End-stage renal disease makes up 7.2 percent of Medicare spending, even though those patients represent less than 1 percent of the Medicare population, according to a database that tracks chronic kidney disease.

Despite the gnashing of teeth about the runaway costs of Medicare spending, the national health-care system for the elderly, younger people with certain disabilities and chronic kidney disease appears to have found one way to lower costs.

Congress established the end-stage renal disease (ESRD) Prospective Payment System in 2008, as part of the Medicare Improvement for Patients and Providers Act. It mandated that ESRD Medicare patients treat themselves at home if able.

The new payment system introduced two incentives to increase home dialysis use: bundling injectable medications into a single payment for treatment and paying for training for patients to give themselves injections and treatment at home.

A new study by Stanford researchers shows home dialysis treatment among Medicare patients increased by 5.8 percent from January 2006 through August 2013. The researchers also found that non-Medicare patients covered by other forms of health insurance also turned to home dialysis by a jump of 4.1 percent.

“These spillover effects suggest that major payment changes in Medicare can affect all patients with end-stage renal disease,” the authors wrote in the study published in the latest edition of the Journal of the American Society of Nephrology. “One of the stated goals of the PPS payment reform was to incentivize an increase in-home dialysis use, and it appears that it has succeeded in this stated goal.”

Eugene Lin, a postdoctoral fellow in nephrology at the Stanford School of Medicine and lead author of the study, told me that most nephrologists believe the trend toward home dialysis is good for the taxpayers and for the patients.

People going through this phase of chronic kidney disease — when dialysis or a kidney transplant are the only chance of survival  — cost less to take care of at home and have similar outcomes to in-center hemodialysis patients.

“It’s hard to say if one therapy is definitively better than the other,” Lin said, “though home dialysis generally offers patients more independence and potentially better quality of life.”

Lin explained the difference between in-center hemodialysis and home treatment: At a center, blood is filtered through a machine, whereas home dialysis entails either having a hemodialysis machine at home (and having a caregiver help with the treatments) or performing peritoneal dialysis.

The latter is the most commonly used at-home treatment and involves using the abdominal compartment as a filter. The toxins in the blood get filtered through the abdominal membranes into clean fluid, which is then removed and discarded.

Similar drugs are used both in centers and at home, but they’re easier to give in the hemodialysis setting, so had a higher likelihood of overuse prior to payment reform.

“Once they bundled the drug reimbursement with the treatment, we saw dramatic decreases in the use of these drugs and a concurrent increase in home dialysis use,” Lin said.

The researchers, including senior author Jay Bhattacharya of Stanford Health Policy, noted that home dialysis remained stagnant at around 11 percent from 1983 to 1992 and steadily declined until 2008.

“While the cause of this decline is unknown, several policies made home dialysis less favorable than in-center hemodialysis economically,” they wrote.

First, the federal Centers for Medicare & Medicaid Services in 1991 revised its reimbursement policy for the erythropoietin-stimulating agent needed for functioning kidneys, making it the most profitable component of in-centers hemodialysis. Then, CMS introduced a tiered fee-for-service physician payment in 2004, providing the potential for enhanced revenues with in-center dialysis.

But the PPS bundling shifted erythropoietin from the profit side to the cost side, so it was no longer advantageous to use high doses common with in-center hemodialysis, Lin said. This paved the way for an increase in home dialysis use, which is less costly to administer.

Stanford Health Policy’s Douglas K. Owens has been appointed vice chair of the U.S. Preventive Services Task Force, an independent, volunteer panel of national experts in prevention and evidence-based medicine.

Owens, the Henry J. Kaiser, Jr. Professor at Stanford University is a general internist at the VA Palo Alto Health Care System, and a professor of medicine, health research and policy, and management science and engineering at Stanford.

He is the director of the Center for Health Policy in the Freeman Spogli Institute for International Studies, where he is also a senior fellow, and the Center for Primary Care and Outcomes Research in the Department of Medicine and School of Medicine, and Associate Director of the Center for Innovation to Implementation at the VA Palo Alto Health Care System.

