Monday, September 18, 2017

The Energy, Metabolism and Entropy Within Organizations

October 26, 2017

Nilza I. Cruz Ruiz 
939-644-7683



"Philosophy is written in that great book which ever lies before your eyes – I mean the universe… This book is written in mathematical language and its characters are triangles, circles and other geometrical figures, without whose help… one wanders in vain through a dark labyrinth."

"With regard to matters requiring thought: the less people know and understand about them, the more positively they attempt to argue concerning them."

– Galileo Galilei


The "Macro" Picture

 Life: quite probably the most complex phenomenon in the Universe. It takes on an impressive variety of forms, properties, functions and behaviors over a huge range of scales. Each of the organisms that constitute the biosphere have evolved by the process of natural selection following a unique historical path. Then, add to the biological life, the underlying complexity related with social life, which we, as humans have introduced into the planet, especially in the form of cities, and all the astounding phenomena they encompass: culture, commerce, organizations and architecture.  A common property shared by humans, cities, and organizations is that they are complex systems. The cities created by humans have a bright side representing economic and academic development, innovation, and also opportunities for development as engines of wealth and politics which will open the door to POWER (which may approach the not so bright side). On the darker side, cities represent an opportunity for crime, poverty, pollution and consumption generators of energy and other resources.

The related challenges and threats we are facing nowadays are not new. All have been with us since the beginning of the Industrial Revolution, but because of the exponential or highly accelerated rate of urbanization, they feel like catastrophe is highly predictable within the interrelated (one has led to the other) perspectives of social, economic and long term climate changes we have been confronting. This does represent and opportunity to think about, create, develop and study a "science of cities" and by extension a "science of companies". In other words, a formal framework for understanding their landscapes, dynamics, growth and evolution. Similar to the framework used to study the environments, growth, dynamics and evolutions of us as humans. The point of convergence of cities, companies and humans: Complex Systems.

Dynamics and Non-linearity in Complex Dynamical Systems

A universal characteristic  of a Complex System is that the whole is grater than, and significantly different from, the simply linear sum of its parts. In many instances the whole seems to take a life of its own, almost dissociated from specific characteristics of its initial building blocks. Furthermore, even  if we understood  how the individual agents interact with one another, predicting the systemic behavior as a whole is not usually possible. "Conspiracies" within the agent dynamics also occur at moments in time in space which are naked for the human eye. Agents may auto-organize to produce outcome. This collective outcome, in which the system manifests a significantly different behavior than that of the individual parts, is called emergent behavior. Non-linear systems are dynamical systems. It is a recognizable characteristic of economies, financial markets, companies and organisms.

Energy, Metabolism,  and Entropy 


From the human or social life perspectives, there is an amount of energy needed for survival. For humans, this is quantitatively expressed in terms of a metabolic rate, which is the amount of energy needed per second to keep an organism alive. As social mammals now living in cities, we require homes, lighting, heat, automobiles, roads, computers, and so on. These represent the social metabolic rate. The social metabolism and human energy invested in the development of cities, countries, etc. should positively correlate with the society and city infrastructure which we use to promote growth.
Thus, energy is processed as part of the metabolic or social metabolic rates.
When energy is processed, there is always a price to pay. Because energy underlies the transformation and operation of almost everything, no system operates without consequences. There is a law of nature: The Second Law of Thermodynamics, which states that whenever energy is transformed into a useful form, it also produces "useless" energy as a degraded by-product: "unintended consequences". For example, as humans we need to eat in order to stay alive, but after eating, sooner or later you would have to go to the bathroom for a physical manifestation of your personal entropy production!
The word Entropy is the literal Greek translation of "transformation" or "evolution". So, in making order, or in a closed system, disorder is inevitable. To maintain order and structure in an evolving system requires the continual supply and use of energy whose by-product is disorder. In organizations, implementing order produces disorder as a consequence. As we know the saying: "No pain, no game" This is why as humans, in order to stay alive,  we need to continually eat to combat the inevitable, destructive forces of entropy production. This is no different for organizations or cities, which require more energy for innovation, maintenance and growth.
The battle to combat entropy by continually having to supply more energy for growth, innovation, maintenance, and repair, which becomes increasingly more challenging as the system ages, underlies mortality, resilience and sustainability, whether for organisms, companies or societies.

Energy, Metabolism,  and Organizations 

As humans, after growing rapidly in their youth, almost all companies with sales of over about $10 million end up floating on the ripples of the stock market. This is a precarious situation because if a big wave comes they can drown. If companies are left alone while suffering losses (even if profits are growing exponentially),  companies become vulnerable if they are unable to keep up with the growth of the market. A sizeable fluctuation in the market or some unexpected external perturbation or shock at the wrong time can be devastating to a company whose sales and expenses are balanced. This sequence of events is not very different to the process that may lead us, humans to our own death. We too, are finely balanced between metabolism and maintenance costs. Ultimately, we reach a stage where even a small perturbation just as a minor cold or heart flutter can lead to death.
The death of a company may refer to their disappearance because of a merger or acquisition, rather than by liquidating or going bankrupt. A useful definition is to use sales as the indicator of a company's viability, the idea being that if it's metabolizing, it's alive! Birth would be defined as a time when organization first reports sales and death when it ceases to do so.
In synthesis, organizations, as humans, are born, require energy, maintenance, metabolize, stay alive, suffer diseases, survive, or not; (i.e; die). They are, as us, complex dynamic systems which adapt to changes.  They also consist of  agents interacting non-linearly with properties and behaviors which interact, and even conspire within each other in a self organized manner. The emerging behavior is often not possible to predict, even though tools as agent based modeling and systemic dynamics can help simulate the behavior of these systems. We need to continually strive to think this way, to understand emerging behavior is not the linear result of the system's agents or constituents. Non-linear systems are dynamical systems, and dynamical systems, as for example differential equations, are used to study the instantaneous rates of change within systems. For example, in organizations, we focus on financial results and economic behavior, but not on the rate of change of these results, and the associated underlying factors [regulation, operational infrastructure, technology, human capital, etc.] associated with these rates of change are seldom addressed. We may refer to these underlying factors as the organization's genetic code. In this case, the organization's economic behavior would be a function of the rates of change associated with the dynamics resulting from the interactions of its genetic code. This, within existing landscapes.


Next week we'll talk more about Dynamical Systems, Non-Linearity  and Applications


Monday, September 11, 2017

Yes...WE CAN !

