There is much debate among health policy researchers about the performance of the Medicare Advantage plans, which are sold and run by private insurance companies, but are regulated by the government to provide Medicare benefits.

Enrollment in Medicare Advantage plans — mostly commonly HMOs and PPOs — grew from 5.4 million consumers in 2005 to 16.8 million in 2015, or about 31 percent of the Medicare population, according to the Kaiser Family Foundation.

Some argue the private alternative to the traditional insurance program for seniors is less expensive than the public programs; others say it’s just the opposite. And still others argue that that the government overpays for people enrolled in private plans since traditional Medicare could have covered these patients for less money.  But there had not been broad analyses of the prices actually paid by these plans.

Now, researchers from Stanford Medicine, the Stanford Law School and the Graduate School of Business have conducted one of the largest systematic analyses of the prices that Medicare Advantage plans pay to doctors and hospitals, relative to the prices paid by Medicare fee-for-services or commercial plans.

They found Medicare Advantage plans actually pays 8 percent less to hospitals for their services than traditional Medicare. If you make adjustments for the smaller, cheaper network of hospitals that Advantage plans allow their patients to use, the program pays 5.6 percent less to hospitals than FFS Medicare.

The researchers shared their findings in an online article in Health Affairs this week.

“The surprise is that Medicare Advantage is paying hospitals less,” said lead author Laurence C. Baker, professor of health research and policy at Stanford Medicine and a senior fellow at the Stanford Institute for Economic Policy Research. 

“That suggests that in an era when there are real questions about escalating health-care costs, we may want to think more about the potential benefits of Medicare Advantage plans,” Baker said. “It seems they are negotiating better prices.”

Either way, the savings or losses are always going to impact the patient.

“If you’re looking at it as a question of policy, this may be useful,” Baker said. “In the long run, we could pay less taxes to support the Medicare program and maybe people in Medicare Advantage would get to share in those savings.”

The other co-authors of the study are M. Kate Bundorf, professor of health research and policy and a faculty research fellow at the National Bureau of Economic Research; Aileen M. Devlin, a research fellow at the Law School and Daniel P. Kessler, a professor in the Law School and the Graduate School of Business.

They used data from Medicare and the Health Care Cost Institute to identify the prices paid for hospital services by Medicare Advantage, FFS Medicare and commercial plans in 2009, 2011 and 2012.

The data included information from Aetna, Humana, and UnitedHealthcare on approximately 40 million individuals who represent all 50 states, accounting for 27 percent of the nonelderly population covered by commercial insurance, and 31 percent of the elderly Medicare Advantage population.

The authors also found the rates paid to hospitals by commercial plans were much higher than those of either Medicare Advantage or FFS Medicare, and that these rates are continuing to grow.

Some of the difference is a result of the much higher prices commercial plans pay for very profitable services such as orthopedics and interventional cardiology.

“However, commercial plans pay higher prices than FFS Medicare for almost all types of admissions in almost all geographic areas,” they wrote. “Thus, our work echoes the growing concerns expressed by several researchers about the consequences of high commercial-plan prices for health spending.”

The importance of detecting high cholesterol in older adults is well understood. But there’s still not enough evidence about lipid disorders in children and adolescents to determine whether they should be routinely screened.

The U.S. Preventive Services Task Force has concluded the evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years or younger. The report appears in the Aug. 9 issue of JAMA.

High cholesterol in individuals 20 years or younger can be caused primarily by genetics, known as familial hypercholesterolemia, or from both genetic and environmental factors, such as a high-fat diet.

“We are calling for more research to better understand the benefits and harms of screening and treatment of lipid disorders in children and teens and on the impact these interventions may have on their cardiovascular health as adults,” Task Force vice chair David Grossman said in a news release.

The Task Force is an independent panel of experts who make recommendations about the effectiveness of specific preventive care services such as screenings, counseling services, and preventive medications.

The task force does, however, recommend screening children who are 6 years and older for obesity and making referrals as needed for counseling on weight management. Helping children improve diet and exercise may also improve heart health.

“Cardiovascular health in young people is important and the goal is to prevent the development of cardiovascular disease as people age,” said Douglas K. Owens, a professor of medicine at Stanford and a member of the task force when the guideline was developed. “But many important questions remain unanswered about how to do so.”

Owens, a leader at Stanford Health Policy, said that for now, physicians should use their clinical judgment when counseling young patients on lipid disorders.

“Research on screening and treatment of lipid disorders in children and teens and the impact of these interventions have on cardiovascular disease in adults should be a high priority,” he said. “The USPSTF suggests that all children and teens eat a healthy diet, maintain a normal weight, and engage in physical activity.”

Recent estimates from the National Health and Nutrition Examination Survey indicate that 7.8 percent of children age 8 to 17 years have elevated levels of total cholesterol (TC) and 7.4 percent of adolescents age 12 to 19 years have elevated LDL-C, or the “bad cholesterol” that can lead to heart disease.

Four editorials related to the recommendation accompanied the report JAMA, including one from physicians from Stanford and UCSF who suggest that the U.S. health-care system should focus more on high-value solutions to major public health concerns such as climate change, poverty, obesity and gun violence.

