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.

Fellows will arrive at Stanford in July to begin the three-week academic training program taught by Stanford faculty, policymakers and thought-leaders in the technology sector.

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Stanford's Center on Democracy, Development, and the Rule of Law is proud to announce the 2017 class of Draper Hills Summer Fellows, which is composed of 28 leaders – selected from among hundreds of applications – advancing democratic development in some of the most challenging corners of the world.

In Bahrain, Burma, Rwanda and Sudan our fellows are working on peace-building initiatives to create more tolerant and inclusive societies. Judges and lawyers are holding government and criminals accountable and reforming the rule of law in Argentina, Guatemala and the Philippines. Gender rights activists are creating new tools and programs to protect the safety and freedom of women and girls in India, Kuwait and Papua New Guinea.

In Egypt, Morocco, Pakistan, Serbia and Ukraine, our fellows are serving inside the government as members of Parliament and senior civil servants to advance reform and new policy agendas. Business leaders in Jordan and India launched initiatives to support more inclusive economic growth and social development.

CDDRL is excited to launch another powerful network of leaders determined to advance change in their communities. They will emerge with new tools, frameworks and connections to enhance their work and deepen their impact on democratic reform.

The 2017 class will mark the 13th cohort of the Draper Hills Summer Fellows Program and the fellows will join the Omidyar Network Leadership Forum, an alumni community of over 300 alumni in 75 countries worldwide.

This is the eighth and last in a series of interviews by the Korea Times on North Korea. CISAC's Siegfried Hecker is featured in this story below by Kim Jae-kyoung:

NK estimated to have ability to produce 7 nuclear bombs a year

By Kim Jae-kyoung

A world-renowned nuclear scientist said that U.S. President Donald Trump must to talk to North Korean leader Kim Jong-un by sending an envoy to Pyongyang to avoid a nuclear catastrophe.

"I believe the first talks should be bilateral and informal by a presidential envoy talking directly to Kim Jong-un," said Siegfried S. Hecker, a senior fellow at the Center for International Security and Cooperation (CISAC) at Stanford University, in an interview.

"I believe both Seoul and Beijing would support such talks. These talks may then also help to build the foundation for renewed multilateral negotiations, which, first and foremost must involve South Korea, as well as China," he added.

Hecker, the co-director of CISAC from 2007 to 2012, has visited North Korea several times to assess the plutonium program at the Yongbyon Nuclear Scientific Research Center since 2004.

He stressed that it is most important to convey the message that nuclear weapons cannot be used under any circumstances.

"There is no such thing as a limited nuclear war. Any explosion of a nuclear device on the Korean Peninsula is a catastrophe of indescribable proportions," he said.

The internationally recognized expert in plutonium science, global threat reduction and nuclear security said that the Trump administration and the new South Korean government face the challenge of avoiding a nuclear detonation on the Korean Peninsula.

He believes that such an incident could result from a miscalculation or overconfidence by the Kim Jong-un regime as well as an accident with the nuclear weapons in the North.

"A conventional confrontation may turn nuclear with an inexperienced leader in charge," he said. "Or, in the case of instability in the North, who will control the nuclear weapons? These are serious concerns that must be addressed now," he added.

Hecker, who served as the director of the Los Alamos weapons laboratory in New Mexico, the birthplace of the atomic bomb, from 1986 to 1997, estimated that North Korea, although he is uncertain, may have sufficient material for 20 to 25 nuclear weapons.

NK's nuclear capabilities evolving 

He explained that the size of its nuclear arsenal depends primarily on how much plutonium and highly enriched uranium North Korea has produced.

"The sophistication of the arsenal depends primarily on nuclear testing. With five nuclear tests conducted over 10 years, North Korea is likely able to produce nuclear devices small enough to fit on missiles that can reach all of South Korea and Japan," he said.

He also estimated that the totalitarian country can produce sufficient plutonium and highly enriched uranium for six to seven bombs per year.

"However, all estimates are uncertain because we know little about the North's capacity to produce highly enriched uranium since it is not possible to monitor such facilities from afar," he said.

In his view, the world does not have to accept the reclusive country as a "nuclear weapons state," but it must be treated as a country with a nuclear arsenal.

"Whether we like it or not, North Korea is a country with nuclear weapons," he said. "The final aim is to have a denuclearized Korean Peninsula, but that will take time. It will have to be done in sequence of halt, roll back and then eliminate."

However, Hecker dismissed North Korea's claim that it has the capability to fire an intercontinental ballistic missile (ICBM) all the way to the U.S. mainland.

"I do not believe North Korea is capable of reaching the U.S. mainland with a nuclear-tipped missile today. It is working on developing such a capability, but it will likely take another five years or so," he said.

Hecker explained that it has not demonstrated all the aspects of necessary rocket technology or the ability to make a nuclear warhead small enough to be able to survive atmospheric reentry.

"Besides, to actually launch a nuclear warhead on an ICBM you must have complete confidence that it will not blow up on the launch pad," he added. "They cannot have such confidence based on their missile launch history."

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.

When one thinks of the casualties of war, it is easy to imagine severed limbs, bullet holes, shrapnel, perhaps even sarin gas or Agent Orange. But in a recent Daedalus essay, Paul Wise argues that the most damaging health impacts of war are often indirect. Losing access to food supplies, medication and electricity can kill more people than battle itself. In this video by the American Academy of Arts and Sciences, Wise, a professor of pediatrics and Stanford Health Policy core faculty member, explains how fatal the indirect costs of war can be.

