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Global Health, Health Costs, Health Policy, Stanford News

Pharmaceutical adventures in India

Pharmaceutical adventures in India

medication in IndiaIn the course of a recent trip to India, I developed some minor health problems and found myself doing what many locals do: consulting with a pharmacist. India’s cities are peppered with these modest little storefronts, some the size of a large closet, which sit along the street, the pharmacists stationed on a stool behind a counter awaiting customers.

The pharmacies are stocked floor-to-ceiling with a plethora of remedies for whatever ails the human body and spirit. My husband and I sought treatment for an affliction common both to travelers and local Indians, caused by contamination in food and water: diarrhea. Despite our best food precautions, we managed to contract a case of the runs after eating at a very elegant restaurant in Jaipur in the northern province of Rajasthan. When a dose of Lomotil did not prove entirely effective, we decided to turn to a pharmacist for advice, as my experience traveling abroad is that local practitioners often know best how to treat common local problems.

The pharmacist asked us several questions in perfect English: Did we have a fever? Any vomiting? Any stomach cramps? No to the first two, yes to the last. He radiated a sense of confidence. He then produced two sets of pills in silver and green packages. We were advised to take these twice a day. He also gave us an electrolyte replacement solution, to be mixed with purified water and consumed twice daily as well. The pills had names I did not recognize, so I largely took them on faith, explicitly following his directions. The total cost for both of us: the equivalent of $2.50.

“You actually behaved in many ways like a many locals would – like a person who doesn’t have easy access to a health-care provider,” Nomita Divi, program manager of the Stanford India Health Policy Initiative, told me recently when I related my experiences.

Divi took a group of Stanford students – one med student, one masters and two undergraduates – to India for 8 weeks this summer to study this very phenomenon: the role of pharmacists in healthcare delivery in India, where a dire shortage of physicians, particularly primary care physicians, severely limits access to care. These pharmacists often serve as first-line providers, she said. Some have formal training, but many do not and operate on the basis of experience, as the students observed this summer, she said.

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Big data, Events, Health Costs, Health Policy, Medicine X

Peter Bach on drug pricing: “A system so broken even a child could manipulate it”

Peter Bach on drug pricing: “A system so broken even a child could manipulate it”

Peter Bach at MedX

The U.S. medical system is like a New England toll road: It’s designed to extract tolls from patients all along their health-care journeys, with a callous disregard for whether or not these travelers arrive at their desired destination, a place of better health.

This was the angry message delivered by Peter Bach, MD, director of Memorial Sloan Kettering’s Center for Health Policy and Outcomes, who was the keynote speaker at today’s Medicine X conference.

Dr. Bach is a physician, an epidemiologist, a researcher and a respected health-care policy expert whose work focuses on the cost and value of anti-cancer drugs. He was also a caregiver who has traveled down the patient side of the system as his wife died of cancer.

In his talk, Bach discussed three of the major toll takers in the system — pharmaceutical companies, hospitals and researchers — and how the public’s wielding of a growing body of health-care data could be used to reign in a process that is driven more by profit than health outcomes.

This week no discussion on escalating health-care costs could pass without mentioning Martin Shkreli, the 32-year-old hedge fund manager whose drug company raised the price of a decades-old anti-parasite drug by more than 5,400 percent. “He made it clear that the system is so broken even a child could manipulate it,” said Bach.

But Bach went on to show some promising quality improvement projects that are helping to bring accountability into the health-care system.

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Global Health, Health Costs, Health Policy, Stanford News

Exploring the cost-effectiveness of treating parasitic-worm diseases

Exploring the cost-effectiveness of treating parasitic-worm diseases

A group of tiny worms are the source of great distress – and sometimes death – for a staggering 1.5 billion people in the developing world. Yet a small percent of affected people are treated for these ailments, which include helminth infections, such as hookworm, roundworm and whipworm, and schistosomiasis.

The offending worms, found in soil and water, can latch onto people while they walk barefoot in contaminated soil or bathe in infested lakes and streams. The parasitic worms then slither their way into the intestine or into the blood vessels around the intestines or bladder, where they cause great discomfort and disease.