September 11, 2017

Nilza I. Cruz Ruiz

939-644-7683



The overall circumstances and unique social, cultural and economic situations we’ve been facing in Puerto Rico have served as motivation for sharing my story. I do have to take one moment and commend the all the staff in public and private hospitals, firemen, policemen, maintenance personnel, and a very special thanks to our brothers and sisters who have risked their lives representing the Puerto Rico Electric Power Authority and our Puerto Rico. I feel very proud, and we ALL should.... Bravo!

Also, our ongoing prayers to our less fortunate neighbors, families and friends in the Caribbean, and Florida; whom we are helping from our island.


New York, New York

In June 1966, I began my physical journey into this world born in the Jacobi Hospital located in the Bronx, NY to my beloved parents Manuel and Carmen. Both, Puerto Rican immigrants who moved to New York in the quest of the American Dream. I have an elder sibling, Manuel Jr. Dad, a hard-working butcher who worked mainly at racetrack restaurants and mom, a housewife; who departed to another beautiful life in December, 2013, but is always in my heart. Neither completed high school before migrating to the big apple. They spoke very little English. We lived in the Bronx, at 525 Rosedale Ave. Apt. 1G. It was a two (2) room apartment one (1) bathroom, small living room and very tight kitchen/diner. My brother and I shared one bedroom. This was part of a housing project (like the caseríos in PR) surrounded by “bodegas”, people who would call us “fucking Porto Ricans” each time the saw us, and other nicer folks. I was never allowed to go out and “play” unless accompanied by one of my parents; oh, and because I was a girl and “girls were never to be left alone”. I wasn’t even allowed to go to a baseball game with dad and my brother just for being a girl!

With much sacrifices, they (my parents) sent my brother and myself a couple of years to Holy Cross, a catholic school in the Bronx. I loved the school. I remember my teachers were “Brothers”, “Sisters” and a faculty composed mainly of Jewish, Polish and/or Italian backgrounds. This intrigued me. I loved the fact that my gym teacher was “Brother Frank” (with the long brown cloak), my math teacher was “Sister Christopher Joseph” (a nun), and my math teacher was not a nun, but Polish, and very “smart”; at least, from my perspective.  For another couple of years, when Dad couldn’t afford Holy Cross, my brother and I attended PS 169, a public-school right across the street from our previous one. It was hard, but we had to adapt, the hard way; either do it, or do it! But not going to school was NOT an option. 

Our daily journey to school was a fifteen (15) minute daily walk in the morning, and in the afternoon. Mom would always walk us! I loved to learn, discover, and be creative; especially in math and science! I remember asking so many questions. All related to the why, how, when where, etc. I was (still am) a dreamer. This was (is) my nature. Many times, transposing concepts or the abstracts I thought about or created about certain conceptions; (many of them math or science related), into new “things” I could discover, “see” and just continue to think about.  Then the intersections of what I could “see” with experiences in my daily life, and other concepts I either read or was introduced to in school, or simply by speaking with the owner of the nearest bodega; Mr. Abelardo. I loved this feeling, and oh, I was very insistent in understanding. How? I would always read, and like to draw my interpretation of what I read and understood, and then connected with the existing and other logical concepts. Then I looked at myself in the mirror and I would narrate what I understood, looking for my own approval and meeting of my own mind with that of the author’s. It was a kind of game; the game of understanding which required a hell of a lot of perseverance. Oh, and I never left from the front of that that mirror until I was fully satisfied with my performance!!!

At home, it was both my parents, and my parent’s family and friends in New York, speaking Spanish all the time. As for the music, it was Willie Colon, La Fania, Hector Lavoe and salsa all the way. It was an exquisite menu of rice and beans, fried eggs, corned beef, salami, Italian bread (which I loved), and especially for dad, Colt 45, Budweiser or Schaeffer. During the weekends, I would bring beer to my dad, open them, and of course, grab a sip! It was cold as hell during the winter and dry hot during the summer, my favorite part of the year. We would visit Orchard Beach with a pot of rice, cheese puffs, beer, and a blanket for the family. And oh, the Puerto Rican parade. That was it! The people, the colors, the loudness!!  I could understand Spanish, but hardly speak it. My frustration, I was never allowed to a ballgame with my dad and brother because I was a GIRL!!! Really?? Yes....



Off to “Porta Rico”

Spring 1976. For reasons I have to be frank about and confess I still do not entirely understand, mom decided my brother and myself would re-locate or move with HER to Puerto Rico. She said the island was beautiful and we would live a much better life in a beautiful “private home”, different from the projects we were living in. She would also tell us about the “flamboyanes” and beautiful beaches. So off we were to the island in July 1976. We arrived at Puerto Rico to the town (county, if you will) of Cabo Rojo. In Cabo Rojo, we lived in a neighborhood (“barrio”) named “Parabueyon”, a rural area with a lot of sugar cane and dirt streets.  A small town located at the south west part of the island and minutes away from beautiful beaches. We moved in with mom’s father (elderly 78 year old-“Jovino”, whom my brother and I had never met before), and her youngest brother, my uncle “Tato”.  The house, a three room wooden home with a zinc roof. The side wood had quite a few holes, and the floor was also wooden with many holes as well.  The foundation of the wooden house was composed of a few wooden plinths (zócalos) embedded in clay. It was full of bugs and during the evenings, bats and giant cockroaches would make frequent visits. This pretty much framed the beginning our new environment. Mom, my brother and I slept in the same bed with a mattress that was terribly uncomfortable. At the time, I was 11 and very upset. It was soon to be August and on the island school would begin in this month.

So off we went to Saint Augustine School in Cabo Rojo. Even though mom didn’t have a job, she relied on the fact that dad would send her enough money to make monthly payments for my brother and I catholic school tuition. Off we went.  We began in our new school. I didn’t speak the language, I lived in a very poor home in a very poor “barrio” and here I was in a private school commencing my 6th grade. But of course, the kids at school named me “la jíbara muda de parabueyon” (the country mute girl from the “hood”). I didn’t even understand what this meant, but I remember the deceptive laughs and making fun of me. There was a lot going on. The radical environment change, the school, the mean kids, and the economic limits. You see, many years later I learned dad was either unemployed or employed with less income, and it was extremely hard for him to keep us with private school payments, food, etc. Oh, and mom didn’t work. Shortly after, mom was on welfare. She received food stamps and health benefits from the Puerto Rico Commonwealth.  I clearly recall one day I went with her to the supermarket for groceries. In a particular aisle, I spotted a “Cosmopolitan” magazine with an executive image of a woman on the cover. I immediately said to myself, “I don’t know how, but I am going to be an executive”. Even though mom was receiving assistance from the government, I was just not happy with the feeling of dependence. I felt embarrassed. But this was my Reality, and I had to cope with it and move on.

