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Health Policy

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

Health Policy, In the News, Medicine and Society, Pediatrics, Stanford News

Stanford researchers analyze California’s new vaccine law

Stanford researchers analyze California's new vaccine law

CA vaccine photoWhat do California, West Virginia and Mississippi have in common? Stumped?

Thanks to a recent law signed by California Gov. Jerry Brown, these three states now have strict vaccine policies that require children to be vaccinated before entering school, unless they have a medical exemption. The new requirements eliminate religious and philosophical exemptions.

Stanford’s Michelle Mello, JD, PhD, and David Studdert, LLB, ScD, (along with co-author Wendy Parmet, JD) heralded the change in a New England Journal of Medicine commentary published this week. From a Stanford News release:

“The move represents a stunning victory for public health that affects not only California schoolchildren, but the prospects for strengthening vaccination requirements nationwide,” they wrote.

The new laws come in the wake of a measles outbreak that started at Disneyland last year. It fueled a nationwide debate about the merits of vaccines, and of the large number of children unvaccinated due to parental objections.

The new California law requires all children enrolled in private and public schools and day-care facilities to be vaccinated against measles, whooping cough and several other diseases.

Yet the law is sure to face challenges, particularly from opponents who say it violates their religious rights. In addition, a lack of enforcement may weaken the law’s ability to ensure widespread protection.

Nonetheless, California’s new law is worth celebrating, they say:

“Although California politics may be distinctive, its experience with SB277 teaches us that even strong opposition can be overcome with the right combination of astute public education, political strategy and legislative fortitude,” they wrote. “Fewer vaccination exemptions and vaccine-preventable illnesses would be accomplishments that other states would find difficult to ignore.”

Previously: A discussion of vaccines, “the single most life-saving innovation ever in the history of medicine”, Science Friday-style podcast explains work toward a universal flu vaccine and Side effects of childhood vaccines are extremely rare, new study finds
Image by Niyazz

Cancer, Health Policy, NIH, Public Health

Draining the cancer swamp

Draining the cancer swamp

4011473415_46405053bd_zThere’s an old adage that applies to many difficult situations that we face in life: When you’re up to your armpits in alligators, it’s difficult to remind yourself that you should have drained the swamp.

I’ve come to view cancer as a vicious predator lurking in dark waters, eager to attack one out of two of us in our lifetimes. Cancer is the second most common cause of death in the United States.

Looking at the current national funding model for cancer research, I wonder if society has lost track of a vital goal: preventing cancer, not just treating it. Wouldn’t it be better if we prevented cancer in the first place? Cancer prevention would reduce the devastating physical, psychological, emotional, social and economic burden placed on patients, their families and their friends.

As he stepped down from the role of Director of the National Cancer Institute, Harold Varmus, MD, spoke about the deep complexity of cancer and the tremendous amount of basic research that needs to be done. While recognizing the need for clinical testing, he also called for more pioneering discoveries into who gets cancer, where and why.

The financial constraints facing scientific research force us to make difficult choices. Right now, our current health-care model prioritizes “identifiable individuals” over “statistical individuals.” Identifiable individuals are those real persons in distress who have been diagnosed with cancer. They need treatment, and we are highly motivated to help cure them. The cost of doing so, however, is high: The average monthly cost of cancer treatment has more than doubled to $10,000 over the last decade. Of course, we are willing to pay the costs – these victims are our mothers, our fathers, our sons and our daughters.

Statistical individuals are those who may be at risk, but they may not know it. They may never know that scientific research “rescued” them from a devastating disease. Through prevention measures enacted by individuals themselves (e.g., getting more exercise, avoiding tobacco use) or by society (e.g., limiting chemical exposures in the environment, banning the use of tanning beds for minors), these individuals may be able to escape the scourge of cancer.

When making choices about where to invest limited dollars, it is so much easier to say “no” to statistical people rather than real people.

I don’t advocate taking money away from cancer treatment, but I do advocate a greater investment of federal dollars in research that leads to reducing the incidence of cancer in the healthy population. By tracking and analyzing patterns and trends of cancer, we can identify potential risk factors and inform individuals and communities about positive changes they can make toward living cancer-free lives.

It is estimated that over 50 percent of the 585,720 cancer deaths in the U.S. in 2014 were related to preventable causes. As such, federal dollars directed toward statistical individuals will save both money and lives.

We need to drain the swamp. Our ultimate societal goal shouldn’t be to treat cancer more effectively, but to prevent it altogether. We need to intervene as early as possible in the trajectory of cancer. By doing so, we will greatly reduce the extent and depth of human suffering.

Donna Randall, PhD, is chief executive officer of the Cancer Prevention Institute of California.

