Changing the U.S. Health Care System

Figures and Tables xv Foreword to the Third Edition xix Foreword to the Fourth Edition xxi The Editor xxv The Authors xxvii Introduction and Overview xliii Acknowledgments lvii PART ONE: ACCESS TO HEALTH CARE 1 1 The Patient Protection and Affordable Care Act of 2010 3 Gerald F. Kominski Learning Objectives 3 Events Leading to the Enactment of the ACA 4 Major Provisions of the ACA 7 Future Directions 20 Summary 25 Key Terms 26 Discussion Questions 28 2 Improving Access to Care 33 Ronald M. Andersen, Pamela L. Davidson, Sebastian E. Baumeister Learning Objectives 33 Understanding Access to Health Care 34 Future Directions 60 Summary 63 Key Terms 63 Discussion Questions 64 3 Racial and Ethnic Disparities in Health Status 71 Antronette K. Yancey, Roshan Bastani, Beth A. Glenn Learning Objectives 71 Epidemiology of Health Disparities 73 Factors Underlying Chronic Disease-Related Disparities 82 Future Directions 92 Summary 94 Key Terms 94 Discussion Questions 95 4 Racial and Ethnic Disparities in Health Care 103 Arturo Vargas Bustamante, Leo S. Morales, Alexander N. Ortega Learning Objectives 103 Definition of Disparity in Health Care 105 Historical Overview of Disparities in Medical Care 109 Scientific Evidence of Disparities in Health Care 115 Future Directions 122 Summary 125 Key Terms 126 Discussion Questions 126 5 Multilevel Social Determinants of Health 135 Ninez A. Ponce, Michelle Ko Learning Objectives 135 Policy Frameworks for Social Determinants of Health 137 Mechanisms by Which Social Context Affects Health Care 142 Future Directions 147 Summary 148 Key Terms 149 Discussion Questions 150 6 Public Health Insurance 157 Shana Alex Lavarreda, E. Richard Brown Learning Objectives 157 Medicare, Medicaid, and CHIP 159 Who is Left Out of Public Coverage? 169 Enactment of the Affordable Care Act of 2010: A Political Success Story 179 Future Directions 183 Summary 183 Key Terms 184 Discussion Questions 185 7 Private Health Insurance 191 Nadereh Pourat, Gerald F. Kominski Learning Objectives 191 Evolution of Private Health Insurance 192 Concepts in Private Health Insurance 194 Employment-Based Health Insurance 200 Individually Purchased Health Insurance 207 Significant Trends in Private Health Insurance 208 Future Directions 213 Summary 216 Key Terms 216 Discussion Questions 218 PART TWO: COST OF HEALTH CARE 223 8 Measuring Health Care Expenditures and Trends 225 Thomas H. Rice Learning Objectives 225 Measuring Health Care Expenditures 226 Trends in Health Care Expenditures 233 Future Directions 239 Summary 239 Key Terms 242 Discussion Questions 243 9 Containing Health Care Costs 245 Thomas H. Rice, Gerald F. Kominski Learning Objectives 245 Framework 246 Future Directions 263 Summary 264 Key Terms 264 Discussion Questions 265 10 Promoting Pharmaceutical Access While Controlling Prices and Expenditures 269 Stuart O. Schweitzer, William S. Comanor Learning Objectives 269 The Problem of Drug Expenditures 271 Interpreting Pharmaceutical Price Data 275 International Price Comparisons 279 Determining Drug Prices 281 Approaches for Containing Pharmaceutical Costs 289 The Link Between Pharmaceutical Expenditures and Research 293 Recent Events Surrounding Pharmaceutical Costs and Access 294 Future Directions 298 Summary 298 Note 299 Key Terms 299 Discussion Questions 300 PART THREE: QUALITY OF HEALTH CARE 305 11 Measuring Health-Related Quality of Life and Other Outcomes 307 Patricia A. Ganz, Ron D. Hays, Robert M. Kaplan, Mark S. Litwin Learning Objectives 307 Definition, Conceptualization, and Measurement of