Mom defaulted at our school payments. With luck, my brother received a sports scholarship at Saint Augustine and even though I was also in the volleyball team, (yes, me), the scholarship was just for one; my brother. So mom continued defaulting on my payments and there were many times I was scolded by school administration in front of my classmates because my mom didn’t pay. At home, it was eating whenever there was food depending on food stamps, grabbing mangos, "guanábanas" and coconuts from nearby trees, and supporting the most terrible menstrual pains with no medication what so ever. Mom just said: “there’s no medicine, take the pain” ("carajo, aguanta y no te quejes"). Tough for a teen!  But there’s something I could tell you, again, this was reality. And it was up to myself to be / or not, whatever it was I wanted to become in the future. Of course, there were days with no food, embarrassments, no money, bugs, bats, cockroaches and a lot of fear. Mom did what she could. Dad, also. It was NOT their fault.  I had a great cousin who was kind enough to help me in my Spanish, and in school, I focused on getting good grades (studying twice or maybe triple as hard because lectures were in Spanish), and in volleyball. Boy did that volleyball help me focus. The sport exploited my competitive side and shielded my poverty. I felt like the “Queen of el Barrio Parabueyon”.  I always wanted to help and lead. I was president of my class at the 11th grade and fought for equality amongst my classmates. I almost got expelled from grade 11 for not agreeing with naming a student who was included as member of the National Honor Society with a GPA of 2.50 , but his parents were very generous in $ contributions to the school. Of course, I was punished with not being part of the Honor Society myself at senior year with a 3.55 GPA and complied with all requirements. Also, I was demoted to VP of my class. What was new? I did get the message across!

After so much adversity, I managed to graduate thanks to Sister Anne Eugene Vivas, school director at the time, who pardoned my mother’s tuition debt with the school and my “faulty” actions with the National Honor Society kid incident. She understood I was a leader and she believed I would someday be very successful. Thanks Sister Anne!!!

I applied to the University of Puerto Rico, Mayaguez Campus. I wanted to study Pure Mathematics just because I loved math, it satisfied my intellectual challenges, and I understood it could help me establish a frame of mind or thought for my ongoing curiosity of things and inquisitive thoughts, imagination, and creativity. I was accepted!!! So in August, 1984 I began my undergraduate studies. I would rely on public transportation, the food stamps mom continued receiving, state health program, the federal Pell grant, and a part time job at Almacenes Rodriguez (shoe & purse store) at the Mayaguez Mall as a cashier for the next four (4) years. To make ends meet, I learned how to sew my own clothes (using an old Singer sewing machine Dad sent me from New York) to go to work at the Mall.  I didn’t sleep at least 3 out of 7 days a week. I helped support mom as well. There were times I cried and cried, because sometimes it seemed impossible, but I graduated from Pure Mathematics with a minor in Statistics in May, 1989, even though I completed required undergrad credits in December 1988. In May, 1989, I received a job offer from the NSA, which I refused just to stay in PR and support mom. I know, it was a tough decision, which I don’t regret! I enrolled in graduate school at the Mayaguez Campus to pursue my MS in applied statistics in August, 1989. During this time, I was a TA at the Mayaguez undergrad school of mathematics. At the same time, I taught Geometry and Pre-Calculus at a private high school at Mayaguez. It was a nice experience, up until the director of the school instructed me to change a student’s grade from 81% to 91% in Geometry because the student wanted to pursue studies in engineering in the US and 81% in Geometry (what was earned) wouldn’t help much. This was a huge deception for me yet a great experience; of life. This happens! I denied the petition and handed my letter of resignation effective immediately. This was totally against my work ethics; and most important; to my understanding, this action would not help this student.



Bull’s Eye

By 1991, I was convinced I wanted to move from the southwest part of the island  to the capital of Puerto Rico (which I had never visited!): San Juan. My brother’s mother n’ law sent me a newspaper add which stated that the Office of the Commissioner of Insurance in San Juan was seeking for an ”Auxiliary Actuary”. So I went for it. I embraced a three hour ride from Cabo Rojo to San Juan in my 1979 Omega which lacked air conditioning. And there it was! I got the job which would pay me (net) $630.00 a month. This, for rent, food, gas, etc. But from this point on, I entered the insurance industry as an Underwriting Trainee, then Commercial Lines Underwriter, Quality Administrator, and at 30 years, I was Vice President at a Multinational Insurance Company. Excellent pay, benefits, Banker’s Club privileges, great office, parking, golf. Oh, and in the Financial District of PR in San Juan!
Bull’s eye!! I was finally the executive woman I had pictured back in 1981! In parallel, I completed an MBA and graduate certification in the Insurance Institute of Philadelphia and the College of Insurance in New York.  Not to mention my traveling to home office in Miami and great worldwide learning experiences!

It’s not as beautiful as expressed. There were lessons learned the hard way. Components related with internal politics, rules and regulations, culture, and behavior are embedded within performance and results obtained conformed great part of said lessons. Within these organizational frames of work, said components, especially rules and regulations, are meant to be followed. All eyes are on our performance, which means we are not only perceived as the results we obtain, but how are we as leaders, as a function of how well we can “navigate” within the organizational landscapes, and internal politics play a critical role in this navigation quest. What is fair for us may be perceived in a different manner by others, in an intentional or non-intentional manner. It all depends… as a professor, mentor and someone very close whom I’ve learned very much from, has taught me.

I learned that even though I was trained as a scientist, we need not always communicate as scientists, subject to who our audience is. We need to understand and accept that social and cultural components should always be considered in studies we conduct. Also, the art of negotiations. Obtaining balances, and carefully identifying and understanding tradeoffs; from all sides. We need to acquire more perspectives related to Systems Thinking and Complexity Science. Organizations, Cities, as Ourselves are Complex Systems! We need to understand this and think about the fact that even though we as humans, corporations and cities are VERY different, all are born, grow, develop, and die! Just think about it!!! There is genetic code within a person, a corporation and a city. They all need resources, maintenance, investment and development in order to survive! I find this fascinating.....

But as of today, I am part of the big picture: PUERTO RICO. I am continuously conducting research and studies with a group of associates geared towards the interrelations of mathematics, statistics, physics, finance, social sciences, arts, law and economy with the development of organizational landscapes that would promote higher levels of efficiency within government and private ecosystems. In particular, health and academic systems.