Photo by William Warby

Global Health, Health Policy, Stanford News

Stanford India Health Policy Initiative fellows are in Mumbai – come follow along

Stanford India Health Policy Initiative fellows are in Mumbai - come follow along

India Health Policy students

Today, I’m on my way to India to join the 2015 Stanford India Health Policy Initiative fellows. These fellows are part of a program that designs and conducts collaborative student projects focused on generating new, on-the-ground insight into the factors that distinguish health-delivery success and failure. This summer, the four fellows are Mark Walsh, a rising senior who is majoring in economics; Pooja Makhijani, a second-year medical student; and Lina Vadlamani and Hadley Reid, both rising seniors who are majoring in human biology.

The students are spending seven weeks investigating the pharmaceutical networks in urban Mumbai in an effort to understand how informal providers interface with these networks and whether it impacts how providers practice, prescribe and dispense medication. The fellows are traveling house to house to investigate community preferences for medications.

We’ll be updating this Storify page with stories on their time there, and we’ll be tweeting from @StanfordHP (and using the hashtag#StanfordHealthIndia) over the next few weeks. I hope you’ll follow along.

Beth Duff-Brown is communications manager for the Center for Health Policy and Center for Primary and Outcomes Research (CHP/PCOR).

Photo, of Walsh, Makhijani and Vadlamani, courtesy of CHP/PCOR

Health Policy, Research, Stanford News

Exploring the link between patient-record fees and doctor switching

Exploring the link between patient-record fees and doctor switching

HCCH-medical_recordsWho owns your medical records – you or your doctor? If you answered that you do, you’re like most patients, according to a recent survey. But you would be wrong.

Legally, the doctors or hospitals who create medical records own them. Although federal law states they have to provide records to patients who request them at a reasonable cost, the definition of “reasonable” varies quite a bit. And that cost also has some surprising repercussions.

Three Stanford researchers – health economist Kate Bundorf, PhD, Laurence Baker, PhD, chief of health services research, and health and political economist Daniel Kessler, PhD, JD – examined the issue in a recent study in the American Journal of Health Economics. They compared rates of doctor-switching between states that have caps on medical-record copying fees and those that don’t.

The team found that patient record charges decreased the number of patients who switched doctors and that when there were caps on copying fees, more providers switched to electronic medical records. A Stanford GSB article described the findings in detail:

In states that imposed caps on fees for medical records, patients changed their primary doctors 11% more frequently and their specialty doctors 13% more frequently. In addition, the researchers found that health care providers were about 12% more likely to establish electronic medical records in states that imposed caps on copying fees.

The fact that more than 1 in 10 people would switch doctors if their records were easier to get means that copying fees matter. In addition, other research suggests that adoption of electronic medical records can significantly reduce mortality in complicated cases; to the extent this is correct, caps on copying fees not only enhance patient convenience but also save lives.

Kessler says the study suggests there is a good case for regulating the fees charged for medical records: “You can’t make it impossible for people to switch doctors. We know that can’t be the right direction.”

Baker agrees, telling me, “No one should have to feel like they’re stuck with a doctor when they’d like to switch. Policies that help people get reasonable access to their medical records look like they can help.”

Previously: Can sharing patient records among hospitals eliminate duplicate tests and cut costs?U.S. Olympic team switches to electronic health recordsA new view of patient data: Using electronic medical records to guide treatment and Do electronic health records improve health? It’s complicated
Image by Jackhsiao

Global Health, Health Policy, Research, Stanford News

Health aid may be allocated efficiently, but not always optimally

Health aid may be allocated efficiently, but not always optimally

malaria bed net

Foreign aid to the public-health sectors of developing countries often appears to be allocated backwards: The global burden of non-communicable diseases such as diabetes or heart disease is enormous – yet these disorders receive little health aid.

By comparison, the global burden of HIV is much smaller, yet it receives more health aid than any other single disease.

An alignment in health aid could best be improved by focusing on malaria and TB, especially where addressing those diseases is highly cost effective

So will a wholesale reversal in health aid priorities improve global health? The answer, according to a new study by Stanford researchers, is that if the goal is to maximize the health benefits from each donor dollar, health aid is actually allocated pretty well.

Still, reallocating foreign aid to step up the fight against malaria and tuberculosis (TB) could lead to greater overall health improvements in developing nations. And it could be done without spending more money, the researchers show.

For their work, Eran Bendavid, MD, an assistant professor in the Department of Medicine and a core faculty member at the Center for Health Policy and Center for Primary Care and Outcomes Research, and three researchers focused on 20 countries that received the greatest total amount of aid between 2008 and 2011, a period of historically unprecedented growth in health aid. The 20 countries – from Afghanistan to Zambia – received $58 billion out of the $103.2 billion in recorded health aid disbursements to 170 countries between 2001 and 2011.