“Through his stellar work, Dr. Owens enables Stanford Medicine to advance its mission to precisely predict and prevent disease,” said Lloyd Minor, MD, dean of the Stanford School of Medicine. “As our country faces an increasingly diverse, aging patient population and rising health care costs, I am thrilled that Dr. Owens will contribute his perspective and expertise to this national task force.”

Owens served a previous four-year term on the independent, volunteer panel of national experts in prevention and evidence-based medicine. He will serve for two years as vice chair and then a year as chair. Members come from health-related fields ranging from internal medicine, family medicine, pediatrics, behavioral health, obstetrics/gynecology, and nursing.

The task force issues preventive care guidelines based on detailed assessment of the evidence about preventive interventions and is supported by the Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services.

“It’s humbling because the task force guidelines impact virtually every primary care patient in the United States,” said Owens, who is also past president of the Society for Medical Decision Making. “Having an unbiased, independent assessment of the benefits and harms of preventive services is very important for primary care clinicians and patients.”

The task force works to improve American’s health by making evidence-based recommendations about clinical preventive services such as screenings, counseling services and preventive medications. Its members have tackled everything from whether to screen for certain cancers, which medications should be taken to prevent diseases and reduce blood pressure and high cholesterol, and screening for infectious diseases, including HIV, HCV, TB, syphilis and other sexually transmitted diseases.

“We are honored to welcome Dr. Owens back to the task force in a leadership role,” said task force chair David C. Grossman, MD, MPH, a senior investigator and medical director for population health strategy at the Group Health Research Institute.

“His experience in guideline development, both with the task force and partner organizations, and his work in evidence-based medicine and clinical decision-making are valuable additions to our leadership team,” Grossman said.

The task force, for example, just released its draft guideline on prostate cancer screening. And some of the medical topics under development are screening for cervical and BRCA-related cancer, as well as pre-exposure prophylaxis for HIV infection.

Owens said that it was critical that the task force remains unbiased and independent. The 16 volunteer members who are nationally recognized experts in prevention, evidence-based medicine and primary care, carefully evaluate the science behind preventive interventions.

“The task force has very rigorous methods for assessing evidence, and we are fortunate to have state-of-the-art evidence reviews provided by AHRQ funded Evidence-Based Practice Centers,” he said.

Each year, the task force makes a report to Congress that identifies critical evidence gaps in research related to clinical prevention services and recommends priority areas that deserve further explanation. All their reports and recommendations are made public on the task force website and leave room for public comment.

The Journal of General Internal Medicine (JGIM) has appointed Stanford Health Policy’s Steve Asch as an editor-in-chief.

JGIM is the highest rated journal for primary care research in the world. It publishes research on health services, implementation science, medical education and the humanities in addition to primary care.

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“Steve is widely known as an outstanding writer and editor, and as having very broad methodological expertise,” said Douglas Owens, director of the Center for Health Policy/Primary Care and Outcomes Research. “He's a terrific choice to lead JGIM.”

Asch’s work focuses on quality improvement, and he has lead several national projects to develop tools that measure quality of care for veterans, Medicare users and the public. An avid mentor, Asch has trained dozens of physician fellows in health services research at Stanford and the VA system.

“We’re going to try to get research out there where it can make a difference in the world,” said Asch.

The editor team plans to focus more on best practices and implementation science. By combining the efforts of many researchers, they hope to ensure that doctors get the best answers to the big questions in health care.

“I think it’s going to be fun,” said Asch.

He looks forward to mentoring researchers to submit articles to journals like JGIM.

“Primary care is important,” said Asch. “As the health-care system transforms, it will play an increasingly important role, and the journal is very much in the lead in trying to publish new ways of organizing primary care.”

After the 2012 mass shooting of children and teachers at Sandy Hook Elementary School in Connecticut, a leader of the National Rifle Association proclaimed: “The only thing that stops a bad guy with a gun is a good guy with a gun.”