Time to Move On

Time continued forward and I have two beautiful kids. Sofi 19, and Jean,  17. After a second Vice President position in another Multinational Insurance Company, I was self-employed for many years. During 2011 and 2012, I worked directly with a special musical project at the PR Conservatory of Music, geared towards providing needy children in PR the opportunity of discovering and expressing their creativity by playing an instrument and forming part of an orchestra. This would also provide them discipline. It was in December 2012 that I was invited to join the management team of the Puerto Rico Medical Services Administration. At first, awkward. But after much thought, I was born in a public hospital in New York, and I was raised under the Puerto Rico’s public health system; at the time; Arbona System. Why not try public service within the public system I myself grew up in? Of course, now the Model was based on the Health Reform System, not Arbona, but why not contribute to make it better? This was my frame of mind and I accepted. But thinking about the job and accepting is one thing, but being part of the system, I mean, is another. Talking with patients and families receiving health services in the emergency room, outpatient clinics, and other facilities within the medical center make you really UNDERSTAND that there are people in need, and expect much from public service employees. We need to continue to be their role models, and continue to research and study alternate and more efficient methods from which they, the people of Puerto Rico, the private sector and all components which constitute our island’s macro-economy can benefit. We need to step up as leaders and be more creative. We need to continually research and study, no matter our age!! Education and leadership are key. It is our responsibility to promote these qualities we all have in a NON POLITICAL MATTER. As Former Medical Service Administrator, I gained knowledge of understand how I can contribute to make Puerto Rico  a better place towards achieving all goals, macroeconomic, financial, organizational, cultural, and behavioral; particularly in achieving an integrated  healthcare, economic, academic and social structure.

This is what I’m focused on along with an exceptional group of professionals. Another thing, we cannot work alone. We are responsible for assembling networks that will help us achieve our endeavors.

I barely slept or ate for a long time, but it wasn’t impossible. As part of our system, there are rules to follow. Following them or not will always generate positive causal loop feedbacks, but we have to increase levels of perseverance, be wise and obtain balances within everything/everyone we work on or achieve. We need to lead, facilitate, coach, and "roll our sleeves". We need to dive into the deepest waters that will only provide us with the most beautiful opportunities of "seeing" in order to understand. You see, we're not entitled to understand something we don't "see". 

Let’s be open to new dimensions, ones that are very close to us and waiting for our attention and implementation.  Only when our minds are open will we see; outside of traditional existing models or frames of work.

Where we are today, or where we’ll be tomorrow, depends on us, and where our minds and creativity position us, along with the intersections we promote with groups of people and other components associated with our islands economic, structural, fiscal, and social landscapes.


 I say, Yes…We Can! 

y Vamos Pa'lante


Next week we'll talk about the astounding similarities within humans, corporations, and even cities within the context of Complexity Science.

Monday, September 4, 2017

The Mountains We "Can Not" or "Do Not Want" to See...


Nilza I. Cruz Ruiz
939-644-7683


"The tragedy of bad economic ideas is that once they grab hold of society's imagination, it becomes nearly impossible to persuade people to abandon them. Instead, the ideas must be... disproved by experience".

Thomas I. Palley,,economist and author From Financial Crisis to Stagnation (2012)


Equilibrium is  frequently heard as the heart of modern macro-and microeconomics. Associated models start with the simplest concept of supply and demand. The downward-sloping demand curve intersects the upward-sloping supply curve. The intersection represents an equilibrium point at which supply = demand at a price which results satisfactory to both sides.

In this case, agents are represented by consumers and producers. Equilibrium is reached as a result of the interrelation between these agents in a given environment defined within a landscape which is many times composed of interrelated sub-landscapes. Agent properties and behaviors, as well as environment characteristics may be defined, designed and controlled, in order to "predict" or anticipate "expected" results. This definitely sounds like an optimal scenario. But the truth: the financial system, as many other systems as for example the healthcare system,  are Complex Dynamic Systems.

In particular the healthcare system in the US and in Puerto Rico has been presenting symptoms related with recursive arrhythmia for the past years. A heart attack within the system is very clearly presented within every mountain in the existing landscapes or structural healthcare models. How can the healthcare system  in Puerto Rico reach a point of equilibrium when more than fifty percent (50%) of the island's population is below the level of poverty within a universal third party payer system model the government cannot afford? 

Just last week, I was watching a program in which licensed health care administrators were discussing the financial challenges most of the hospitals on the island (public and private) are facing. It struck me they were focusing on how the number of "empty beds" was increasing, and that "things had to be done". But what, and based on what underlying factors? You see, I'm not focusing on a fish bone cause diagram or what's on the tip of the iceberg; I'm talking about identifying and understanding how the system's genetic code or DNA works. I'm referring to  discovering and "seeing" what cannot be seen! Then interrelate this genetic code, and design conceptual models aided by simulations that would lead expected outputs or results to be different!

The dynamics of complex systems are best understood using Complexity Theory, a hard science that offers the knowledge and tools to see and understand catastrophe coming in advance. Complex dynamic systems (e.g.; healthcare systems) produce unexpected results by means of "conspiracies" developed (intentionally or not) by the interactions of agents that lead to the systems instability resulting in emerging behavior as output.

Internal instability within the state of the system causes ruptures which, as a domino effect, create more recursive ruptures and so forth. Ruptures are really represented as fractals within the system at different scales. A perfect example are the unsustainable financial results emerging from the Government Healthcare System, and how this financial unsustainability is growing exponentially on a yearly time series that has been path dependent. 
The government in its role as a  buyer of health insurance pays insurers to  "assume the risk". The risk defined as providing healthcare services to millions of humans under the level of poverty by a provider distribution network contracted and controlled by insurers. Providers depend on performing healthcare services through different healthcare facilities they don't control unless they own the facilities. Talking about complexity and the dynamics within!!! The most interest part of the system relies on the financial model. Contracted healthcare facilities bill insurers for incurred services through providers based on fixed rates that represent less that $.30 for each $1.00 incurred by the different healthcare facilities (PSG rates have dramatically decreased). Payments or collections are then received by facilities up to thirty (30) days after the services are provided. Think about cash flow and liquidity constraints for healthcare facilities and providers under this system! How's this for equilibrium? Think about which agent is really assuming the risk.

This is the mountain we should all be closely observing and transforming! The existing structure of the healthcare system, including the financial model. This cannot be political, but again, there's a price to pay; by US!  A price related to the consequences associated with the pathway imprinted by administrative deficiencies of many government administrations, associated with politics, governance, inefficient structures, and internal infighting within government entities. Yet, there have been various proposals submitted to the government, legislature, and other entities; but again...silence, and many  don't want to see the mountains!

There is a dissonance between the political world view and the real-world in healthcare, as in economics,  that we need to stand up for! The catastrophe is closer, and the mayor healthcare earthquake is just a matter of time...far more predictable than hurricane IRMA...