Children commonly develop anemia and stunted growth and cognitive problems. Adults may also have abdominal discomfort and pain, wasting and sometimes more serious complications, such as a bowel or bladder obstruction or renal failure, which can be deadly.

WHO guidelines mostly target school-aged children for treatment, which costs pennies to administer, because children are heavily affected and are easily treated as they congregate in schools, says Stanford’s Nathan Lo, author of a new study on treatment of these parasitic worm diseases. The study, which appears online in Lancet Global Health, shows that treating an entire community, including adults, reaches many more people and is highly cost-effective.

Lo, a third-year Stanford medical student and research associate, said he decided to do the study after he realized the WHO guidelines hadn’t changed for decades and had never been rigorously analyzed. He and his colleagues modelled patterns of these diseases in four different communities in the Ivory Coast to see whether it was worthwhile and cost-effective to expand drug treatment, which is cheap and readily available. The drug albendazole costs about 3 cents and a pill and significantly reduces the number of worm eggs from the soil-transmitted helminths, while praziquantel costs 21 cents a pill and effectively reduces egg production in cases of schistosomiasis, he said.

“Most of the money spent on treating these diseases is focused on helping kids,” Lo told me. “But there are a lot of symptoms of disability in adults as well, and our results support the expansion of treatment to this adult population.”

Moreover, he noted, “If you only treat children, it might help them, but they often come home to neighbors, parents and teachers who may be infected, and the children can once again become infected. It’s more effective for children if you treat them and the people around them.”

In fact, the researchers’ findings show that community-wide treatment is highly cost-effective, even if it’s assumed that costs are 10 times what the researchers assumed. They also found that it’s worth the investment to treat people more frequently – at six-month intervals – and to do the drug treatments together, rather than as separate programs.

Given the findings, the scientists strongly urge the WHO to re-evaluate its guidelines to expand treatment to communities as a whole.

Photo of hookworms from Wikipedia

Global Health, Health Costs, Health Policy, Medicine and Society, Research

Chinese clinicians use inpatient visits to compensate for drug revenue loss

Chinese clinicians use inpatient visits to compensate for drug revenue loss

For decades, many doctors in rural China boosted their incomes by both recommending and selling drugs, often at steep markups. With mounting evidence of overprescription, in 2009 the Chinese national government largely banned markups, undermining doctors’ financial incentive to over-provide them. Instead, the government provided physicians with a subsidy to compensate for the loss in profits.

Since then, a number of scholars have examined the effects of the policy. But no one has looked at the unintended consequences — until now.

In a study published today in Health Affairs, a team of researchers found the policy had the unintended consequence of boosting hospitalizations and the provision of inpatient care.

“When you have a regulation that affects pricing, it’s like pushing a balloon in in one place — then it pops out in another,” said Grant Miller, PhD, director of the Stanford Center for International Development, senior fellow at the Freeman Spogli Institute for International Studies and an associate professor of medicine. The first author is Hongmei Yi, PhD, program manager of FSI’s Rural Education Action Program in China.

The team, which also includes Scott Rozelle, a senior fellow at FSI, examined data from rural Chinese clinics between 2007 and 2011. They found clinics that were most heavily reliant on drug revenues before the policy change more than doubled their provision of inpatient services when compared with the clinics least reliant on drug revenues before the change. These centers also experienced little change in revenue, which indicates they were able to offset the losses of drug revenue with income from inpatient stays.

Based on their analysis, the team also believes that this increase is not driven by demand for inpatient services, Miller said.

By also surveying and conducting follow-up phone interviews with patients, the researchers also found some evidence that clinics may be artificially boosting their inpatient tallies to increase their compensation from the government.

He said he was not surprised the policy had unexpected ramifications. “Humans are adaptive creatures and doctors are not categorically different than the rest of us. If you take away a source of livelihood, it’s not surprising they found another way to make it up.”

Rural primary care doctors in China “are also not at the top of the economic pyramid,” Miller said.

Health-care reform is on the national agenda in China and it’s possible that this study could inform future policies, Miller said. “It raises a much broader set of questions about how you design in a more holistic way a proper set of incentives for providers,” he said.