Quality of Life 310 Contributions From the Literature 318 Comparative Effectiveness Research 328 Future Directions 331 Summary 332 Key Terms 333 Discussion Questions 334 12 Evaluating the Quality of Care 343 Elizabeth A. McGlynn Learning Objectives 343 The Multiple Dimensions of Quality 344 Criteria for Evaluating Quality Measures 345 A Conceptual Framework for Quality Assessment 347 Structure 348 Process 355 Outcomes 365 Future Directions 371 Summary 372 Key Terms 373 Discussion Questions 374 13 Public Release of Information on Quality 381 Elizabeth A. McGlynn, John L. Adams Learning Objectives 381 Public Information on Quality 383 Some Methodological Issues in Performance Reporting 391 What is Known About the Impact of Public Reporting? 402 Future Directions 406 Summary 406 Key Terms 407 Discussion Questions 408 14 Health Care Information Systems 413 Jeff Luck, Leah J. Vriesman, Paul Fu Jr. Learning Objectives 413 Information Systems and Informatics 414 Benefits, Implementation Barriers, and Federal Policy Responses 414 Applications of Information Systems by Health Care Providers 417 Public Health Informatics 434 Applications of Information Systems by Health Plans and Payers 438 Future Directions 441 Summary 445 Key Terms 445 Discussion Questions 446 15 Performance Measurement of Nursing Care 455 Jack Needleman, Ellen T. Kurtzman, Kenneth W. Kizer Learning Objectives 455 Why Measure Nursing Performance? 455 The Scope of Nursing's Contribution to Inpatient Hospital Care 457 Issues in Constructing Nursing-Sensitive Performance Measures 461 Measuring Nursing Performance 463 Measuring Nursing Performance: The State of the Science 478 Future Directions 485 Summary 486 Key Terms 487 Discussion Questions 487 PART FOUR: SPECIAL POPULATIONS 493 16 Long-Term Services and Supports for the Elderly Population 495 Steven P. Wallace, Nadereh Pourat, Linda Delp, Kathryn G. Kietzman Learning Objectives 495 Institutional Care 497 Community-Based Services 502 Informal Care 507 Workers in the Long-Term Care System 509 Future Directions 516 Summary 517 Note 517 Key Terms 517 Discussion Questions 518 17 HIV and AIDS in the Twenty-First Century 523 Erin G. Grinshteyn, William E. Cunningham Learning Objectives 523 The Changing Epidemiology and Clinical Treatment of HIV/AIDS 525 Prevention and Education 538 Policy Implications and Research Needs for Management, Planning, and AIDS Policy 543 Future Directions 546 Summary 547 Key Terms 548 Discussion Questions 550 18 Children's Health 559 Moira Inkelas, Neal Halfon, David Lee Wood Learning Objectives 559 Special Health Needs of Children 561 Health Service Delivery for U.S. Children 564 Financing Children's Health Care 569 Improving the Child Health System 576 Future Directions 585 Summary 585 Key Terms 586 Discussion Questions 587 19 Homeless Persons 593 Lisa Arangua, Lillian Gelberg Learning Objectives 593 A Profile of the Homeless 594 Health Status 597 Mental Illness and Substance Abuse 604 Use of Physical Health Services 606 Use of Mental Health and Substance Abuse Services 608 Barriers to Health Care 609 Future Directions 610 Summary 612 Key Terms 612 Discussion Questions 613 PART FIVE: DIRECTIONS FOR CHANGE 621 20 Changing the Health Care Delivery System 623 Nadereh Pourat, Hector P. Rodriguez Learning Objectives 623 Conceptual Framework: Intervention and Innovations to Correct System Failures 625 Future Directions 641 Summary 642 Key Terms 642 Discussion Questions 644 21 Medicare Reform 651 Gerald F. Kominski, Jeanne T. Black, Thomas H. Rice Learning Objectives 651 Origin and Philosophy of Medicare 652 Evolution of Medicare 656 Is Medicare Facing a Crisis? 