We have to see the mountain, acknowledge it, and most of all, master it...

I guess, ideas may after all be disproved by experience.




Monday, August 21, 2017

The Mathematics and Physics within Organizational Landscapes and Finance



Posted on August 21, 2017
Nilza I. Cruz Ruiz

939-644-7683


"Physics cannot predict the madness of men..."
Albert Einstein

I began thinking about studying Pure Mathematics in college at about the age of fourteen (14). First, I was passionate about numbers and what was behind them. Second, for as long as I can remember, I've always been inquisitive not only about understanding what I was reading or studying, but about "seeing" and giving life to each subject. That is, making the transfer from pure abstraction to physical matter.
I would "draw" my interpretations on paper as I could picture them. 
Interpretations of different subjects, most math related. But the most fascinating parts were interconnecting subjects that logically, or not, led to the other. And the most exciting part was relating topics I suddenly noticed made sense, but they were not all  within the "mathematical world".  As a child,I would observe and stare at objects at school, at different houses, in the street, and  save a "picture" in my memory. After, for days and sometimes months, 
these observed "things" (even with motion!) would  arise in my imagination. There was a deep sense of understanding what numbers were, what was behind them,why they existed, and how can they help the world be better. Even going to the beach, playing with the sand, observing my hand through the water would ignite many questions! At a very young age, there was  very much disposition to openness; that is creativeness, if you will.

And what a fascinating base to begin with in College! Little did I know at that point in time what a spectacular journey it would turn out to be, especially when later combining the field of Pure Mathematics with Statistics, Insurance, Risk Management, Physics, Business Administration, Marketing, Finance and Complexity Science (Fractals, Agent Based Modeling, Chaos). Learning is a lifelong experience.


I. Context

I've read much and have been directly exposed in my different work and study experiences of how ideas and concepts arising from math and physics have been used to understand the financial markets, for example. As we discussed last week, from the perspective of organizational landscapes, models can be built using tools as Agent Based Modeling which heavily rely on mathematics and computer science to simulate the interrelations between its (the organizations) agents/stakeholders and their environments. This, in order to research the existing organizational behavior, and the emergence of defined phenomena; for example, economic behavior.
But science isn't a body of knowledge. It's a way of thinking and learning about the world.It's a continuous process of discovery, testing, and revision. Learning about the would is equivalent to learning about moving targets, so models or simulations we would use as tools need to incorporate ongoing dynamics.Models used to predict financial sustainability or asses existing organizational structures are just models! They depend on assumptions and we should never mistake a good model for the "truth" of what the "Real World" (e.g.; financial sustainability, organizational structure, etc.) really represents.

Ilustration of Agent Based Model created to Simulate Emergency Room Patient Flow






If we think about the 2008 fall in the US, the financial meltdown, previously, there had been many ideas from mathematics and physics that had been used to understand financial markets, and there was a strong connection between the fields. It seems that no matter the level of influences within the fields, it was impossible to do science on Wall Street. But this is nothing new! When we think about Puerto Rico' s Government Fiscal and Economic Standing and Politics, can the fiscal/economic measures that need to be enforced be deployed within a Political environment? 


II. The Mathematics and Physics within Organizational Landscapes

The problem in the financial markets, as we all know is predicting the unpredictable. It is easy to make money when markets are rising. But predicting the "unpredictable" has been an excellent business for some, precisely because a market crash is a dramatic profit opportunity, if and only if you see it coming.

Organizational landscapes are no different than financial markets. They are composed of stakeholders, rules and regulations, norms, internal politics, governance, and operational structures. But let's reiterate the fact that a great portion of the stakeholders represent human capital, which make organization's behave as Complex Adaptive Systems in which the sociological and psychological components are critical. The Organization is a "Living Bubble" which possesses an Internal Stability within its State, which may be exposed 
to a change in Stability (i.e.; Instability, caused by different factors)  making it (the organization) Susceptible  to explode. The organization's state need to be unstabilized in order for the external cause to hold. Hence, if the bubble the organization is within bursts, it is not directly associated with one or various causes. In order for the external causes to trigger, there needs to be a change in state or instability within the bubble.

The bursting of an organization is one of a variety of a phenomena known as ruptures.  When organizations are put under significant amount of stress, small fractures begin to appear. Sometimes these fractures grow and combine into larger fractures. These larger fractures may grow into still-larger fractures, and so on, until you may get a very large fracture. These fractures follow patterns that are known as fractals, where the tiniest fractures are self-similar to the larger ones; scales only varying. The difficulty is that tiny fractures may not affect the stability and state of the system, but large ones can be catastrophic.

Sometimes, the different components within the system (organization, in this case) begin to Conspire against one another. They display a king of herding effect. When this occurs, it's almost as if the components within the system have unionized. A kick in one part of the system can significantly make it's state unstable and sensitive to certain causes of disruption. This kind of Conspiracy is sometimes referred to as Self-Organization.

For example, this is how a small labor strike differs from a catastrophic one. All strikes are caused by the same categories of sparks: unfair termination, cut wages, etc. A large strike is like a small strike that, for whatever reason didn't stop! The difference is that the biggest strikes require something more than just a spark: they require labor movement with a high degree of structure and a capacity of coordinated action.
They require a mechanism of system-wide feedback and amplification, something to transform an otherwise small event into a large event. This said, if you want to predict a major strike, forget about the grievances. Look for the Unions, the patterns of organization! This is exactly what we're after, when conducting research and constructing models to predict catastrophic events as earthquakes and hurricanes.


III. Mathematics, Physics, and Economics

I really couldn't answer the question regarding changing the sociology of the math, physics or economics departments. But what I can say is that there should be more focus at the highest levels of the government, institutional and the private sector pertaining to major interdisciplinary research initiatives. Commitment at the highest levels could hold the community together and keep it on track.

One of the most prominent arguments against mathematical modeling in finance might be thought of as an argument from psychology and human behavior. The idea is that ideas from physics are doomed to fail in finance because they treat markets as pulleys. As Newton said, physics cannot predict the madness of men. But men are part of the system, and so this reason , they too should be part of the solution.
Modeling represents one component of the macro system, and as we mentioned before, they rely on assumptions which are correlated with dynamic occurrences. States of systems can be measured with numerical standards, but changes in state are caused by influx and outflux flows. Considering that the emerging phenomena related to complex systems need not only be evaluated by their states or changes in states, agent/environment interactions should be interrelated with changes of states under different conditions.