It would seem that many Californians agreed, according to new research by Stanford Health Policy’s David Studdert and other researchers at academic institutions.

In the six weeks after the Newtown shootings — when a young man fatally gunned down 20 children and six adults — handgun acquisitions in California rose by 53 percent among first-time gun owners over expected levels.

When a couple armed with semi-automatic weapons targeted a San Bernardino County public health event in December 2015, killing 14 people in 2015, handgun purchase rates were 85 percent higher than expected among residents of the city of San Bernardino and adjacent neighborhoods, compared with 35 percent higher elsewhere in California.

In a new study in the Annals of Internal Medicine, lead author Studdert, a professor of medicine at Stanford Medicine and professor of law at Stanford Law School, writes that their findings have implications for public health as firearm ownership is a risk factor for firearm-related suicide and homicide.

“There is strong evidence linking gun ownership to risks of gunshot injuries, so any sudden boost in firearm ownership could have public health implications,” Studdert said. On their own, these two mass shootings are unlikely to have caused enough of a change in ownership patterns to have significant public health effects.

“But over time, purchasing responses to a succession of unnerving events like this — from mass shootings to terrorist attacks, to elections — could change levels of gun ownership enough to increase overall rates of gun injury and death.”

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The authors write that for some, mass shootings may induce repulsion at the idea of owning a weapon. But for others, they note, it may motivate acquisition.

“Mass shootings are likely to boost sales if they heighten concerns over personal security because self-protection is the most commonly cited reason for owning a firearm,” they said.

More than 32,000 people die of gunshot wounds in the United States each year, according to the Centers for Disease Control and Prevention. While mass shootings account for less than 1 percent of those deaths, they are the most visible form of firearm violence because of the extensive broadcast and social media coverage that surround them.

Using detailed individual-level information on firearm transactions in California between 2007 and 2016, the researchers analyzed acquisition patterns after two of the highest-profile mass shootings in U.S. history. They found large and significant spikes occurred among whites and Hispanics, and among individuals who had no record of having previously acquired a handgun.

Although these spikes in handgun purchases after both mass shootings were large, they were also short-lived and accounted for less than 10 percent of annual handgun purchases statewide.

“Concerns about firearm violence and the public health risks of firearm ownership should stay focused on the much larger volume of weapons that routinely changes hands, and the immense stock that already sits in households,” write Studdert and his colleagues, Stanford Health Policy researcher Yifan Zhang, PhD; Jonathan Rodden, PhD, a professor of political science at Stanford; Rob J. Hyndman, PhD, a professor of statistics at Monash University in Australia; and Garen J. Wintemute, MD, MPH, an expert on gun violence at the University of California, Davis.

“On the other hand, the cumulative effect of such ‘shocks’ as Newtown and San Bernardino shootings on firearm prevalence may be substantial,” they write. “Moreover, firearm acquisitions seem to be sensitive to a range of other events that are also common, such as federal elections, new firearm safety laws, and terrorist attacks.”

Taken as a whole, they said, these events may drive significant increases in overall firearm prevalence, which may, in turn, increase the risk for firearm-related morbidity and mortality in the long run. The authors urge further research should explore the cumulative effects and temporary shifts in acquisition patterns, their causes, and their implications for public health, crime and social cohesion.

Pandemics are a growing health concern in the United States and abroad. But as global health specialists are ramping up efforts to prevent them, funding may be slipping away.

President Trump's proposed budget would eliminate the National Institutes of Health's Fogarty International Center, a key player in the fight against diseases worldwide.

According to a USA Today column by Michele Barry, Director of the Center for Innovation in Global Health and a Stanford Health Policy affiliate, and David Yach, a former cabinet director at the World Health Organization, Fogarty's global health research benefits the United States along with other countries. The center has produced insights into Alzheimer's research, is looking into the genetics of obesity and diabetes, and has started developing early warning systems for pandemics.

But its most important accomplishment, according to Barry and Yach, is training scientists in more than 100 low- and middle-income countries. These experts have emerged as leaders in their own countries and around the world.