Previously: Seeking solutions to childhood anemia in China, Better school lunches — in China and Stanford India Health Policy Initiative fellows are in Mumbai — come follow along

Aging, Health Costs, Health Policy, Patient Care

A look back at Medicare’s 50 years

Hand in HandOn Friday, KQED’s Forum offered a look at Medicare and Medicaid to mark the programs’ 50-year anniversary. Stanford health policy researcher Laurence Baker, PhD, participated in the discussion, which covered issues such as how the programs drive the way prices for care are negotiated with medical providers, how the large population of Baby Boomers will affect the system, and how reimbursement rates affect the kind of care Medicare and Medicaid patients receive.

The panel also discussed the gaps in coverage — services like dental care are not covered by Medicare — and the challenges they create. Medicare coverage has grown from the narrow set of conditions it first covered, and Baker thinks the conditions are right to begin a new national conversation about expanding coverage:

One of the things that’s really ripe for discussion is how this country is going to handle the long-term care issues. Medicare’s got to be at the center of that. And it almost feels like the time is coming that we’re going to have to think about that much more seriously.

And when host Mina Kim asked Baker the question that’s on a lot of people’s mind — Is Medicare sustainable for the long term? — Baker noted:

The program is pretty important; it’s clearly something the country values across the political spectrum. Lots of people want to see it sustained. It may not be a pretty process. It might not be fun to watch the politics of how we work all this out, but there are lots of ways to keep the program solvent, so I’m optimistic.

Previously: Competition keeps health-care costs low, Stanford study findsWhat’s the going rate? Examining variations in private payments to physiciansCheck the map – medical procedure rates vary widely across CaliforniaMedicare payment reform shown to cut costs and improve patient care and KQED health program focuses on baby boomers and the future of Medicare
Photo by Garry Knight

Addiction, Emergency Medicine, Health Costs, Patient Care, Research

Questionnaire bests blood test at identifying patients with risky drinking behaviors

Questionnaire bests blood test at identifying patients with risky drinking behaviors

3144132736_9de39a590d_zAs many as half of the patients who visit the emergency room with traumatic injuries have alcohol in their bloodstream, and roughly 10 percent of these patients will return to the ER within a year. Today, many emergency rooms use blood alcohol tests to screen for patients with risky drinking behaviors. Yet a new study by researchers from Loyola University Medical Center suggests that a questionnaire may be a better way to identify at-risk patients.

In the study, researchers reviewed 222 records from patients 18 years of age and older that were admitted to Loyola University Medical Center’s level I trauma center between May 2013 and June 2014. Each of the patients in the study had a blood alcohol test and had answered the World Health Organization‘s 10-point questionnaire, called the Alcohol Use Disorders Identification Test (AUDIT). The research team compared the results of the blood test to that of the AUDIT test and found that the questionnaire was 20 percent more effective at identifying at-risk patients with dangerous drinking habits than the blood test.

As the researchers explain in their study, blood alcohol tests only provide “a snapshot of the patient’s recent drinking behaviors” by measuring of the amount of alcohol in the patient’s system at the instant the test is taken. In contrast, the questionnaire assesses the patient’s overall drinking behaviors by asking questions such as, how often they drink, how much they drink per day and if they have feelings of guilt or remorse after drinking.

These findings are significant because blood alcohol tests are often the only tool used to assess at-risk drinking behavior in ER patients. Their findings call this common practice into question and suggest that the AUDIT questionnaire may be a better way to identify, and ultimately prevent, potentially dangerous drinking behaviors.

Previously: Alcohol-use disorder can be inherited: But why?Could better alcohol screening during doctor visits reduce underage drinking? and How to make alcoholics in recovery feel welcome this holiday season
Via: Business Wire
Photo by: Julie °_°

Health Costs, Health Policy, Medicine and Society, Orthopedics, Research, Stanford News

When physicians work together, costs can rise

When physicians work together, costs can rise

97187153_16040f08b7_zOnce upon a time, patients received care from a local doctor, who usually worked alone or with a few partners. Now, most physicians belong to large practices, which have standardized procedures and costs.

These mergers have been greeted warmly by regulators and the public, who believe that larger groups can take advantage of economies of scale. But these alignments could also give physicians greater bargaining power with insurers, a move that could push costs up, according to a new study by Stanford researchers.