This kind of criticism draws on ideas from a field known as behavioral economics. But using math or physics
 as a springboard for new ideas in finance does not include describing people as theorems or pendulums.
Physicists like Mandelbrot and Osborne, made progress in understanding markets by drawing on their familiarity with statistics to identify new ways of thinking about market and risk. Others, like Farmer and Packard, used their expertise at extracting information to identify local patterns that could be useful for trading.

We need to be more open to creativity in a holistic way connecting the fields of mathematics, physics, economics, social sciences, psychology and anthropology. Among the major personality traits, it is openness that best predicts performance on divergent thinking tasks. Openness also predicts real world creative achievements, as well as engagement in everyday creative pursuits. The curiosity many of us always have to examine things from all angles may lead others in high openness to "see" more than the average person, or to discover "complex possibilities laying dominant in so called "familiar" environments".

Change of mind, openness, new thinking opportunities begin at our homes. How we teach our children. How we lead them to see. The environment we create for them to think creatively. Schools. their structures, And Universities, their holistic, or not, approaches. It's just the beginning....

Familiar?

Next week we'll continue our discussion on Science, Research, and Real World Experiences








Monday, August 14, 2017

Understanding the "Real World" before talking "Re-structuring" or "Re-engineering" within organizations

Posted August 14, 2017

Nilza I. Cruz Ruiz
939-644-7683


"It can scarcely be denied that the supreme goal of all theory is to make the irreducible basic elements as simple and as few as possible without having to surrender the adequate representation  of a single datum of experience"


- Albert Einstein - 1933




Part of Puerto Rico's Fiscal Plan relates to "right-sizing" as one of the measures for obtaining fiscal stability. But if we look closely, we have a plan referring to this tactic defined as "right-sizing" or "re-engineering" geared towards serving as a temporary fix in order to comply with a fiscal target of an $X dollar amount.

But what happens with the Real World in Puerto Rico? The Real World is the set of existing organizations (e.g.: agencies, corporations, etc.) within the government Macro - Structure that serve as base for emerging unsustainable output; in this case, data which leads us to define "Real World Financial Unsustainable Results". 

The Fiscal Plan is then proposing right-sizing efforts within the existing underlying structures which serve as base for producing adverse results in terms of services, operations, and financials. We may then conceptualize the Plan is proposing "right-sizing" components (which are not duly defined or communicated within the "plan") within an existing Real World that itself needs to be re-structured.  Right-sizing requires investment expecting greater returns after the corresponding plan is implemented as a function of time: T and of course, other factors or variables. But, realistic return projections would be accurate  if and only if the efforts are performed over a solid, re-conceptualized structural base. This is not the case for Puerto Rico.

Inspired by this dichotomy consisting of "investing" over the existing "Real World  deteriorating Structure"; and not focusing on tackling its structure changes, I decided this was today's topic! Again, this has been repeated  many times. For example, we need to begin to think differently and strategically about Complexity and it's application to the organizations we are within. This, in addition to our active roles as complexity thinkers!


I.Complex Systems, Emergence and Feedback

Before talking about the "Real World" within organizations, and need to take a small step back and briefly talk about Complex Systems, Emergence and Feedbacks.

Complex Systems are composed  of many interacting parts (hereinafter agents) in which the Emergent Outcome of the System = product of the interactions between the agents and the feedbacks between that emergent outcome and the individual decisions of the agents.

                                    


MODEL I : Complex Systems, Emergence and Feedback





Emergence is the idea that the action of the whole is more than the sum of the parts (John Holland, 2014). In other words, what emergence of a complex system does is not "linearly" sum the outputs of the individual agents; but represents a global pattern which evolves considering individual agent interactions within themselves and the environment. Agents follow sets of rules and/or policies under defined structures which include governance and internal politics as critical components embedded within the system.

Emergent Phenomena provides Feedback that then affects future decisions of other agents within the System.

An example is Market Share. My individual decision of buying brand A; [one of two similar products, ( one brand A and the other brand B )] is a decision on my own. It then contributes to the market share of product brand A vs the market share of product brand B. That market share then contributes to my decision or future decisions of other people as to whether buy the product of brand A or brand B. This is repeated for other brands and is repeated so forth.

II. The "Real World Assessment" within Organizations

So let's just take some time to think about defining the "Real World" in the organizational context. It may apply to organizations within the private or government sector.  For this presentation's purposes, It is the comprehensive assessment of the Existing - Actual representation of the organization which includes:

a. Agents 
b. Agent Properties
c. Agent Behaviors
d. Rules, Regulation and policies they (agents) follow
e Internal Politics
f. Existing Landscape - Structure 
g.Governance
h.Environment (Mission, Vision, Values, Strategic Objectives)
i. Type of Organization (for example : Path dependent)
j. Economic Resources - Operation Financing Model, State Funds? Federal Funds?
k Infrastructure Resources
l. Human Capital Resources and Skills
m. Information Technology Structure and Resources
n. Output - Fiscal Results, Intelligence Results (data mining and anaylsis) *
o. Macro Ecosystem rules and regulations

* It is critical to identify and obtain critical data for at least the past ten (10) years or 80% of the organizational lifespan (if not 100%) which serves as input within the organizations global and operational core business processes. This data should be validated and commensurate with our organization's output data (i.e., costs, financial, compliance, service levels, etc.). This critical data will represent the Macro Overall Operational and Financial results which will constitute the Real World Baseline Assessment Results.

In other words, if we were to "map" a representation of our organization's real world, what would it look like, who are the agents? and what are the results (output), based on what data (input), and macro conditions ?

Of course, this is not as simple as exposed. We would have to conduct a "Real World" Assessment, including the above referenced factors.  Assessment results would then serve as baseline and input  to define the pathways to design and construct one (1) or various Alternate Models that what comply with our "Re-structuring or Re-engineering" objectives.  This pathway is illustrated as follows: 


                                   MODEL II : The Roadmap to Organizational Re-Structuring or Engineering



Validation is the process of making sure the Alternate Implemented Model is commensurate with the Alternate Conceptual Modeling planning process and design.
Verification is the process of making sure the Alternate Conceptual Model matches the Alternate Implemented Model (i.e.; after the Alternate Conceptual Model is implemented, it will be our Real World).

These processes require extensive communication amongst the stakeholders which are part of the existing structure (Real World)  or will be impacted by the Alternate Model Implementation in some way.

During meeting or other encounters of agents within the Alternate Model Planning Phase, it is expected each stakeholder will think about their individual interests. This predicts fighting and non-conclusive meetings. But this should behavior occurs naturally because of the setting of having different thinkers with different interests in one same room (for example). It is highly predictable behavior given the conditions.