“The need for clinicians and leaders to focus on sustainability and health-care value has never been greater, and it is likely that policy and community-based interventions will get us there much more quickly than adding more clinic-based interventions that have low value and are wasteful of resources and clinicians’ time,” they wrote.

It’s always great to see the work of one of our researchers shouted out in the New York Times. It’s even better when it becomes the scientific basis of an argument thrown into the mix of a presidential campaign.

Nicholas Kristof asserted in his column on Sunday that when women are involved in the political process and given the capacity to shape public policy, everyone benefits, particularly when it comes to health.

Kristof, who covers human rights, women’s rights, health and global affairs for the Times, wrote in his column:

Put aside your feelings about Hillary Clinton: I understand that many Americans distrust her and would welcome a woman in the White House if it were someone else. But whatever one thinks of Clinton, her nomination is a milestone, and a lesson of history is that when women advance, humanity advances.

Grant Miller of Stanford University found that when states, one by one, gave women the right to vote at the local level in the 19th and early 20th centuries, politicians scrambled to find favor with female voters and allocated more funds to public health and child health. The upshot was that child mortality rates dropped sharply and 20,000 children’s lives were saved each year.

Many of those whose lives were saved were boys. Today, some are still alive, elderly men perhaps disgruntled by the cavalcade of women at the podium in Philadelphia. But they should remember that when women gained power at the voting booth, they used it to benefit boys as well as girls.

Miller, an associate professor of medicine and core faculty member of Stanford Health Policy, first wrote about this issue in the Quarterly Journal of Economics in 2008, arguing that women’s choices appear to emphasize child welfare more than those of men.

He presented evidence on how state-to-state suffrage rights for U.S. women from 1869 to the adoption of the 19th Amendment in 1920, which gave all women the right to vote, helped children benefit from scientific breakthroughs.

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Simple hygienic practices — including hand and food washing, boiling water and milk, refrigerating meat and the renewed emphasis on breastfeeding — were among the most important innovations in the 19th and early 20th centuries to help protect children from often-fatal diseases such typhoid fever, smallpox, measles and scarlet fever.

“Communicating their importance to the American public required large-scale door-to-door hygiene campaigns, which women championed at first through voluntary organizations and then through government,” explained Miller, who is also a senior fellow at the Freeman Spogli Institute for International Studies and the Stanford Institute for Economic Policy Research.

As women became more and more involved in state and federal politics, Miller found, child mortality declined by 8 to 15 percent, or 20,000 fewer child deaths each year.

“Public health historians clearly link the success of hygiene campaigns to the rising influence of women,” Miller wrote, citing examples with data and graphs.

That women have been — and can be — so influential seems like a no-brainer, but it’s nice to have the science to back it up.

The U.S. Preventive Services Task Force has adopted decision modeling as one of its methods in developing its evidence-based recommendations about preventive health care.

The USPSTF has developed a framework that will help the independent body of medical experts determine when to use modeling as a complementary, quantitative approach as they deliberate on their recommendations for clinical practice and medical policy. 

“This is methodologically important because it describes a framework the Task Force can use to assess when decision models may aid in the development of recommendations,” said Douglas K. Owens, who led the decision-modeling group at the USPSTF.

Owens, of the VA Palo Alto Health Care System, and a professor of medicine at Stanford Medicine and a leader at Stanford Health Policy, said the task force spent three years developing the framework.

“Modeling can be a very useful tool to complement empiric studies and can enable you to answer questions that you couldn’t otherwise answer,” he said. “For example, what’s the implication of starting mammography screening at 40 versus 50, or colorectal cancer screenings at 50 versus 45? How might a preventive intervention perform in a population that is slightly different from the ones that have been studied?”

Modeling provides insights about how benefits and harms of an intervention may vary in such circumstances, he said.

The framework for using modeling was described in the July 5, 2016, online edition of the Annals of Internal Medicine, the journal of the American College of Physicians.

The article emphasizes how decision modeling can be useful in answering important medical questions that have not been addressed in clinical trials.

“Decision models are a formal methodological approach for simulating the effects of different interventions — such as screening and treatment — on health outcomes,” the authors write. “Unlike epidemiologic models that project the course of disease or seek to make inferences about the cause of disease, decision models assess the benefits and harms of intervention strategies by examining the effect of specific interventions.”

The USPSTF has used decision models in the development of recommendations for screening colorectal, breast, cervical, and lung cancer. It’s also used modeling in recommendations for use of aspirin to prevent cardiovascular disease and colorectal cancer.

For these services, decision models allowed the USPSTF to consider the lifetime effect of different screening programs in specific populations and at various ages.

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For example, the effect of HIV screening on mortality has not been directly assessed in clinical trials. But there is evidence that HIV can be diagnosed accurately and that early treatment reduces mortality and HIV transmission.

In contrast, a recent assessment of screening for thyroid dysfunction found that the evidence was insufficient to assess benefits and harms, so this topic would not be a candidate for modeling.