Eric Sun, MD, an instructor of anesthesiology, perioperative and pain medicine, working with senior author Laurence Baker, PhD, investigated the fees charged by orthopedic surgeons for knee replacements between 2001 and 2010. They also ranked how concentrated physicians’ health-care markets scored on a commonly used index.

They found that physicians’ fees in markets with a high concentration of physician groups rose $168 compared to fees in the least concentrated markets — a jump of 7 percent.

The research has implications for the Affordable Care Act, which encourages physicians to join alliances. “The point is not to say that consolidation is a bad thing,” Sun concluded in our press release on the study. “But as we think about encouraging these kinds of mergers, we really want to weigh the costs against the benefits.”

The study appears in the June issue of Health Affairs.

Previously: Health-care policy expert Arnold Milstein weighs in on Medicare’s plan to prioritize “value over volume”, Steven Brill’s Bitter Pill and What’s the going rate? Examining variations in private payments to physicians
Photo by Waldo Jaquith

Emergency Medicine, Health Costs, In the News, Research, Stanford News

Thinking twice before doing blood transfusions improves outcomes, reduces costs

Thinking twice before doing blood transfusions improves outcomes, reduces costs

7413610060_317879301e_zStanford Hospital has figured out that doing fewer blood transfusions saves lives – and millions of dollars annually. In two studies headed by Stanford’s Lawrence Goodnough, MD, professor of pathology and hematology, doctors were gently nudged by a computer program to think twice before performing a blood transfusion. The impressive results were discussed in a Nature news feature published Tuesday:

The number of red-blood-cell transfusions dropped by 24% between 2009 and 2013, representing an annual savings of $1.6 million in purchasing costs alone. And as transfusion rates fell, so did mortality, average length of stay and the number patients who needed to be readmitted within 30 days of a transfusion. By simply asking doctors to think twice about transfusions, the hospital had not only reduced costs, but also improved patient outcomes.

Transfusions are common procedures in industrialized countries, but scientists are finding that they’re overused. More research needs to be done to determine when, exactly, transfusions cross the line between helpful and harmful. They do save lives, but probably only for the most critically ill patients.

Decades of established practice and protocol are hard to change, though. Clinicians acting in the moment refer to their experience, not to guidelines. That’s one reason Stanford’s simple computer innovation is so important. Goodnough, quoted in Nature, speculates about why it succeeded: Not only did alerts remind doctors about the guidelines and provide links to the relevant literature, they forced them to slow down and think instead of running with the default. The alerts may have provided an opening for more individualized discussion among caregivers:

‘Maybe the intern, who was ordering the blood because they were told to, goes back to the team and says, “I have to give a reason”, and then they discuss it,’ Goodnough says. The clinicians might decide to order the blood anyway, of course. Or they might stop, consider the evidence, and come to agree with what Goodnough believes is its clear message. ‘The safest blood transfusion,’ he says, ‘is the one not given.’

Check out the article for more on the history of blood transfusions, other research into their optimal use, and new practices being pioneered around the world.

Previously: Fewer transfusions means better patient outcomes, lower mortality, Stanford Hospital trims use of blood supplies, Stanford test a landmark in the blood banking industry and Should the US create a national blood transfusion reporting system?
Related: Against the flow: What’s behind the decline in blood transfusions?
Photo by Banc de Sang i Teixits

Health Costs, Health Policy, In the News, Patient Care, Public Health

Health-care policy expert Arnold Milstein weighs in on Medicare’s plan to prioritize “value over volume”

Health-care policy expert Arnold Milstein weighs in on Medicare's plan to prioritize "value over volume"

8266476742_4967a82707_zAmerican health-care spending is the highest in the world, yet some question whether that money really leads to improved patient outcomes. But significant reforms taking place within Medicare, the US’s biggest healthcare payer, over the next few years aim to quell these concerns and reduce costs while improving quality of care.

Health policy experts explained the context of these changes last week in a webinar hosted by Reporting on Health and supported by the NIH’s Health Care Management Foundation. The panel featured Stanford’s Arnold Milstein, MD, MPH, director of the Clinical Excellence Research Center, as well as health economist Austin Frakt, PhD, professor at Boston University School of Medicine, and Jordan Rau, a correspondent for Kaiser Health News.

Health-care’s dominant “fee for service” (FFS) model has been around “since doctors were getting paid in chickens,” said Rau in the webinar, but it has no link whatsoever to quality. Many think this model needs to be changed because it incentivizes physicians to do more (and more expensive) procedures, regardless of the effect they have on patient outcomes. “Better, less expensive care is a national imperative,” said Milstein. “The cost to society of inefficiently delivered care is creating enormous opportunity cost.”

Starting in 2011, Medicare began to tie payments to quality: Doctors get paid 2 percent more if quality goes up, and 6 percent less when it goes down, based on patient ratings and rates of readmission and infection. In 2014, quality-linked FFS accounted for around 80 percent of care, of which around 20 percent featured some more radical change. The new plan is that 50 percent of payments will be non-FFS by 2018.

Options to reform this model could include bundled fees (a flat rate per “episode” that includes all complications and follow-up care), accountable care organizations (ACOs) that take responsibility for all patient needs and costs, incentives for cross-provider cooperation, and population-based payment in which doctors receive a set fee for any patient (currently being pioneered in Maryland).

How will we know which changes to push? Milstein used a graph to indicate “positive value outliers,” institutions with high quality and low cost, whose strategies and techniques will be emulated to see if they can be effective elsewhere. He explained what researchers found makes them different:

[Positive value outliers] tended to have deeper, more personal relationship with their patients; their patients trusted that if they called these doctors on nights and weekends, someone who knew something about them would be rapidly responsive. Doctors’ vision of their responsibility to their patients extended far beyond producing a perfect office visit; it really meant being a steward for their patients’ best interests as their patients traversed emergency room doctors, hospitalists and medical specialists. And lastly, these doctors were not trying to be solo heroes – they did a wonderful job hiring and training medical assistants and taking advantage of a team… and it was associated with a substantial improvement in value. Our next step is to splice this DNA into average performing primary care practices and verify that this is indeed the right stuff.

Some other ideas for achieving the targets were mentioned, such as sending physicians to homes so patients don’t get admitted, or in the longer term, having an intensive-care unit (ICU) “airline control tower” with more perspective than those on the “frontline” of critical care, an idea Milstein said was studied across 56 American ICUs and resulted in a 25 percent mortality reduction.

Milstein said such approaches could lower baseline health-care costs by 30 percent, but moreover could slow the rate at which health-care spending outgrows the economy, which is the real measure of success. Innovators in this area, he said, will need to draw from behavioral and computer science to think about problems differently.

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Events, Global Health, Health Costs, Health Disparities, Health Policy, Stanford News

Global health expert: Economic growth provides opportunity to close the “global health gap”

Yamey talkStanford’s Center for Innovation in Global Health hosted a recent seminar for Stanford students and faculty with global health-policy expert Gavin Yamey, MD, MPH. The discussion focused on the disparity in heath care between higher- and lower-income countries and how economic growth in lower-income countries could set the stage for big improvements in global health.

During the talk, Yamey explained that millions of lives could be saved if economic gains in low- and lower-middle-income countries were invested in health care. “I can’t think of any other investment on the planet that could improve human welfare in such a huge way,” Yamey told the audience.

As described in an online story on the event, Yamey cited Rwanda – a country that rebuilt its economy and healthcare after the 1994 genocide – as an example of how this scenario could play out elsewhere:

Over the past decade, Rwanda has experienced significant drops in mortality associated with HIV, malaria and maternal death, and achieved the greatest drop in child mortality rates in recorded history. While scholars acknowledge several factors that contributed to such an extraordinary rebound, government spending on public health, the smart use of aid, and economic growth were all integral to the equation.

“We have an extraordinary opportunity to bring down maternal, newborn and infectious disease deaths to universally low levels everywhere,” Yamey said. “But for that to happen, we need an aggressive scale up of existing tools and interventions, investment in new tools and a build-up of delivery systems.”

Previously: Minimum wage: More than an economic principle, a driver of healthHealth care in Haiti: “At risk of regressing”Child-mortality gap narrows in developing countries and Stanford general surgeon discusses the importance of surgery in global health care
Photo, of Gavin Yamey (left) and moderator Paul Costello, courtesy of the Center for Innovation in Global Health

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