Their contributions have not only improved health but have influenced the World Health Organization and leading global health donors.

Said Barry and Yach, "To eliminate the Fogarty Center now would undermine progress, erode trust in America’s leadership in global health, and increase the risk of a devastating and preventable epidemic in the U.S. Keeping Fogarty would preserve health, both of Americans and populations all over the world."

Read the full article.

When Americans think of gun violence, we typically think of homicide and the never-ending debate over Second Amendment rights. But we rarely consider gun violence —and the growing rate of suicide by firearms — as a public health epidemic.

There were 36,252 gun deaths in the United States in 2015, according to the Centers for Disease Control and Prevention. America’s firearms homicide rate is 25 times greater than the average of other high-income countries.

In fact, guns have killed more Americans since 1968 than in all the combined deaths on the battlefields of all American wars. These numbers are astounding.

Yet audience members at the recent symposium on “Race, Policing and Public Health,” sponsored by the Stanford schools of law and medicine, learned that the Centers for Disease Control and Prevention haven’t funded research into gun violence since 1997, when Congress passed a bill barring the agency from funding any research that would “advocate or promote gun control.”

It’s just too much of a political hot potato.

The audience of the daylong symposium on March 6 also learned that twice as many Americans commit suicide using a gun than there are homicides in this nation. While black men are 14 times more likely than white men to be shot and killed with guns, older, middle-aged white men have the highest rate of firearm suicide.

“Who knew that firearm violence was increasingly an old white guy problem?” said Garen Wintemute, an emergency physician, and director of the Violence Prevention Research Program at UC Davis School of Medicine.

Wintemute, one of the country’s leading experts on the public health crisis of gun violence, said the aggregate annual cost of firearm deaths is about $229 billion per year after considering the full range of costs: prison terms, lost wages and the law enforcement costs to the American taxpayer.

“So far we have taken a traditional risk-based focus on the problem,” he said. “But there is a complementary approach, the population health approach, which suggests perhaps we should look at the burden of illness.”

Wintemute added the problem is so widespread that “elements of our society who do not think they have a stake in the problem — are so wrong.”

David Studdert, a faculty member at Stanford Health Policy and a professor of law and professor of medicine, moderated the panel. In a special communication in JAMA Internal Medicine, Studdert and colleagues analyzed the federal laws that protect firearm dealers and makers from tort litigation.

“Garen made the crucial point that gun violence is not one epidemic, but several sub-epidemics, each with very different properties and racial profiles,” Studdert said. “While firearm homicide rates are highest among young black men, rates of firearm suicide are highest among middle-aged and elderly white men. These different sub-epidemics clearly call for different policy responses.”

Also speaking at the conference attended by health and law faculty and students from Stanford, UC San Francisco and UC Berkeley, were Marcella Alsan, a physician and economist at Stanford Health Policy; Charles H. Ramsey, the former police commissioner of the Philadelphia Police Department who is now a visiting fellow at Drexel University; Suzy Loftus, assistant legal counsel at the San Francisco Sherriff’s Department; and Jeff Rosen, the district attorney for the County of Santa Clara.

“It was terrific opportunity to get the perspectives of both public health researchers and law enforcement leaders on the problem of gun violence,” Studdert said. “These perspectives don’t intersect as often as they should.”

Ramsey, who also worked in the Chicago Police Department before heading up the departments in Washington, D.C. and then Philadelphia, was asked whether the fatal shooting of black men by white police officers is new and on the rise.

“No, it’s not new,” said Ramsey. “I think what’s new is social media and cable news; those things are new. Now you have video that’s played over and over and over again on cable news, so it does give the impression that things are more severe now than they have been in the past.”

According to the Washington Post’s Fatal Force tracker of deadly shootings by police, 963 people were shot and killed last year, down from 992 in 2015. While 40 percent of those killed were black, African-American men make up a mere 6 percent of the nation’s population.

A student asked Ramsey whether there was implicit bias against African-American men by white police officers who target black communities.