Models are also useful for weighing the harms and benefits of an intervention. Clinical studies have shown, for example, that aspirin can prevent non-fatal heart attacks and strokes. But it also causes intracranial and gastrointestinal bleeding.

“How do you weigh these different benefits and harms? Modeling can be very useful in understanding the tradeoff between benefits and harms,” Owens said.

The Task Force is a leader in evidence-based methods for guideline development, Owens noted. “I hope this work will also be useful to the broader community that is developing clinical guidelines.”

Larry Diamond writes for online magazine The Cipher Brief how the extended period of democracy has not brought a dramatic deepening of democratic norms in Latin America countries.

Read the full article here.

A study of health insurance claims showed that patients undergoing 11 of the most common types of surgery were at an increased risk of becoming chronic users of opioid painkillers, according to researchers at the Stanford University School of Medicine.

But the slight overall increase in risk of 0.5 percent in no way suggests that patients should skip surgery over concern of becoming addicted to opioids, the study said. Instead, it’s a reminder that surgeons and physicians should closely monitor patients’ use of opioids after surgery — even patients with no history of using the pain-relieving drugs — and use alternate methods of pain control whenever possible.

The study was published July 11 in JAMA Internal Medicine.

“For a lot of surgeries there is a higher chance of getting hooked on painkillers,” said the study’s lead author, Eric Sun, MD, PhD, a Stanford Health Policy researcher and instructor in anesthesiology at Stanford. Sean Mackey, MD/PhD, professor of anesthesiology, is the senior author of the study and SHP's Laurence Baker was another co-author of the study.

Patients who had knee surgery had the largest risk, as they were roughly five times more likely than a control group of nonsurgical patients to end up using opioids chronically, followed by those undergoing gall bladder surgery, whose risk was three-and-a-half times greater than those in the control group.

“We also found an increased risk among women following cesarean section, which was somewhat concerning since it is a very common procedure,” adding that the risk was 28 percent higher than among the control group, Sun said.

Other factors that contributed to an increased risk for chronic opioid use included being male, elderly, taking antidepressants or abusing drugs.

The opioid abuse epidemic

Since prescription painkillers became cheap and plentiful in the mid-1990s, drug overdose death rates in the United States have more than tripled, according to the Centers for Disease Control and Prevention. Seventy-eight Americans die every day from an opioid overdose, it reported.

Previous studies have shown increased risks of chronic opioid use post-surgery, but unlike past studies, Sun and colleagues set out to examine patients who hadn’t received prescriptions for opioids for at least one year prior to surgery. Among the opioid prescription drugs examined in the study were hydrocodone, oxycodone and fentanyl — the drug responsible for the recent accidental overdose death of legendary musician Prince.

The researchers examined health claims from 641,941 privately insured patients between the ages of 18 and 64 who had not filled an opioid prescription in the year prior to surgery, then compared them with about 18 million nonsurgical patients, who also hadn’t received opioid prescriptions for at least a year. The claims were filed between 2001 and 2013 and provided by Marketscan, a database of 35 million beneficiaries.

Except for the minor procedures known to be somewhat pain-free, such as a cataract surgery and laparoscopic appendectomy, all 11 types of surgery were associated with an increased risk of chronic opioid use, the study said.

Other pain-control measures

“The message isn’t that you shouldn’t have surgery,” Sun said. “Rather, there are things that anesthesiologists can do to reduce the risk by finding other ways of controlling the pain and using replacements for opioids when possible.”

Sun said he and his colleagues in surgery and anesthesia at Stanford try to use regional anesthetics when possible to reduce the need for opioids post-surgery. He added that patients should also be encouraged to use pain-management alternatives such as Tylenol following surgery.

Sun is featured in this CBS news story:

 

“Even when taken exactly as prescribed, opioids carry significant risks and side effects,” said study co-author Beth Darnall, PhD, clinical associate professor of anesthesiology and author of the book Less Pain, Fewer Pills: Avoid the Dangers of Prescription Opioids and Gain Control over Chronic Pain. “Ideally, opioids are avoided in treating chronic pain, and pain treatment should emphasize comprehensive care, including physical therapy, pain psychology and self-management strategies.”

As a pain psychologist and clinician-scientist, Darnall emphasizes alternate methods of pain management based on evidence-based techniques that can help calm the nervous system such as diaphragmatic breathing, progressive muscle relaxation and mindful meditation.

She is studying the use of a pain psychology class at Stanford for women undergoing surgery for breast cancer called “My Surgical Success” designed to help patients develop a personalized pain-management plan to control the anxiety associated with anticipating surgical pain.

“It turns out that a lot of chronic pain develops from surgery, and pre-surgical pain ‘catastrophizing’ is a major risk factor for having a lot of pain,” Darnall said. “We hope that by optimizing patients’ psychology — and giving them skills to calm their own nervous system — they will have less pain after surgery, need fewer opioids and recover quicker.”

The research was funded by a grant from the Foundation for Anesthesia Education and Research and the Anesthesia Quality Institute.

Stanford’s Department of Anesthesiology also supported the work.

 

Tracie White is a science writer for the medical school’s Office of Communication & Public Affairs. Email her at tracie.white@stanford.edu.