Jonathan Chen has a doctorate in computer science and could have his pick of lucrative jobs here in Silicon Valley today.

Instead, he pursued his medical degree and is working on ways to help physicians quickly mine clinical data to reach better diagnoses for their patients.

“I walked away from higher paying jobs because I was looking for a greater purpose in my work and a rewarding career,” said Chen, a physician-scientist at Stanford who was a VA Medical Informatics Fellow at Stanford Health Policy.

Future works like his — supported by a five-year grant from the National Institutes of Health — may be on the chopping block.

The Trump administration’s proposed budget intends to cut NIH funding by $7 billion over the next 18 months, which could severely compromise research grants that lead to major biomedical breakthroughs.

Chen is currently building OrderRex, a digital platform that data-mines electronic medical records that show clinical practice patterns and outcomes to inform medical decisions. He hopes it will one day be the Amazon of electronic medical records.

After more than 20 years of hard work — a college freshman when he was only 13  — Chen is finally poised to become a junior faculty member. But now he has to wonder whether he made the right choice.

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“Seeing the proposed research budget cuts gives me pause,” Chen said. “And I’m considering whether it is foolish for me to even be joining the academic ranks now, chasing down grants that will be increasingly difficult to come by, amidst a political climate that does not seem to care for science.”

The administration has said it respects and would support the work of the NIH, which Secretary of Health and Human Services Tom Price recently called “very important.” But, he added, the American taxpayers should be getting “a bigger bang for the buck.”

About 80 percent of the federal NIH funding goes to grants for clinical and translational researchers at small businesses and academic institutions.

Here at Stanford Health Policy, the grants have funded research into everything from the epidemic of diagnostic errors to the economic harm of the tsetse fly on African economies; the impact of urbanization on obesity and chronic disease in India, to a global data analysis about whether foreign aid is directly linked to an increase in life expectancy in developing countries.

The National Institutes of Health — which has supported the research of some 148 Nobel Prize winners — has touched the work of nearly every SHP researcher.

“Cutting scientific research budgets could turn a generation of young minds away from the larger purposes of academic medical research and instead send them off into finance, tech, pharma — leaving behind the country’s talent pool in the decades to come,” said Chen.

Eran Bendavid, an assistant professor of medicine and core faculty at Stanford Health Policy, uses political science, economics, and epidemiology to study the prevention and treatment of infectious diseases in developing countries.

The infectious disease physician also depends, in part, on NIH funding.

“There is no substitute for NIH support for basic and applied research,” Bendavid said. “It has been a central actor in the progress of the biomedical fields and made the U.S. the global leader in innovation. It is also good diplomacy, promoting cooperation and partnerships across the globe.”

Bendavid and SHP colleague Grant Miller led the research that showed that declining use of safe contraception led to an increase in abortion rates in sub-Saharan Africa, a region in which family planning services are heavily financed by U.S. foreign aid. Their work was widely cited in news reports as a counterpoint to the Trump administration’s pledge to cut funding to international family planning organizations that also offer abortion.

“Even if many of the budgetary provisions are scaled back, this is an unfortunate place to anchor the negotiations,” Bendavid said of the proposed NIH cuts, which are so severe they are already facing opposition from some members of Congress. “This could signal real changes in what we do as individuals, as a division, and as an institution.”

House Speaker Paul Ryan was asked specifically about President Trump's proposed cuts to the National Institutes of Health. The speaker avoided criticizing the administration for that proposal — but indicated it was unlikely Congress would go along.

“I don’t try to get into making my opinion on this, on specific provisions,” Ryan said. “All I would say is perhaps the most popular domestic funding we have among Republicans is NIH.”

Michele Barry, director of the Center for Innovation in Global Health and senior associate dean for Global Health at Stanford University — as well as one of SHP’s key faculty members — wrote in this editorial on March 28 that such drastic cuts to biomedical research would make us more susceptible to global epidemics.

“We live in a time when pandemics cross borders faster than ever,” Barry wrote. “Yet to the horror of many of us working in global health, President Trump’s budget would completely eliminate the NIH’s Fogarty International Center — one of the most effective tools we have to fight global diseases.”

The GOP’s proposed American Health Care Act may have gone down in flames, but health policy experts say there are plenty of other health-care reforms the Trump administration may attempt.

Michelle Mello and David Studdert, both professors at Stanford University School of Medicine and Stanford Law School and core faculty members at Stanford Health Policy, say medical malpractice reform, for one, is back on the federal policy agenda.

The two write in this New England Journal of Medicine commentary that Secretary of Health and Human Services Tom Price, an orthopedic surgeon and Republican congressman from Georgia before he was appointed to the Trump administration, sponsored several bills aimed at limiting medical liability.

House Speaker Paul Ryan and Price have both said medical malpractice is in crisis, with frivolous lawsuits driving up malpractice insurance premiums and forcing physicians out of business. Hospitals and doctors are so afraid of being sued they overprescribe costly tests and treatments, driving up the cost of health care.

But according to a study published last year, medical errors are the third leading cause of death in the United States. And those who follow medical malpractice insurance say the industry has stabilized in the last decade.

Mello and Studdert write that medical malpractice reform is worth pursuing. The liability system has a host of well-documented problems and its reform was omitted from the Affordable Care Act.  But, they argue, Republican proposals tilt too far towards protecting physicians, with harmful consequences for patients.

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“Two of the key reforms measures on the Republican agenda — ‘safe harbors’ for physicians who comply with clinical practice guidelines and the adjudication of medical injury disputes by expert panels — are promising ideas that have received a good deal of attention in the academic literature over the last 20 years,” Studdert said.

“However, design details matter,” he said. “The versions currently being considered in Congress are quite unconventional; they look more like physician-protection initiatives than reforms designed to improve safety or protect the interests of patients in other ways.” 

The “safe harbors” from liability for providers who adhere to clinical practice guidelines would involve the establishment of tribunals of medical experts who would decide malpractice claims. Price has also proposed “administrative health-care tribunals” that would be presided over by special judges with health care expertise and would issue binding rulings aided by testimony from independent experts.

One worrisome aspect of the Republican proposals is that they would replace ordinary standards of evidence with a requirement that patients prove “gross negligence.” 

“That means that if your physician was merely careless or unskilled, you’re out of luck as a plaintiff,” Mello explained. “You have to show something akin to willful and wanton misconduct — like the case in Boston where the surgeon left in the middle of an operation to deposit money in his bank.”

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Price has claimed that defensive medicine is responsible for a quarter of U.S. health-care spending, about $650 billion, but the authors’ best estimates are closer to $50 billion.

Yet, in their commentary, the authors say this could be an ideal time to pursue reform, which ordinarily rises on the policy agenda only when a “malpractice crisis” occurs and liability insurance costs spike.  “When acutely stressed providers are clamoring for 
immediate relief, cool-headed policy deliberation rarely ensues,” they wrote. 


But, they add, reforms must be fair to patients as well as providers. They note that Price articulated a vision of health system reform that puts patients’ needs front and center.

“Medical liability reform needs the same vision,” they said.

Read More

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:

About two-thirds of American patients see doctors who receive payments from drug companies, but almost none of them know it.

In a collaborative study between Drexel, Stanford and Harvard, researchers found that 65 percent of participants had visited a doctor within the last year who had received payments or gifts from pharmaceutical or medical device firms.

Payments to physicians can take the form of meals, travel, gifts, speaking fees and research.

Only 5 percent of participants knew that their doctor had received these payments.

“The concern is that physicians with financial ties to drug and device companies may be more likely to recommend those companies' products to their patients, even when other choices would be better for the patient, or just as good but less costly,” said Michelle Mello, the Stanford author and a professor of law and of health research and policy.

Open Payments, which reports pharmaceutical and device industry payments to physicians, was set up as part of the Physician Payment Sunshine Act, a provision of the Affordable Care Act (ACA). The website exists to make industry payment information available to the public.

But the study found that only 12 percent of patients knew this information was accessible. The authors stated that the act’s impact is highly dependent on whether patients know about it.

“Transparency can act as a deterrent for doctors to refrain from behaviors that reflect badly on them and are also not good for their patients,” said Genevieve Pham-Kanter, the lead author and an assistant professor at Drexel’s Dornsife School of Public Health.

Drug and device companies tend to target “key opinion leaders” who are likely to influence the choices of other physicians. During the year studied, the average American physician received $193 in payments. However, the median payment for doctors visited by patients in the study was much higher, $510 for the year.

“We may be lulled into thinking this isn’t a big deal because the average payment amount across all doctors is low,” said Pham-Kanter. “But that obscures the fact that most people are seeing doctors who receive the largest payments.”

Payments vary widely across specialties. Among patients surveyed, 85 percent of those who saw an orthopedic surgeon saw a doctor who had received payments. The next highest was obstetrics and gynecology physicians at 77 percent.

“Drug companies have long known that even small gifts to physicians can be influential, and research validates the notion that they tend to induce feelings of reciprocity,” said Mello.

Despite potential changes to the ACA, Mello believes the Sunshine Act is here to stay. The current version of the American Health Care bill, which would repeal and replace the ACA, does not dismantle it.

This leaves the question of how policymakers can make information about payments to physicians more visible to patients. The authors suggested that the Centers for Medicare and Medicaid Services (CMS) could provide a one-stop shop for patients to view industry payments and other information about their providers online. Mello added that private insurers could make this information available on their “Find a Physician” websites.

“Finding the physician who is right for you depends on a lot of factors,” said Mello. “Whether a physician accepts money from industry may or may not be important to you, but my general view is that the more informed these choices are, the better they will be for patients.”

Non-communicable diseases such as heart and respiratory disease, cancer, obesity and diabetes are now responsible for some two-thirds of premature deaths around the world. And most of those are in low- and middle-income countries.

The United Nations has estimated that on top of the social and psychological burdens of chronic disease, the cumulative loss to the global economy could reach $47 trillion by 2030 if things remain status quo.

“That was a big whopper of a number and got a lot of attention, and that was good because it raised awareness,” said Rachel Nugent, vice president for global non-communicable diseases (NDCs) at the research institute RTI International.

“It’s an issue that is driven by a lot of different factors, “ she said. “And understanding how the larger social and economic factors affect NDCs, at a policy level, very little progress has been made — there’s been very little collaboration.”

Nugent was addressing the fourth annual Global Health Economics Colloquium at University of California San Francisco, with health experts, policymakers, students and researchers from Stanford, Berkeley and UCSF who gather every year to take a deep dive into the economics of a global health issue. More than 200 experts from 10 universities and public health departments attended the conference.

The daylong gathering focused on recent developments in the economics of NDCs, looking at case studies from around the world, and new guidelines for cost-effectiveness analysis and the role of economics in reducing health inequality.

“The donors are not convinced that there are cost-effective things that we can do in these countries; a lot of them are very skeptical that this is affecting the poor,” said Nugent, a member of the World Health Organization’s expert advisory panel on the management of NCDs.

In India, for example, much of the population still defecates outdoors, contaminating water sources and agricultural products, which can lead to malnutrition and physical and cognitive disorders. Many donors would rather see funds go to building latrines as they can see tangible results; NDC prevention is a long-term slog.

“But I don’t think we should necessarily think of NDCs as either-or,” said Nugent.  “I think that integration of services and programming is very much at the forefront of what is the right way to go.”

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Cost-effectiveness Analyses

Nugent’s research has shown five cost-effective interventions would avert more than 5 million premature deaths from NCDs by 2030, or a reduction of 28.5 percent in projected mortality from chronic disease around the world. And the average benefit-cost ratio is 9:1, at a global cost of $8.5 billion a year.

The interventions are raising the price of tobacco products by 125 percent through taxation; providing aspirin to 75 percent of those suffering from acute myocardial infarction; reducing salt intake by 30 percent; reducing the prevalence of high blood pressure with low-cost hypertension medication; and providing preventive drug therapy to 70 percent of those at high risk of heart disease.

Gillian Sanders-Schmidler, a professor of medicine at Duke University Medical Center and former assistant professor of medicine at Stanford Health Policy’s Center for Primary Care and Outcomes Research, addressed the colloquium about recommendations of the Second Panel on Cost-Effectiveness in Health and Medicine.