663 Future Directions 670 Summary 673 Key Terms 674 Discussion Questions 675 22 Public Health and Clinical Care 681 Jonathan E. Fielding, Lester Breslow, Steven M. Teutsch Learning Objectives 681 Public Health's Mission and Scope 682 Prevention In Clinical Care Services 685 Public Health and Provision of Clinical Care Services 689 Direct Medical Service Delivery by Government 691 Future Directions 692 Summary 699 Key Terms 700 Discussion Questions 700 23 Strengthening the Safety Net 703 Dylan H. Roby Learning Objectives 703 Defining the Safety Net 704 Ensuring Access to Care for the Poor, Uninsured, and Underserved 705 Financing the Safety Net 706 Size and Scope of the Safety Net 707 Reducing Costs 715 Improving Quality 716 Future Directions 719 Summary 719 Key Terms 720 Discussion Questions 721 24 Ethical Issues in Public Health and Health Services 727 Pauline Vaillancourt Rosenau, Ruth Roemer, Frederick J. Zimmerman Learning Objectives 727 Overarching Public Health Principles: Our Assumptions 730 Ethical Issues in the Allocation of Resources 730 Ethical Issues in Research 737 Ethical Issues in Economic Support 738 Ethical Issues in Management of Health Services 740 Ethical Issues in Delivery of Care 741 Future Directions 744 Summary 745 Key Terms 746 Discussion Questions 747 Index 753 11181298573ENPreface xv CHAPTER 1 Introduction to Systematic Trading 1 1.1 Definition of Systematic Trading 2 1.2 Philosophy of Trading 3 1.2.1 Lessons from the Market 3 1.2.2 Mechanism vs. Organism 5 1.2.3 The Edge of Complexity 5 1.2.4 Is Systematic Trading Reductionistic? 6 1.2.5 Reaction vs. Proaction 6 1.2.6 Arbitrage? 7 1.2.7 Two Viable Paths 7 1.3 The Business of Trading 7 1.3.1 Profitability and Track Record 8 1.3.2 The Product and Its Design 10 1.3.3 The Trading Factory 12 1.3.4 Marketing and Distribution 15 1.3.5 Capital, Costs, and Critical Mass 16 1.4 Psychology and Emotions 19 1.4.1 Ups and Downs 19 1.4.2 Peer Pressure and the Blame Game 20 1.4.3 Trust: Continuity of Quality 20 1.4.4 Learning from Each Other 21 1.5 From Candlesticks in Kyoto to FPGAs in Chicago 22 PART ONE Strategy Design and Testing CHAPTER 2 A New Socioeconomic Paradigm 33 2.1 Financial Theory vs. Market Reality 33 2.1.1 Adaptive Reactions vs. Rigid Anticipations 33 2.1.2 Accumulation vs. Divestment Games 37 2.1.3 Phase Transitions under Leverage 38 2.1.4 Derivatives: New Risks Do Not Project onto Old Hedges 40 2.1.5 Socio-Political Dynamics and Feedbacks 41 2.2 The Market Is a Complex Adaptive System 42 2.2.1 Emergence 43 2.2.2 Intelligence Is Not Always Necessary 44 2.2.3 The Need to Adapt 45 2.3 Origins of Robotics and Artificial Life 45 CHAPTER 3 Analogies between Systematic Trading and Robotics 49 3.1 Models and Robots 49 3.2 The Trading Robot 50 3.3 Finite-State-Machine Representation of the Control System 52 CHAPTER 4 Implementation of Strategies as Distributed Agents 57 4.1 Trading Agent 57 4.2 Events 60 4.3 Consuming Events 60 4.4 Updating Agents 61 4.5 Defining FSM Agents 63 4.6 Implementing a Strategy 66 CHAPTER 5 Inter-Agent Communications 73 5.1 Handling Communication Events 73 5.2 Emitting Messages and Running Simulations 75 5.3 Implementation Example 76 CHAPTER 6 Data Representation Techniques 83 6.1 Data Relevance and Filtering of Information 83 6.2 Price and Order Book Updates 84 6.2.1 Elementary Price Events 85 6.2.2 Order Book Data 85 6.2.3 Tick Data: The Finest Grain 88 6.3 Sampling: Clock Time vs. Event Time 89 6.4 Compression 90 6.4.1 Slicing Time into Bars and Candles 90 6.4.2 Slicing Price into Boxes 96 