“There’s not a person in this room who doesn’t have implicit bias, we all have it,” he said.

There were 277 murders in Philadelphia last year, down from 391 a decade earlier.

“But 85 percent of the homicides victims in Philly were African-American, due to poverty, poor housing, high unemployment and drug use,” Ramsey said. “They’re in these concentrated pockets. So I’m trying to make a decision about where I should deploy my assets. Where do you think I should put them, in Chinatown?”

Ramsey finds it disturbing that neither the FBI nor the Centers for Disease Control and Prevention keep up-do-date statistics on the number of police-involved shootings, limiting transparency about the extent of the problem.

As Co-Chair of the President’s Task Force on 21^st Century Policing, convened by President Barack Obama in 2014, Ramsey said community policing is key to ending the mistrust and fatalities among officers and civilians.

“Every cop in Philly starts on foot patrol, they’re on the ground and when they’re out there and you start to meet Miss Jones and Miss Smith, who are afraid to come out, you start to get a more balanced sense of who is actually a threat to that community.”

All the videos from the daylong symposium can be watched here.

Like any energetic 7-year-old, your daughter loves running around outside, playing with her friends and kicking around a soccer ball. So you’re concerned when she starts losing energy. She looks pale and refuses to eat. You take her to the pediatrician, and her test results show the worst: she has leukemia. Once you work through the shock, you do you what any parent would do: find the best possible care to get her through it. But where do you go?

Health care for children is different from care for adults. Treating kids requires doctors who are experienced with their unique needs, and according to Stanford pediatricians Paul Wise and Lisa Chamberlain, this experience is developed and lives in children’s hospitals.

And these facilities are highly dependent on Medicaid.

“Children are the poorest segment of the United States population,” said Wise, a Stanford Health Policy core faculty member.

Nearly one out of every five children lives below the poverty line, according to the United States Census Bureau. Very few children need extensive health care, but of those that do, about 44 percent rely on Medicaid or other public insurance programs.

Because so many of their patients use Medicaid, these children’s hospitals need reimbursements from the program to support their services. Without this income, some might have to downsize or even shut down, and if they do, services would suffer for all children.

“If you want to kill rich kids, cut Medicaid,” said Wise. “If you’re a rich kid with a serious chronic problem, you’re going to want facilities that provide high-quality care. Those facilities are intensely dependent on Medicaid.”

If the American Health Care Act (the Republican replacement for Obamacare) passes Congress, Medicaid will convert to a per capita cap system. Instead of providing coverage to all who meet its criteria — which is primarily based on income and need — the federal government would cap how much money the federal government could provide each person.

Wise and Chamberlain worry that a set amount allocated for states or individuals would not be able to keep up with health industry inflation, causing payments to effectively decrease over time. They are also concerned that children would be particularly affected by these changes because their medical needs are so different from adults’.

“Caring for seriously ill children requires a wide range of services and specialists, from pediatric surgeons to speech therapists to hospital teachers who make sure kids don’t fall behind,” said Chamberlain. “In pediatrics we work as a team — and cutting Medicaid will reduce our ability to do that.”

Not only would the funds available for child health coverage erode, but according to Wise, the focus on adult health concerns in the emerging Medicaid changes could, without immediate attention, undermine 40 years of progress in developing strong, regionalized child health systems.

Providing for children’s needs should be simple because their expenditures are relatively low. Child health care makes up less than nine percent of all federal health expenditures in the United States.

But because the health policy debate in the United States focuses on older populations, children are often left out.

“I think it’s really important that we have these conversations about the unique needs of children,” said Chamberlain.

Wise and Chamberlain hope to alert policy-makers to the fiscal needs of children and how they affect care for all kids.

“Our elected officials have to cope with a wide range of issues, and they welcome engaged professionals exchanging ideas about active legislation,” said Chamberlain. “Those conversations really matter – now is the time to let them hear what we think.”

To hear more from Wise and Chamberlain about child health and Medicaid, listen to their podcast on World Class: