Medicare Post-election by Stanford Health Policy on Exposure

Robert MacCoun, a professor of law and a senior fellow at the Freeman Spogli Institute for International Studies, relays the potential risks and benefits of legalizing marijuana. His research focuses on drug policy, and he has written extensively about the effects of marijuana from a legal and health perspective.

California, Massachusetts and Nevada all legalized marijuana in the last election. Does this mean the legalization movement has reached a tipping point?  

If Hillary Clinton had won the election, it would probably feel that way, not because she’s a legalization advocate, but because she’d have bigger fish to fry and would probably continue President Obama’s laissez-faire approach. With the Trump administration’s new cabinet, all bets are off. Still, one in five Americans now live in a state where recreational use of marijuana is legal, and that’s a big market. And as the market grows, the industry’s lobbying clout grows.

What are the health risks post-legalization?

That depends on how much consumption levels increase. There are good reasons to expect marijuana prices to fall, which will increase consumption. Because many people use marijuana without health consequences, I worry less about an increase in the number of people using marijuana than about an increase in the number who use it one or more times daily. There is growing evidence that heavy marijuana use is associated with an increased risk of psychosis. We don’t know if it is a true cause-and-effect relationship; let’s hope it is not. But I think the biggest health threat is dependence, which for marijuana is something like getting stuck in the La Brea tar pits — your world just gets smaller and smaller as you get more dysfunctional.

Robert MacCoun, PhD

How can legalizing states combat these risks?

The good news is that legalization makes possible all sorts of regulatory options that weren’t available under prohibition. States should insist that no marijuana products are to be packaged in a way that entices children. Doses should be standardized, and there should be accurate labeling about the THC content. States should discourage products with high levels of THC, and perhaps encourage products with higher levels of cannabidiol (CBD), an ingredient that seems to counteract some of the harmful effects of THC.

The bad news is that the state ballot initiatives didn’t do much more than give lip service to public health and safety, and industry entrepreneurs are pushing back hard against state regulators. I think the industry is being foolish here — they’ve won eight states but still have 42 states to go. I don’t think they realize how quickly a backlash could emerge if those eight states show rising rates of various adverse outcomes.

Could there be any positive health effects of marijuana use?

Absolutely. There are plenty of lines of evidence suggesting medical benefits for some patients. Intriguingly, several new studies suggest that medical marijuana states may be experiencing reduced levels of opioid use and opioid overdoses. The Catch 22 is that the DEA decided not to reschedule marijuana because there isn’t enough rigorous evidence, but there isn’t enough rigorous evidence because the Feds have made such studies almost impossible to conduct.

Some of the biggest health benefits of marijuana will occur if it turns out that marijuana use is a substitute for binge drinking. There are both physiological and economic reasons to think that might be the case, but while some studies show substitution, others show complementarity. For a researcher, one big benefit of legalization is that it is going to help us finally answer a lot of these research questions.

Consider the lowly worm. For some, it’s just a garden pest. But for more than a billion people in the developing world, parasitic worms can be a pernicious threat, causing disease, disability and sometimes death.

In a newly published perspective in the medical journal The Lancet, Stanford researchers, including Stanford Health Policy's Eran Bendavid and a host of distinguished colleagues, urge the World Health Organization to develop sweeping new guidelines to help end parasitic worm diseases, one of the world’s most prevalent health problems. They call for greatly expanded treatment of these diseases, which could save years of human suffering and an estimated $3 billion in lost productivity — similar to the impact of the Ebola and Zika epidemics of recent years, they say.

“Now everyone is coming together to say, ‘Now is the time, after more than a decade of new experience and data, to update the way we do things,’ said Nathan Lo, a Stanford MD/PhD candidate who is the first author of the commentary. “There is so much opportunity, whether it’s expanding treatment from children to the entire community or bringing in other strategies, such as sanitation, to strengthen the way we approach these diseases.”

The perspective is published today in Lancet Infectious Diseases and coincides with a WHO meeting in Geneva where officials, including many of the authors, are gathering to consider new treatment guidelines.

Read More

Stanford Health Policy faculty members Michelle Mello, David Studdert and Laurence Baker discuss repealing the Affordable Care Act (ACA) and how it could affect health coverage in the United States.

Now that the United States has elected a Republican president and Congress, what is likely to happen to the Affordable Care Act (ACA)?

Michelle Mello and David Studdert: Exactly what will happen is unclear at this point, particularly since President-elect Trump’s own position on the ACA seems to be evolving by the day. In an interview on Nov. 11, he said he is interested in keeping some of the key provisions of the law, such as a ban on insurers discriminating on the basis of pre-existing conditions and provisions allowing young people to stay on their parents’ plans until age 26. But his opposition to other provisions, including the cornerstone provision requiring individuals to purchase insurance coverage, likely will remain. At this point, about the only thing one can say with certainty is that substantial change is coming.

Is the ACA likely to be repealed fully, or will some components be spared?

Mello/Studdert: On the campaign trail, President-elect Trump said repeatedly that repealing Obamacare is a priority. House Republicans have said the same. A complete repeal seems unlikely in the short term, though. There’s more opposition to some provisions of the act than to others, and millions of Americans now depend on health insurance coverage made available through the ACA. More likely, Republicans will target certain key elements – the individual mandate, minimum essential coverage rules, the subsidies available to low-income purchasers of health insurance and federal financing arrangements for the Medicaid program. Eliminating all of these features would spell the end of Obamacare as we know it. Eliminating any one of them would seriously threaten its viability, because the ACA’s strategy depends on having all major legs of the stool in place.

What is the legal process for repeal, and what issues would likely arise?

Mello/Studdert: Although Republicans will have a majority in the House and Senate, they fall just short of a filibuster-proof majority (60 votes) in the Senate. This is why a repeal is not likely to occur – at least not straight away – unless several Senate Democrats break ranks in the vote. A more likely scenario is that Republicans will use the budget reconciliation process to make the kind of changes mentioned above. Bills of this kind require only a simple 51-vote majority in the Senate, which they have.

Laurence Baker: Republicans have substantial ability to remove parts of the law under budget reconciliation. They can make changes to aspects of the ACA that involve financial in- and outflows to the federal government, but not other things. Reconciliation thus allows them to make changes to the major things like the mandate – because it involves a tax penalty – the subsidies and Medicaid. But they would not be easily able to repeal things like the exchange structures, guaranteed offers of insurance regardless of health status and other provisions. Guaranteed issue would be a real problem for insurance companies without the mandate, so repealing one but not the other threatens significant disruptions in insurance markets.

Most of the discussions thus far have focused on efforts to repeal the ACA’s expanding coverage aspects, but there are other aspects of the ACA that could be addressed. The ACA set up and funds the Center for Medicare and Medicaid Innovation (CMMI) and Patient-Centered Outcomes Research Institute (PCORI), two organizations that have not been discussed much in the repeal debates and which are seen by some Republicans in a more positive light. The ACA also makes changes to Medicare payments. It seems likely that repeal debates will focus more on coverage and less on these things, but it’s hard to tell at this point.

How will this affect Americans who current receive subsidies for health insurance?

Mello/Studdert: Elimination of the subsidies would have a major effect on the ACA’s core objective to cover the uninsured. By 2017, about 25 million people will have purchased their health insurance on the exchanges set up under the ACA, and about three-quarters of them will receive subsidies to help make premiums affordable. If the subsidies disappear, we should expect that health insurance will become unaffordable for many of these people or no longer look like a good deal. The tax credits and health savings accounts currently being discussed won’t make up for what is lost, and many people who currently have insurance can be expected to drop it. Elimination of the individual mandate will further open the way for this to happen.

Baker: The reality of the health care system is that there are not easily available alternatives to the ACA that would protect coverage and be palatable to broad groups of Republicans. Single-payer, or national health insurance, is a non-starter, so they’d be left with market-oriented reforms, and there are not obvious ways to pursue those without at least some core features of the ACA. Most of the proposals recently put forward for a replacement, including those highlighted by the Trump campaign, like cross-state competition, tax credits for insurance purchase and block granting Medicaid, would not really offer coverage to a large number of the people who would lose it under repeal. So a key question is what alternatives the Republicans come up with. In a similar way, the ACA and its provisions have become increasingly woven into our insurance system. Insurers and employers, among others, have made decisions and investments incorporating the ACA. Undoing those threatens disruptions and political challenges.

Michelle Mello is a professor of law and of health research and policy.

David Studdert is a professor of law and of medicine.

Laurence Baker is a professor of health research and policy, chair of the Department of Health Research and Policy in the School of Medicine and a senior fellow at the Stanford Institute for Economic Policy Research.

Stanford researchers have determined that more than 15 million children are living in high-mortality hotspots across 28 Sub-Saharan African countries, where death rates remain stubbornly high despite progress elsewhere within those countries.

The study, published online Oct. 25 in The Lancet Global Health, is the first to record and analyze local-level mortality variations across a large swath of Sub-Saharan Africa.

These hotspots may remain hidden even as many countries are on track to achieve one of the U.N. Sustainable Development Goals: reducing the mortality rate of children under 5 to 25 per 1,000 by 2030. National averages are typically used for tracking child mortality trends, allowing left-behind regions within countries to remain out of sight — until now.

The senior author of the study is Eran Bendavid, MD, MS, an assistant professor of medicine and core faculty member at Stanford Health Policy. The lead author is Marshall Burke, PhD, an assistant professor of Earth System Science and a fellow at the Freeman Spogli Institute’s Center on Food Security and the Environment.

Decline in under-5 mortality rate

The authors note that the ongoing decline in under-5 mortality worldwide ranks among the most significant public and population health successes of the past 30 years. Deaths of children under the age of 5 years have fallen from nearly 13 million a year in 1990 to fewer than 6 million a year in 2015, even as the world’s under-5 population grew by nearly 100 million children, according to the Institute for Health Metrics and Evaluation.

“However, the amount of variability underlying this broad global progress is substantial,” the authors wrote.

“Mortality numbers are typically tracked at the national level, with the assumption that national differences between countries, such as government spending on health, are what determine progress against mortality,” Bendavid said. “The goal of our work was to understand whether national-level mortality statistics were hiding important variation at the more local level — and then to use this information to shed light on broader mortality trends.”

The authors used data from 82 U.S. Agency for International Development surveys in 28 Sub-Saharan African countries, including information on the location and timing of 3.24 million births and 393,685 deaths of children under 5, to develop high-resolution spatial maps of under-5 mortality from the 1980s through the 2000s.

Using this database, the authors found that local-level factors, such as climate and malaria exposure, were predictive of overall patterns, while national-level factors were relatively poor predictors of child mortality.

Image

Temperature, malaria exposure, civil conflict

“We didn’t see jumps in mortality at country borders, which is what you’d expect if national differences really determined mortality,” said co-author Sam Heft-Neal, PhD, a postdoctoral scholar in Earth System Science. “But we saw a strong relationship between local-level factors and mortality.”

For example, he said, one standard deviation increase in temperature above the local average was related to a 16-percent higher child mortality rate. Local malaria exposure and recent civil conflict were also predictive of mortality.

The authors found that 23 percent of the children in their study countries live in mortality hotspots — places where mortality rates are not declining fast enough to meet the targets of the U.N. Sustainable Development Goals. The majority of these live in just two countries: Nigeria and the Democratic Republic of Congo. In only three countries do fewer than 5 percent of children live in hotspots: Benin, Namibia and Tanzania.

As part of the research, the authors have established a high-resolution mortality database with local-level mortality data spanning the last three decades to provide “new opportunities for a deeper understanding of the role that environmental, economic, or political conditions play in shaping mortality outcomes.”  The database, available at http://fsedata.stanford.edu, is an open-source tool for health and environmental researchers, child-health experts and policymakers.

“Our hope is that the creation of a high-resolution mortality database will provide other researchers new opportunities for deeper understanding of the role that environmental, economic or political conditions play in shaping mortality outcomes,” said Bendavid.  “These data could also improve the targeting of aid to areas where it is most needed.”

The research was supported by a grant from the Stanford Woods Institute for the Environment. 

China’s recent initiatives to deepen health reform, control antimicrobial resistance, and strengthen primary health services are the topics of ongoing collaborative research by the Asia Health Policy Program (AHPP) at Stanford’s Shorenstein Asia-Pacific Research Center and Chinese counterparts. For example, with generous support from ACON Biotechnology and in partnership with the ACON Biotech Primary Care Research Center in Hangzhou, China, AHPP hosts an annual conference on community health services and primary health care reform in China.

The conference, titled Forum on Community Health Services and Primary Health Care Reform, was held in June at the Stanford Center at Peking University (SCPKU) in Beijing. It featured distinguished policymakers, providers and researchers who discussed a wide-range of topics from China’s emerging “hierarchical medical system” for referring patients to the appropriate level of care (fenji zhenliao), as well as the practice and challenges of innovative approaches to primary care and integrated medical care systems. Yongquan Chen, director of Yong’an City Hospital and representative for the mayor’s office of Sanming, talked about health reforms in Sanming City, Fujian Province, a famous example within China. He discussed the incentives and reasoning behind the reforms, which focus on removing incentives for over-prescription of medications, demonstrating government leadership for comprehensive reforms, consolidating three agencies into one, monitoring implementation and easing tensions between doctors and patients. He pointed out the feasibility and early successes of reform by comparing public hospitals in the city in terms of their revenues and costs, reduced reliance on net revenue from medication sales, and other dimensions of performance. Finally, he addressed reform implementation and future plans on both the hospital's and the government's part.

Xiaofang Han, former director of the Beijing Municipal Development and Reform Commission, shared her personal views on the challenges patients face in navigating China’s health system (kan bing nan) and the need to improve the structure of the delivery system, including a revision to the incentives driving over-prescription in China’s fee-for-service payment system. She emphasized that patients’ distrust of primary care providers can only be overcome by demonstrating improved quality (e.g. with a systematic training program for general practitioners, GPs), and that referral systems should be based on the actual capabilities of the clinicians, not their formal labels. To reach China’s goal of over 80 percent of patients receiving management and first-contact care within their local communities will require improved training and incentive programs for newly-minted MDs, a more flexible physician labor market, and innovations in e-health and patient choice regarding gatekeeping or “contract physician services” (qianyue fuwu).        

Guangde County People's Hospital Director Mingliang Xu spoke about practices and exploration of healthcare alliances and initiatives to provide transparent incentives linking medical staff bonuses to metrics of quality. Ping Zhu from Community Healthcare Service Development and Research Center in Ningbo addressed building solid relationships between doctors and residents and providing more patient-centered services.        

Professor Yingyao Chen from Fudan University School of Public Health discussed performance assessment of community health service agencies based on his research in Shanghai. He introduced the strengths and weaknesses of the incentives embedded in the assessment system for China’s primary care providers, and concluded with suggestions for future research. Dr. Linlin Hu, associate professor at Peking Union Medical College, discussed China's progress and challenges of providing universal coverage of national essential public health services.

Professor Hufeng Wang of Renmin University of China discussed China’s vision for a “hierarchical medical system”– bearing resemblance to “integrated care,” “managed care,” or NHS-like coordination of primary and specialized care – with examples of pilot reforms from Xiamen, Zhenjiang and Dalian cities. Dr. Zuxun Lu, professor of Tongji Medical College of Huazhong University of Science and Technology, also discussed hierarchical medical systems and declared that China currently had a “discounted gatekeeper system.”

Dr. Yaping Du of Zhejiang University presented his research on mobile technology for management of lipid levels and with the help of a volunteer, demonstrated “Dyslipidemia Manager,” a mobile app-based product for both patients and doctors. Innovative strategies for primary prevention of cardiovascular diseases in low- and middle-income countries were the focus of remarks by Dr. Guanyang Zou from the Institute for Global Health and Development at Queen Margaret University, including its connections to international experiences with China’s current efforts in that area.  

In sum, the 2016 Forum elicited lively, evidence-based discussions about the opportunities and challenges in improving primary care and sustaining universal coverage for China.  Plans are underway for convening the third annual ACON Biotech-Stanford AHPP Forum on Community Health Services and Primary Health Care Reform in June 2017 at SCPKU. Anyone with original research or innovative experiences with primary care in China may contact Karen Eggleston regarding participation in next year’s Forum. 

As health-care costs climb ever upward, controlling expenses without sacrificing high-quality care becomes increasingly important. Payment systems based on the value of care are emerging as a way to combat rising costs.

Many researchers like Jason Wang, an associate professor of pediatrics and a Stanford Health Policy core faculty member, have found that bundled payment systems may help health-care institutions achieve better value of care.

In a new study in the Journal of the American Medical Association Oncology, Wang and his co-authors show that a value-based bundled payment system is associated with cost containment and improvement in care, even improving chances for survival.

The study examined Taiwan’s bundled pay-for-performance (PFP) system for breast cancer. Instead of the traditional fee-for-service (FFS) system that is typical in the United States — in which every test, surgery and exam is billed individually — this system includes all aspects of treatment in a single established cost, or bundled payment.

Based on guidelines set by Taiwan’s National Health Insurance Administration (NHIA), the pilot program reimbursed health-care institutions’ costs for breast cancer treatment based on the patient’s cancer stage, 0 to IV. Institutions that exceeded the NHIA’s standards received a financial bonus as an incentive for better performance.

The study followed 4,215 patients in the bundled-care system over a five-year period, comparing the quality of their care, the cost of their treatment and the outcomes of their treatment to 12,506 similar patients in the traditional FFS system.

The authors found that patients in the bundled-payment system received better care throughout treatment, were more likely to survive, and contained medical costs over time, compared to their peers in the FFS system.

Costs for patients in the bundled payment system remained about the same throughout the study. However, the cost of treatment for those in the FFS system steadily increased throughout the study period. By the end, even health-care institutions receiving the maximum bonus incentive would incur lower costs than those in the FFS system.

Yet even though their treatment was cheaper, patients in the bundled system experienced better results. Patients using the bundled system had significantly higher survival rates for cancer stages 0 to III, and they were more likely to receive higher quality care based on quality indicators.

This is largely due to the better coordination of care made necessary by the bundled system, according to Wang.

“When you play in an orchestra, the whole group needs to play together, so it plays the right tune,” said Wang. “Focusing on value for the patient and the health-care system forces people to play the same tune.”

Wang believes the lessons learned from Taiwan’s program could be applied in other parts of the world, including the United States, which is currently moving toward bundled cancer care.

Though the U.S. already bundles care for conditions like appendicitis and chemotherapy — in which costs are fairly predictable — many hospital administrators fear that broadening the use of bundled payments for more complex conditions is too risky, financially.

Wang does not share their misgivings.

“People say, ‘We can’t do this for a very complex disease.’ It’s not true,” he said. “When we went outside of the U.S., we started to find systems that work.”

Wang found that when institutions can coordinate care for patients — that is, when a single institution manages all aspects of a patient’s care — the patient is more likely to have better outcomes.

“If institutions take the leadership of providing the infrastructure to coordinate care, they can really deliver better care with the same or lower costs.”

There are benefits for the institutions, too. Right now, because health insurance providers may accept or reject particular costs in an unpredictable way, care institutions never know how much they’re going to get paid for a service. But in a bundled payment system, costs are much more stable and revenue easier to predict.

Considering the benefits, Wang hopes the Taiwan breast cancer study will show institutions in the United States and around the world that bundled payments for cancer can be done on a broad scale.

The value, he said, is worth the risk.

An Indian businessman approached Stanford Medicine in 2005 with an outlandish proposition: Help us build an ambulance system across the sprawling South Asia nation, which is home to 10 percent of the world’s traffic deaths.

S.V. Mahadevan, MD, an associate professor of emergency medicine at Stanford Medicine, was skeptical the nonprofit GVK EMRI (Emergency Management and Research Institute) could truly pull it off.

They only had 14 ambulances in the world’s second most populous nation.

Today the system has expanded to a fleet of nearly 10,000 ambulances, manned by some 20,000 medical professionals who ply the roads in cities and rural villages to provide access to emergency care to 750 million people — three-quarters of India’s population — according to a story in Stanford Medicine magazine last year.

“It’s hard to fathom what this system has done in 10 years,” said Mahadevan, founder of Stanford Emergency Medicine International, which has provided medical expertise to GVK EMRI over the last decade, helping to train the EMTs who now belong to the largest ambulance service in the developing world.

“It could be regarded as one of the most important advances in global medicine in the world today," he said.

Yet up until now there has been no analytical research on the impact of the ambulance service. Though EMRI says its 911-like service has saved more than 1.4 million lives in its first decade, there has been no published research to back up that claim.

Now, research by Stanford Health Policy scholars published in the October edition of the health policy journal, Health Affairs, indicates EMRI’s system has had a significant impact on saving the lives of newborns and infants, one of the most challenging health dilemmas plaguing India today.

Focusing on the first two states served by GVK EMRI — with a combined population of 145 million — their results show that the organization’s services have reduced infant and neonatal mortality rates by at least 2 percent in high-mortality areas of the western state of Gujarat. There were similar effects statewide in the southeastern state of Andhra Pradesh.

Image

“With our modern medical knowledge, childbirth should not be so risky and newborns should not be dying at such high rates,” said Babiarz.

India has 28 maternal neonatal or infant deaths per 1,000 live births, according to the World Bank, making it one of the highest in the world. The global average is 19.2 deaths per 1,000 births; the rate drops to 4 in North America.

“These issues are particularly compelling to me as a mother,” Babiarz said. “It's wonderful to find a model that has found some success in connecting mothers and their infants with high-quality and timely emergency care when it is most needed.”

The authors used electronic service records from GVK EMRI, matched to population-representative surveys from the International Institute for Population Sciences, and their own survey that they conducted in Gujarat in 2010 through the Collaboration for Health System Improvement and Impact Evaluation in India. The combined surveys include information on over 16,000 live births.

The public-private nonprofit provides its services free of charge and most of its beneficiaries are the poorest of the poor. Each state contributes to the ambulance system, as does the federal government. It also depends on private philanthropy among some of India’s wealthiest industrialists.

The School of Medicine in 2007 signed a formal agreement to develop an educational curriculum and train the initial group of 180 skilled paramedics and instructors. Over the years, the Stanford instructors have learned to tailor the curriculum to local needs.

About one-third of the toll-free calls to 108 — an auspicious number in India — are from women in labor. Deliveries have traditionally been done at home, particularly in rural villages, where women often die of complications. So the Stanford team has since designed a special obstetrics curriculum and helped create the country’s first protocols for obstetric care.

Grant Miller, an associate professor of medicine, core faculty member at Stanford Health Policy and senior author of the study, has worked on many health policy projects in India over the years. The results aren’t always hopeful.

“I’ve conducted a number of evaluations of large-scale health programs in India, and there are disappointingly few programs and policies that we’ve found to be effective,” said Miller, who is also director of the Stanford Center for International Development and a senior fellow at the Stanford Institute for Economic Policy Research and the Freeman Spogli Institute for International Studies. “So it’s exciting to find one that may have worked quite well.”

Miller and his fellow authors note, however, that further research on emergency medical services in other Indian states and by other providers is still needed.

“We need to do a lot more work — but these results suggest that something important has happened,” he said. “With the release of more population-representative data from more states, we’re eager to expand our analysis to the rest of the country.”

Stanford Medicine’s Center for Innovation in Global Health also supported the authors’ research in India.

Ruthann Richter, director of media relations for the medical school's Office of Communication & Public Affairs, contributed to this story.