6.4.3 Market Distributions 97 6.5 Representation 97 6.5.1 Charts and Technical Analysis 99 6.5.2 Translating Patterns into Symbols 101 6.5.3 Translating News into Numbers 102 6.5.4 Psychology of Data and Alerts 104 CHAPTER 7 Basic Trading Strategies 105 7.1 Trend-Following 105 7.1.1 Channel Breakout 106 7.1.2 Moving Averages 106 7.1.3 Swing Breakout 112 7.2 Acceleration 114 7.2.1 Trend Asymmetry 115 7.2.2 The Shadow Index 116 7.2.3 Trading Acceleration 117 7.3 Mean-Reversion 118 7.3.1 Swing Reversal 118 7.3.2 Range Projection 120 7.4 Intraday Patterns 122 7.4.1 Openings 122 7.4.2 Seasonality of Volatility 122 7.5 News-Driven Strategies 124 7.5.1 Expectations vs. Reality 124 7.5.2 Ontology-Driven Strategies 125 CHAPTER 8 Architecture for Market-Making 127 8.1 Traditional Market-Making: The Specialists 127 8.2 Conditional Market-Making: Open Outcry 128 8.3 Electronic Market-Making 129 8.4 Mixed Market-Making Model 131 8.5 An Architecture for a Market-Making Desk 134 CHAPTER 9 Combining Strategies into Portfolios 139 9.1 Aggregate Agents 139 9.2 Optimal Portfolios 141 9.3 Risk-Management of a Portfolio of Models 142 CHAPTER 10 Simulating Agent-Based Strategies 145 10.1 The Simulation Problem 146 10.2 Modeling the Order Management System 147 10.2.1 Orders and Algorithms 148 10.2.2 Simulating Slippage 149 10.2.3 Simulating Order Placement 151 10.2.4 Simulating Order Execution 153 10.2.5 A Model for the OMS 155 10.2.6 Operating the OMS 156 10.3 Running Simulations 158 10.3.1 Setting Up a Back Test 158 10.3.2 Setting Up a Forward Test 160 10.4 Analysis of Results 162 10.4.1 Continuous Statistics 163 10.4.2 Per-Trade Statistics 164 10.4.3 Parameter Search and Optimization 165 10.5 Degrees of Over-Fitting 167 PART TWO Evolving Strategies CHAPTER 11 Strategies for Adaptation 173 11.1 Avenues for Adaptations 173 11.2 The Cybernetics of Trading 175 CHAPTER 12 Feedback and Control 179 12.1 Looking at Markets through Models 179 12.1.1 Internal World 179 12.1.2 Strategies as Generalized Filters 180 12.1.3 Implicit Market Regimes 181 12.1.4 Persistence of Regimes 183 12.2 Fitness Feedback Control 184 12.2.1 Measures of Fitness 186 12.3 Robustness of Strategies 192 12.4 Efficiency of Control 193 12.4.1 Triggering Control 193 12.4.2 Measuring Efficiency of Control 194 12.4.3 Test Results 196 12.4.4 Optimizing Control Parameters 197 CHAPTER 13 Simple Swarm Systems 199 13.1 Switching Strategies 199 13.1.1 Switching between Regimes 200 13.1.2 Switching within the Same Regime 200 13.1.3 Mechanics of Switching and Transaction Costs 205 13.2 Strategy Neighborhoods 206 13.3 Choice of a Simple Individual from a Population 208 13.4 Additive Swarm System 210 13.4.1 Example of an Additive Swarm 211 13.5 Maximizing Swarm System 214 13.5.1 Example of a Maximizing Swarm 215 13.6 Global Performance Feedback Control 216 CHAPTER 14 Implementing Swarm Systems 219 14.1 Setting Up the Swarm Strategy Set 220 14.2 Running the Swarm 220 CHAPTER 15 Swarm Systems with Learning 223 15.1 Reinforcement Learning 224 15.2 Swarm Efficiency 224 15.3 Behavior Exploitation by the Swarm 225 15.4 Exploring New Behaviors 227 15.5 Lamark among the Machines 227 PART THREE Optimizing Execution CHAPTER 16 Analysis of Trading Costs 231 16.1 No Free Lunch 231 16.2 Slippage 232 16.3 Intraday Seasonality of Liquidity 233 16.4 Models of Market Impact 234 16.4.1 Reaction to Aggression 235 16.4.2 Limits to Openness 235 CHAPTER 17 Estimating Algorithmic Execution Tools 237 17.1 Basic Algorithmic Execution Tools 237 17.2 Estimation of Algorithmic Execution Methodologies 240 17.2.1 A Simulation Engine for Algos 