But as a general tactic, the 1st topic in this type of encounter should consist of presenting all stakeholders (by means of using a visual tool in which all audience is focused) the Real World and Alternate Model Story :  explaining a Visual Map of the Real World and its results. In addition, a second Visual Map and comparative explanation of the Alternate Model, its results,  and critical  projected changes in terms of services, operation efficiency, and economic sustainability.

Second, explain to all stakeholders that each of these Complex structures produce Emerging Results  which are a result of the interrelations of all the interests they represent.

III. Conclusion

Therefore, if the Emerging Results arise as a consequence of their (agent/stakeholder) interactions, then the solution for changing the existing emerging results would then require the interactions of the same subsets of agents/stakeholders : THEMSELVES. This includes internal politics and governance as factors underlying agent interactions; amongst other components. 

This strategy would then promote the awareness that emerging outcomes are the results of interactions or interrelations, promoting then continuous communication and feedback between critical agents/stakeholders. This directly addresses strategies and tactics to be used as part of changing the way we think, and obtain different (better) results by means of interrelations. An operational and functional representation of how systems produce emergent results as outcome! This is no different, but above all,  we need to be strategic.



 Next week we'll continue with Agent-Based-Modeling and a Real World Example


Monday, August 7, 2017

ACAA : What this Government Insurance Structure Represents for Puerto Rico's Medical Center, PR Fiscal Plan and Healthcare Economy

Posted August 7th, 2017

Nilza I. Cruz Ruiz
939-644-7683

"The intellect has little to do on the road to discovery. There comes a leap in consciousness, call it intuition or what you will, and the solution comes to you and you don't know how or why."

Albert Einstein

As a continuation of last week's blog, planned for this week was a discussion pertaining to building Complex System Model Simulations. But it was an interview I listened to last Wednesday in which Jay Fonseca interviewed the Executive Director of ACAA [(Administración de Compensaciones por Accidentes de Automóviles) (Administration for Compensation of Accidents of Automobile)];  which motivated me to alter my presentation for this week. 

The trigger? When the Executive Director stated the following as part of the interview:  "ACAA lo cubre todo" ("ACAA covers everything"). This, related to the topic of patients treated in the Puerto Rico Medical Center.

As part of my professional career, I've occupied two VP positions within multinational insurance companies. The first, managing a Life, Property & Casualty portfolios, and the other, Accident & Health lines of business. So, this part of the interview really did strike me! 
Naturally, everything depends on something and we need to present context in addition to the definition of the  perspective or angle in which the discussion will be framed:

I. Context

The Administration of Compensation for Accidents of Automobiles (ACAA) is a public corporation created by  law No. 138 of June 26, 1968, as amended, known as the law of Social protection by automobile accidents, which administers insurance health care and compensation to benefit the victims of motor vehicle accidents and their dependents.

The purpose of this Corporation is to reduce the tragic social and economic effects of road traffic on the family and other dependent victims. The ACAA provides services medical-hospital  and compensation to the victims and to the dependents of deceased victims to avoid  total economic distress.
The ACAA's corporate powers are executed by a Government Board responsible for the Administration and ensure that it enforces the provisions of the Act. The Board appoints the Executive Director responsible for complying with the provisions of the Act, as well as the rules and procedures referred to in this Board.

ACAA is an agile and dynamic institution with all its integrated operational systems, which facilitates efficient, quality services and in the shortest possible time. It has employees trained and committed to excellence in service, targeted to meet the needs of our members and to promote, through education, the prevention of traffic accidents. This is public information obtained from ACAA's website.

The words/phrases I have highlighted in the last paragraph represent the drivers for validation results to be presented and for you to evaluate. The universe of patients for this study consists of ACAA patients* treated at the ASEM Emergency Room and Trauma Hospital within the Puerto Rico Medical Center for the period of 2013-2016.

* ACAA patients are defined as patients for whom claims were submitted to ACAA as the primary insurance because of the nature of the accident (automobile related). It does not imply that the claims were paid by ACAA because coverage was denied as per exclusions stipulated in the ACAA/ASEM (Trauma Hospital is under ASEM governance) contract. In this case, ASEM, a government corporation is a provider of the ACAA Insurer network (another government corporation); i.e; this is a government-government relationship (begin to think about existing government structure and efficiency please!)

II. Key Findings

  • Within the distribution of 100% of claims received in ACAA corresponding to medical-hospital services, at least 80% are from the ASEM Emergency Room/ Trauma Hospital Facilities. So, it seems the ACAA structure and operation is focused on it's main provider: The Puerto Rico Medical Center regarding medical-hospital coverage. (ACAA also provides other coverages as for example disability and dismemberment).
  • Patients under the effects of drugs or alcohol are denied coverage and ASEM incurs in 100% of treatment costs for these patients.
  • The ACAA billing operation is a manual process. Physical claims (in paper) are taken to ACAA Central Office premises and they need to be stamped as received "1 by 1" on the ACAA premises. So, there are ACAA designated employees for this "receive and stamping" function, while another ASEM resources delivers the boxes of claims and waits for them to be "received". Just imagine, one ACAA patient's length of stay in the Trauma Hospital can consist of 90 days before discharge. Services provided to this patient, and billed manually may be equivalent to more than 100 physical papers (which represent services billed).
  • The ASEM Trauma Hospitals costs approximately $45 million by fiscal year. This may surpass 20% of ASEM's fiscal year budget.
  • The ASEM Trauma Hospital is the only hospital in PR and the Caribbean specialized in Trauma. It serves as a resident facility for Medical Science Campus residents as well.
  • While the annual frequency of Trauma patients is low, the severity in terms of costs is significantly high. This is because these patients are "poly traumatized"; implying their health conditions require more services which are highly specialized.
  • An average of 1,900 patients by year have been treated at the Trauma Hospital for a nine (9) year period*.
  • 22% of these patients have been covered by ACAA while 37% by the government health reform (i.e; government-government) relationships (average 9 years). 59% of Trauma patients rely on government related insurance.
  • 22% of ACAA patients have represented an average cost of $23 mm while 37% of health reform patients an average of $26 mm for the same 9 year period). $49 mm in total costs incurred.
  • The ratio of average [patient percentage vs costs incurred] = 22% / $23mm for ACAA Patients and 37% / $26mm for government Health Reform patients. There's a $3mm increase for a 68% patient count increase for non-ACAA government health reform patients. This obeys the fact that financial class ACAA patients may be lower in frequency, but with much higher severe health conditions with require more treatment times resulting in longer lengths of stay in the  hospital.
* FY's 2007/2008 - 2015/2016