“What we found, somewhat to our surprise, is that in nearly all countries, more aid was flowing to finance priorities with more cost-effective options,” Bendavid, said in an interview. “That is partly because more aid was flowing to the treatment and prevention of infectious diseases such as HIV and malaria, and their management can be relatively inexpensive.”

Bendavid, an infectious disease physician, added: “Even though the burden of non-communicable diseases is high and growing, addressing chronic conditions such as diabetes and heart disease is, broadly, more costly than the unfinished infectious disease agenda.”

In their paper, Bendavid and his co-authors write that the “data suggest that [an alignment in health aid] could best be improved by focusing on malaria and TB, especially where addressing those diseases is highly cost effective.” Gains would come from taking some aid earmarked for HIV or maternal, newborn or child health, and putting it toward programs to treat these two disorders, they say.

But it’s also crucial, they conclude, to further study the consequences of realignment of donor funds.

This paper appears in the July issue of Health Affairs.

Beth Duff-Brown is communications manager for the Center for Health Policy and Center for Primary and Outcomes Research.

Previously: Foreign health care aid delivers the goods and Foreign aid for health extends life, saves children, Stanford study finds
Photo, of a mother and son under an insecticide-treated bed net in Tanzania, by the Gates Foundation

Health Policy, In the News, Medicine and Society

Medicare to pay for end-of-life conversations with patients

Medicare to pay for end-of-life conversations with patients

800px-Doctor_and_couple_talking_(1)Remember “death panels?” In the summer of 2009, in the midst of the debate about the Affordable Care Act, aka Obamacare, a small item in the legislation allowing Medicare to reimburse physicians for end-of-life conversations with patients unleashed a tsunami of criticism. Opponents charged that so-called “death panels” – anonymous Washington bureaucrats – would be making decisions about rationing health care and ultimately deciding who would live and who would die. As foolish as that charge was, the Obama administration choose not to fight the opposition and the payment proposal was dropped.

Now, the Centers for Medicare and Medicaid Services has announced a new policy. Beginning January 1, 2016, the government will reimburse voluntary end-of-life conversations that Medicare physicians have with their patients.

We asked Stanford’s VJ Periyakoil, MD, a nationally recognized leader in palliative care, for comment, and she said, “Medicare’s proposal to reimburse doctors to have a conversation with the patient about their values and preferences for care is a quantum leap forward towards the lofty goal of improving quality of care for all Americans at the end-of-life.” But she emphasized that this is just one part of the solution:

Advance care planning is not an event but a process. The key is having conversations in plural, over time as patients’ goals of care change as their illness progresses.

Early in the illness, most patients prefer to have a trial of high-intensity treatments including life support, and this is a very reasonable thing to do. However, there is a tipping point in the illness trajectory where we go from prolonging life with quality to prolonging the dying process. Beyond this tipping point, most patients, if given a choice, prefer to die gently and naturally at home minimizing the burden to their loved ones. But in order for this to happen, we need doctors who are well trained and highly skilled at conducting end-of-life conversations with their patients. We need to ensure that patients and their proxy decision makers are well supported to make end of life decisions. Finally, it takes significant support of both the patient and caregiver by a skilled team of clinicians to ensure a gentle and peaceful death at home.

Unless we have all these components in place, we can’t expect to see major and sustained improvements in end-of-life care.

Previously: “Everybody dies – just discuss it and agree on what you want”In honor of National Healthcare Decisions Day: A reminder for patients to address end-of-life issuesA call to “improve quality and honor individual preferences at the end of life”Study: Doctors would choose less aggressive end-of-life care for themselves and On a mission to transform end-of-life care
Photo by National Cancer Institute

Health Policy, Mental Health, Patient Care, Pediatrics, Stanford News

Stanford expert on new treatment guidelines for teens’ eating disorders

Stanford expert on new treatment guidelines for teens' eating disorders

eatingdisorder-plateEating disorders often begin in the teenage years, but, surprisingly, the medical community long lacked a teen-specific set of guidelines for treating these serious illnesses.

That changed in May with the publication of a set of practice parameters co-authored by Stanford eating disorder expert James Lock, MD, PhD, who also directs the Comprehensive Eating Disorders Program at Lucile Packard Children’s Hospital Stanford. The parameters were based on an extensive review of the current scientific evidence around eating-disorder treatment, including recent studies by Lock and his colleagues that show that teens’ parents can play an active role in helping their children recover from anorexia nervosa. That’s a big shift from traditional thinking about eating disorders, which held that young patients’ families should be shut out of treatment.