“There is a continued emphasis on transparency and comparability across analyses,” said Sanders-Schmidler. “And of course the big changes are that we’re now asking for a second reference case and using an ‘impact inventory’ table to clarify the scope of the findings.”

The independent panel of non-government scientists and scholars, which also included Stanford Health Policy’s Douglas K. Owens, focused on new ways to deliver health care effectively, yet with a focus on efficiency, as health care spending in the United States has reached 18 percent of GDP, much greater than the global average of 10 percent.

The first panel that convened in 1996 recommended that all cost-effectiveness analyses of health interventions include a reference case that uses standard methodological practices to improve comparability and quality. The second panel, which published its findings in September, now recommends that in addition to the societal perspective recommended by the original panel, that CEAs include a second reference case that looks at the health-care sector impact of an intervention. Additional guidance was given on what to include in the societal perspective reference case.

The panel wrote in its JAMA “special communication” that these societal reference cases should include medical costs “borne by third-party payers and paid out-of-pocket by patients, time costs of patients in seeking and receiving care, time costs of informal (unpaid) caregivers, transportation costs, effects on future productivity and consumption, and other costs and effects outside the health-care sector.”

They found most countries, including the United States, give greater weight to clinical evidence in their cost-effectiveness analyses. The panel now recommends an “impact inventory” that helps analysts and end-users of cost effectiveness analyses look at the impact of interventions beyond the formal health-care sector.

“We’re trying to ask people to be explicit,” said Owens, director of the Center of Primary Care and Outcomes Research and Center for Health Policy at Stanford.

“We want them to look at how to value outcomes in a societal perspective, not just the health-care sector, to look at all these other sectors such as productivity consumption, criminal justice, education, housing and the environment,” he said.

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Case Studies

Several case studies presented at the colloquium indicated that policy changes, government intervention and social factors are key to preventing obesity and diabetes and other NCDs.

Kristine Madsen, an associate professor of public health at UC Berkeley who focuses on childhood obesity, spoke about the nation’s first “soda tax” on sugar-sweetened beverages, which was implemented in Berkeley in March 2015.

The city has seen a 21 percent decline in the drinking of soda and other sugary drinks in low-income neighborhoods after the city levied a penny-per-ounce tax on sodas and sugary drinks. At the same time, according to a study in the American Journal of Public Health, neighboring San Francisco — where a similar soda-tax measure was defeated — and Oakland saw a 4 percent increase in the purchase of sweetened beverages.

“This decline of 21 percent in Berkeley represents the largest public health impact in an intervention that I have ever seen,” said Madsen.

Sergio Bautista of the Mexico National Institute of Public Health and UC Berkeley, said that Mexico’s sugary drinks tax implemented in January 2014 is expected to lead to a 10 percent reduction in sugary drinks consumption and prevent an estimated 189,300 cases of diabetes in a country famed for its sugary bottled cola.

William Dow, a professor of health policy management at UC Berkeley, shared his research on Costa Rica, where on average people live longer than Americans, despite the several times higher income and 10 times higher health expenditures in the United States.

Costa Rican men have a life expectancy of 77 and the women typically live until age 82; in Americans the numbers are 76 and 81, respectively. Obesity is low among Costa Rican men and few of their women smoke. Lung cancer mortality in the United States is four times higher among men and six times higher among women.

“It’s remarkable in so many ways,” Dow said, noting that deaths in the Central American country are due predominantly to infectious disease. “Does Costa Rica have any unique effective programs to emulate, or is there something going on upstream driving those health outcomes?”

He believes Costa Rica’s national health insurance and excellent access to primary care for nearly all its people are key. Having this guaranteed lifetime access to health care also reduces the stress and depression that can so badly harm physical health.

“And I would argue that probably diet is one of the most important things going on here,” said Dow, noting their diets are healthy.

Costa Ricans eat mostly unprocessed foods such as rice and black beans, corn tortilla, yam and squash, with little meat and plenty of fresh fruit.

“They also have the highest remaining life expectancy at age 80 of any country in the world, he said. “What we have learned in Costa Rica would be helpful in many other countries.”