issues identified by Barlett and Steels it is also useful to view US health care as part of the network comprising the US Nation state.  Some of the
This page discusses the physical foundations of complex adaptive systems (CAS).  A small set of rules is obeyed.  New [epi]phenomena then emerge.  Examples are discussed. 
key rules
governing health care are defined by Congressional and State laws.  Resource
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 are controlled
directly, or
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
, by Congress.  Congress has acted to integrate the health care network and the
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. 
US financial network
.  This has resulted in the emergence of adaptive relationships which appear parasitic 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.   to the health care network. 

Barlett and Steele highlight problems which are typical CAS effects including:

Barlett and Steele's exceptional journalism is highly informative and should be broadly understood.  While the Patient Protection and Affordable Care Act 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 SCOTUS decision. 
  • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
  • Medical home models.  
  • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
  • Qualifications for ACOs.  Organizations must:
    • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
    • Participate in the MSSP for three or more years. 
    • Have a management structure. 
    • Have clinical and administrative systems. 
    • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
    • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
    • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
    • Demonstrate it meets HHS patent-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
  • CMMI Medicare payment experimentation.  
  • Requirements that pharmaceutical companies must report payments made to physicians. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
of 2010 addresses some of the key issues identified by Barlett and Steele many of the problems still exist and are not resolved.  The cost of US health care continues to rise.  


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This page looks at schematic structures and their uses.  It discusses a number of examples:
  • Schematic ideas are recombined in creativity. 
  • Similarly designers take ideas and rules about materials and components and combine them. 
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As a working example it presents part of the contents and schematic details from the Adaptive Web Framework (AWF)'s operational plan. 

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