In a new Q&A, I talked with Lock about why the parameters were needed. He told me:

There have never been practice parameters that address eating disorders in children and adolescents, and expertise in treating these disorders has been sort of sequestered. Yet eating disorders are so prevalent and are such a severe problem: Lifetime prevalence in adolescent girls is around 1 percent, and the disorders have among the highest fatality rates of all mental illnesses.

Teens need treatment approaches that account for their level of physical and emotional development, the fact that their parents generally want and need to be involved in their recovery, and the fact that they have not usually had eating disorders for as long as adult patients with the same diagnoses.

Lock also discusses how he hopes the new guidelines will improve training of psychiatrists, how recent changes to eating disorder diagnostic criteria are making it easier for doctors to get their patients the help they need, and why outpatient treatment is the new front line for young people with eating disorders.

Previously: Patient tells how social media helped her overcome the “shame” of her eating disorder, Incorporating family into helping teens overcome eating disorders and Story highlights need to change the way we view and diagnose eating disorders in men
Photo by Darren Tunnicliff

Chronic Disease, Global Health, Health Policy, Public Health, Research, Stanford News

Finding the sweet spot in public health law to regulate sugary drinks

Finding the sweet spot in public health law to regulate sugary drinks

lemonade-155663_1280Two Stanford public health law experts say one of the biggest culprits of the obesity epidemic – on top of fast foods and sedentary lifestyles – is sugary drinks. And they believe the sweet spot for public health law in curbing the adverse effects of sugar-sweetened beverages (SSBs) lies in the strategic use of measures such as higher SSB taxes, limits on advertisements targeting kids, and restrictions on soft drinks and sugar-sweetened teas and sports drinks in government institutions, such as public schools.

“Enough is already known about the promise of some legal interventions to curb SSB consumption – significant tax hikes and advertising restrictions are two good examples – to be fairly confident that they would make a difference,” says David Studdert, MD, a professor in the medical and law schools and a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research.

Studdert is the lead author of a review paper, “Searching for Public Health Law’s Sweet Spot: The Regulation of Sugar-Sweetened Beverages,” which was published today in PLoS Medicine.

Studdert and senior author Michelle Mello, MD, also a professor in the medical and law schools, and co-author Jordan Flanders, a former Stanford Law School student, argue that sugary drinks are a substantial, yet preventable contributor to the global burden of obesity and associated health conditions.

A recent study in the journal Circulation linked the consumption of sugary drinks to an estimated 184,000 adult deaths each year, with more than 25,000 of those Americans. While Americans’ consumption of sugary drinks has plateaued, according to the research, about three-fourths of the deaths due to SSBs are now in developing countries. Mexico leads with 24,000 total deaths. The United States still ranks fourth, however, just behind South Africa and Morocco.

The Stanford researchers say the evidence shows that sugary drinks are contributors to the global obesity epidemic, but the appropriate reach of regulation to curtail SSB consumptions remains highly contested.

“Finding public health law’s sweet spot requires regulatory approaches that are capable both of achieving measurable improvements to public health and of winning victories in courts of law and public opinion,” they wrote.

That’s often difficult.

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Health Policy, In the News, Medicine and Society, Public Health

On King v. Burwell and the survival of the Affordable Care Act (and an unexpected birthday present)

On King v. Burwell and the survival of the Affordable Care Act (and an unexpected birthday present)

5362318849_dd1527d632_zToday is my birthday – and the Supreme Court (or, at least, two-thirds of it) just gave me, most people who follow health policy, and millions of now still-insured Americans a present: King v. Burwell.

There’s a lot to say about this decision, but I want to focus on three things: the strength of the conflicting substantive arguments, the possible internal Court dynamics that resulted in the majority and dissenting opinion, and a guess at some deeper meanings of the case for the future of health care in America.

On the substance, this is a case that really could have gone either way. The idea that the Court should apply the words as written, no matter how silly, has precedent in the Court’s history; so does the idea that the Court should try to interpret laws in ways that make them work as intended. The majority — at the end, Chief Justice John Roberts’s opinion — does recognize this conflict; the dissent, from the more textualist end of the Court, rejects the idea of a tension. The majority has it right in the sense that sometimes the Court applies the words as written, sometimes it requires interpretation, and that both are legitimate responses to cases – both are within the culture of legal interpretation that the Court has included over the last two-and-a-quarter centuries.

I do think the Court could have legitimately gone the other way, though I think it would have been foolish and harmful, to the country and even to the conservatives who will now bemoan this outcome. I am glad they did not. I prefer judges who try, when the law – or more accurately its interpretative culture – will allow them to, to make things work in a sensible way. The dissent’s position would have upended a major government program and harmed millions of people for a technicality – like a ticky-tack penalty or foul call deciding the Super Bowl or the World Cup. The Court could have done that, but it would have been wrong.

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