III. ACAA as a government corporation adopting a Universal Third Party Payer System Model


The following Model presents the interrelationship between the three (3) critical Agents in this study:

ACAA-Insurer 
Patient ( future probable insured/claimant)
ASEM - contracted healthcare provider within ACAA'S provider net


What this Model clearly presents is :



  • ACAA administration executes as per Law No 138
  • ASEM contracts with ACAA in compliance with Law No 138 which at the same time drives contracted coverage and exclusions in ACAA/ASEM Contract
  • Patients/Insureds/Claimants have to comply with Law 138 and ACAA/ASEM Contract. This implies these agents within the system follow two (2) sets of rules (one for each corporation), multiplied by the number of sub-rules that apply for each set. This is not a lean service for ACAA /ASEM patients or people (relatives, family, etc) representing them  in the  process of filing a claim! Especially with the patient (market)  we're servicing as a majority: polytraumatized patients...
In synthesis, when coverage is triggered (i.e; an insured /patient is converted to a claimant), the implementation of the operational process begins. Operational processes include :

  • ACAA's cumbersome paper work completion and processing by patient's family, or relatives. This process is by hand, not electronic.
  • ACAA issues ASEM a claim number once  paperwork is received by ACAA and ACAA determines if coverage will not be excluded. For example, if the patient is under the effects of drugs or alcohol, coverage will not be provided. In other words, the patient will be treated by the ASEM  emergency room and trauma hospital, but ASEM will not be compensated for incurred health treatment costs (not under the ACAA primary insurance).
  • Covered claims will be submitted by ASEM to ACAA in paper! This, because ACAA lacks an electronic billing process (at least to December 2016) .
  • Payments will be received by ASEM based on contracted rates, not costs of services. The following represent contracted rates by ASEM up to 2012 (contract was expired and rates had never been modified up to 2013) . Beginning in 2013,   a comprehensive cost analysis was completed by a designated cross-functional team  consisting of excellent existing personnel (doctors, finance, cost, accounting, medical record personnel) facilitated by myself:
                                                                                   ACAA Rate      ASEM per diem (cost study-2013)
"Unidad Aguda"                                                                             $600                       $1,293
"Unidad Aguda-Aislamiento"                                                           625                         1,347
"Telemetria"                                                                                     625                         1,347
"Intensivo Intermedio"                                                                     755                          1,627                                                         
"Intensivo Intermedio-Aislamiento"                                                 780                         1,681
"Intensivo- Critico"                                                                           915                          1,972
"Intensivo-Aislamiento"                                                                    940                          2,026


IV. ACAA DOES NOT COVER EVERTHING!

So, the statement that " ACAA covers everything" is not only misleading, but FALSE. Patients are under this belief until the time of the accident. While it is true that it is our responsibility to prevent drunk driving or under the influence of drugs; ACAA needs to be more aggressive in this matter. Treated patients not covered by ACAA because of drugs or alcohol cost the commonwealth millions. Yet, they are discharged from the Medical Center and their licenses are renewed!! I do hope ACAA Administration is on the road to legislation regarding actions taken amongst irresponsible drivers. It's not only their lives at stake, but other innocent people as well.
For example, gasoline stations are at their peak selling alcohol related products.
































V. Actions Taken and Recommendations


In 2013, ACAA had a debt with ASEM regarding outstanding claims ascending to $6 million. In addition, ACAA would pay ASEM an aggregate of $500,000 by fiscal year. Effective 2014, a contract was negotiated (ACAA/ASEM) which included the payment of $6mm of the outstanding debt (which as paid off) and an the annual aggregate increased to $700,000 by fiscal year distributed by equivalent payments on a monthly basis. Fixed amounts were transferred electronically into ASEM's account before the 10th of each month.  This, to alleviate ASEM cash and liquidity constraints. 

An ASEM/ACAA committee was established and met on a monthly basis. This, to revise core standards pertaining to the operational processes that were developed. Action Plans with designated responsible personnel from both parties and deadlines were agreed and implemented. Corrective and preventive actions as well. Both parties had a better understanding of how each part operated. Why? Because patient service is the utmost common goal for each party. But the existing structure is indeed challenging and complex for patients, ACAA and ASEM personnel, in addition to related agents within the system.

Although the cost incurred by the Medical Center for ACAA patients (under the influence of alcohol or drugs) is still not covered, there was/is an acknowledgement by ACAA and ASEM top management and personnel that even though they are part of two different sub-systems represented by 2 separate corporations, both parts are really components of one (1) same system - the healthcare system. The problem is really structural. Existing separate structures do not promote lean patient service and the fiscal results for the ASEM Corporation, and the government as a macro, are unsustainable. In addition, legislation can be addressed for irresponsible drivers in order to prevent accidents. 

Let's not be blindsided by the fact that ACAA's financial statement may have positive outputs. It's the mere existence of it's actual medical-hospital structure; not the mission it represents, that should be carefully evaluated. This structure represents a $94mm budget within PR's existing financial crisis. It's almost the sole (more than 80% of it's claims are from the PR Medical Center) insurer (Automobile Accident related) for the Medical Center. So, I recommend the creation of a revised ACAA structure (not necessarily a corporation) be created  (including, a raise in the existing annual rate of $35 dollars); and have the Medical Center be auto insured for automobile related claims. (a transformation for the PR Medical Center Structure is recommended as well in a previous blog. it includes revision of relationships between ACAA/ASES/PR Medical Center).

The new ACAA structure could assign ASEM and the rest of the Medical Center components fixed monthly amounts according to cost structure and claims experience. Of course, within an audit structure for continuous revisions of services provided, costs incurred, and payments. ACAA, and the Government Health Reform existing structures, can follow similar landscapes regarding their government-government-government (ACAA-ASES-PR Medical Center) with the medical center. The government structure does not need to have 2 insurers representing $2.9 billion in it's budget. Especially if more than 70% of each of these programs insureds, are treated by the governments health facility structure: The Puerto Rico Medical Center. Patients will be better served.

The transformation of the Puerto Rico Medical Center , ACAA and ASES existing structures will represent the initial steps towards establishing new landscapes for identifying and eliminating the underlying factors causing existing and deteriorating financial constraints in the government healthcare component. Also, impacting the existing PR Fiscal Plan by depending less on the PR general fund and integrating alternate models preparing for the scenario of receiving less federal funds.



Next week we'll continue with Agent based Models and Complexity 










The Energy, Metabolism and Entropy Within Organizations

October 26, 2017 Nilza I. Cruz Ruiz  939-644-7683 "Philosophy is written in that great book which ever lies before your eye...