240 17.2.2 Using Execution Algo Results in Model Estimation 241 17.2.3 Joint Testing of Models and Algos 242 PART FOUR Practical Implementation CHAPTER 18 Overview of a Scalable Architecture 247 18.1 ECNs and Translation 247 18.2 Aggregation and Disaggregation 249 18.3 Order Management 250 18.4 Controls 250 18.5 Decisions 251 18.6 Middle and Back Office 251 18.7 Recovery 252 CHAPTER 19 Principal Design Patterns 253 19.1 Language-Agnostic Domain Model 253 19.2 Solving Tasks in Adapted Languages 254 19.3 Communicating between Components 257 19.3.1 Messaging Bus 258 19.3.2 Remote Procedure Calls 259 19.4 Distributed Computing and Modularity 260 19.5 Parallel Processing 262 19.6 Garbage Collection and Memory Control 263 CHAPTER 20 Data Persistence 265 20.1 Business-Critical Data 265 20.2 Object Persistence and Cached Memory 267 20.3 Databases and Their Usage 269 CHAPTER 21 Fault Tolerance and Recovery Mechanisms 273 21.1 Situations of Stress 273 21.1.1 Communication Breakdown 273 21.1.2 External Systems Breakdown 274 21.1.3 Trades Busted at the ECN Level 275 21.1.4 Give-Up Errors Causing Credit Line Problems 276 21.1.5 Internal Systems Breakdown 277 21.1.6 Planned Maintenance and Upgrades 277 21.2 A Jam of Logs Is Better Than a Logjam of Errors 277 21.3 Virtual Machine and Network Monitoring 278 CHAPTER 22 Computational Efficiency 281 22.1 CPU Spikes 281 22.2 Recursive Computation of Model Signals and Performance 282 22.3 Numeric Efficiency 285 CHAPTER 23 Connectivity to Electronic Commerce Networks 291 23.1 Adaptors 291 23.2 The Translation Layer 292 23.2.1 Orders: FIX 292 23.2.2 Specific ECNs 293 23.2.3 Price Sources: FAST 293 23.3 Dealing with Latency 294 23.3.1 External Constraints and Co-Location 294 23.3.2 Avoid Being Short the Latency Option 295 23.3.3 Synchronization under Constraints 296 23.3.4 Improving Internal Latency 297 CHAPTER 24 The Aggregation and Disaggregation Layer 299 24.1 Quotes Filtering and Book Aggregation 300 24.1.1 Filtering Quotes 300 24.1.2 Synthetic Order Book 301 24.2 Orders Aggregation and Fills Disaggregation 301 24.2.1 Aggregating Positions and Orders 301 24.2.2 Fills Disaggregation 303 24.2.3 Book Transfers and Middle Office 303 CHAPTER 25 The OMS Layer 305 25.1 Order Management as a Recursive Controller 305 25.1.1 Management of Positions 307 25.1.2 Management of Resting Orders 307 25.1.3 Algorithmic Orders 308 25.2 Control under Stress 309 25.3 Designing a Flexible OMS 310 CHAPTER 26 The Human Control Layer 311 26.1 Dashboard and Smart Scheduler 311 26.1.1 Parameter Control 311 26.1.2 Scheduled Flattening of Exposure 312 26.2 Manual Orders Aggregator 313 26.2.1 Representing a Trader by an Agent 313 26.2.2 Writing a Trading Screen 314 26.2.3 Monitoring Aggregated Streams 314 26.3 Position and P & L Monitor 314 26.3.1 Real-Time Exposure Monitor 315 26.3.2 Displaying Equity Curves 315 26.3.3 Online Trade Statistics and Fitnesses 315 26.3.4 Trades Visualization Module 317 CHAPTER 27 The Risk Management Layer 319 27.1 Risky Business 319 27.2 Automated Risk Management 320 27.3 Manual Risk Control and the Panic Button 320 CHAPTER 28 The Core Engine Layer 323 28.1 Architecture 323 28.2 Simulation and Recovery 325 CHAPTER 29 Some Practical Implementation Aspects 327 29.1 Architecture for Build and Patch Releases 327 29.1.1 Testing of Code before a Release 327 29.1.2 Versioning of Code and Builds 328 29.1.3 Persistence of State during Version Releases 328 29.2 Hardware Considerations 329 29.2.1 Bottleneck Analysis 329 29.2.2 The Edge of Technology 330 Appendix Auxiliary LISP Functions 333 Bibliography 341 Index 351