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While the United States has no peers in conventional military power, it is especially vulnerable – as a free and democratic society – to cyber misinformation campaigns, a Stanford scholar says.

Herbert Lin, a senior research scholar for cyberpolicy and security at Stanford’s Center for International Security and Cooperation (CISAC), is the co-author of a new draft working paper that spells out the perilous risks facing democratic, wired-up countries around the world.

America’s adversaries are seeking “asymmetric” methods for social disruption, rather than direct military conflict, Lin said.

“Cyber warfare is one asymmetric counter to Western (and especially U.S.) military advantages that depend on the use of cyberspace,” wrote Lin and his co-author Jackie Kerr, a research fellow at the Lawrence Livermore National Laboratory.

This new type of cyber aggression is aimed at winning – and confusing – hearts and minds, the very control centers of human existence, Lin said.

As a result, “information/influence warfare and manipulation,” or IIWAM as Lin describes it, poses profound implications for Western democracies, even though much of it may not be illegal under international law. This approach is based on the deliberate use of information by one party on an adversary to confuse, mislead, and ultimately to influence the choices and decisions that the adversary makes.

A recent example in point would be the 2016 Russian hacking of the U.S. presidential election and the surge of so-called “fake news.”

Lin points out that while misinformation campaigns are not new, the technology to spread it far and wide globally is. He noted that the patron saint of distorting reality for war-like purposes is Sun Tzu, who wrote that, “The supreme art of war is to subdue the enemy without fighting.”

While traditional cyber attacks typically hit hard targets like computer systems, cyber “influence” campaigns are conducted over longer periods of time and rely on soft power – propaganda, persuasion, culture, social forces, confusion and deception, Lin said. 

Words and images

How does it work? Lin explains:

“Victory is achieved by A when A succeeds changing B’s political goals so that they are aligned with those of A.  But such alignment is not the result of B’s 'capitulation' or B’s loss of the ability to resist – on the contrary, B (the losing side) is openly willing.”  That is, such victory shares the focus on subverting the opponent’s will, though not on destroying his military forces.

The ammunition in these cyberspace battles are “words and images,” the kind that persuade, inform, mislead, and deceive so that the adversary cannot respond militarily. In the example of a “fake news” story, they often take place below legal thresholds of “use of force” or “armed attack,” and at least in an international legal sense, do not trigger a military response.

The target is the “adversary’s perceptions,” which reside in the “cognitive dimension of the information environment.” In other words, such cyber warfare focuses on “damaging knowledge, truth, and confidence, rather than physical or digital artifacts,” according to Lin. It is the “brain-space.”

Additionally, IIWAM injects fear, anger, anxiety, uncertainty, and doubt into the adversary’s decision making processes, he added.  Success is defined as altering such perceptions so the target makes choices favoring the aggressor.

“Sowing chaos and confusion is thus essentially operational preparation of the information battlefield – shaping actions that make the information environment more favorable for actual operations should they become necessary,” the researchers wrote.

These cyber manipulations often prey upon cognitive and emotional biases present in the psychological and mental makeup of human beings, Lin said. 

For example, media channels such as Fox News play to “confirmation bias” for individuals with a right-of-center orientation, and similarly for MSNBC for those with a left-of-center, orientation, he wrote. Confirmation bias is the tendency to interpret new evidence as confirmation of one's existing beliefs or theories.

Countering misinformation

“Naming and shaming” is probably ineffective against many nation states conducting cyber disinformation campaigns, Lin said. And the idea that a government like the U.S. can quickly respond to misinformation created in the private sphere is unlikely to be effective as well.

What, then, might work? Lin suggests new tactics are needed, as no existing approach seems adequate. For example, Facebook is deploying a new protocol for its users to flag questionable news sites.  Google has banned fake news web sites from using its online advertising service. Twitter, YouTube, and Facebook shut down accounts that they determine are promoting terrorist content.  He noted that a recent Facebook letter from CEO Mark Zuckerberg states that, “Our approach will focus less on banning misinformation and more on surfacing additional perspectives and information, including that fact checkers dispute an item's accuracy.”

But such measures are unlikely to stem the “rising tide of misinformation conveyed” through cyber warfare, Lin said, because they mostly require users to do additional mental work.  

Wired world riskier

Today’s Internet-driven Western world offers countless opportunities for cyber influence mischief, Lin wrote.

“Democracy has rested on an underlying foundation of an enlightened, informed populace engaging in rational debate and argument to sort out truth from fiction and half-truth in an attempt to produce the best possible policy and political outcomes,” Lin wrote.

Cyber manipulators have exploited an arguable gap between ideals and reality in democratic systems – “rendered it much more questionable” – through the tremendous reach and speed of misinformation, he said. Many countries cannot deal with the onslaught of such focused efforts. This serves to make the democratic process look weak and unstable in the eyes of its citizens. The same dynamic does not apply equally around the world.

“Cyber weapons pose a greater threat to nations that are more advanced users of information technology than to less-developed nations,” Lin wrote.

He said that less developed or authoritarian countries do not have much Internet infrastructure or that wield control over expression – North Korea is an example.

MEDIA CONTACTS

Herbert Lin, Center for International Security and Cooperation: (650) 497-8600, herbert.s.lin@stanford.edu

Clifton B. Parker, Center for International Security and Cooperation: (650) 725-0224, cbparker@stanford.edu