What is the best way to measure returns on investments in health care?

Does the World Health Organization’s approach help developing countries allocate their limited health-care resources wisely?

What are the economic implications of the global rise in non-communicable diseases?

These are just a few of the global challenges taken up by health economics experts at the third annual Global Health Economics Consortium Colloquium at the University of California, San Francisco.

At the core of the conference is the growing field of health economics, and why cost-effectiveness analysis is fast becoming the underpinning of successful health policies.

Not only is the field expanding, so is the collaboration among researchers and faculty at Stanford Health Policy, UCSF Global Health Sciences, and the UC Berkeley School of Public Health, co-sponsors of the Feb. 12 event.

“It’s been great to see the meeting evolve from a show-and-tell to a platform where we can have nuanced discussions about the challenges and controversies in the field,” said Dhruv Kazi, an assistant professor of medicine at UCSF who helped organize and moderate the event.

Some 180 health policy experts, researchers and speakers representing 11 universities, six non-profit organizations and five for-profit outfits attended the daylong conference on the UCSF Mission Bay campus.

“By building bridges between our universities, we create a space where thought-leaders and students alike can engage in discussions to challenge working assumptions and also spearhead innovate strategies and solutions,” said James Kahn, a professor of health policy and epidemiology at UCSF and the director of the consortium.

The Consortium — known as GHECon — was awarded a five-year cooperative agreement of up to $8 million by the CDC to conduct economic modeling of disease prevention in five areas: HIV, hepatitis, sexually transmitted diseases, tuberculosis and school health.

Taking a break during the third annual Global Health Economics Consortium Colloquium at UCSF on Feb. 13, 2016. Photo by UCSF/Cindy Chew.

As global economies remain turbulent, Kazi said, governments and donors have become increasingly cost-sensitive and want to better understand the societal returns they are getting for their investments in health.

“That enhances the influence of our work, but also increases the scrutiny it receives, creating an opportunity for the community to have an honest discussion about the challenges and opportunities that lie ahead,” he said. “And that is precisely the platform GHECon sees itself becoming.”

Some of the tough challenges consortium members are undertaking:

1. The World Health Organization recommends using per capita GDP as a benchmark for how much money countries should be willing to spend on health-care interventions. GHECon researchers have shown that this approach is problematic and does not always help countries allocate their limited health-care resources optimally.
2. Economic evaluations have typically only considered health-care costs, overlooking the lost income of patients or caregivers during hospital stays. GHECon researchers are working on ways to value this lost productivity in an effort to estimate the true cost of a disease and, conversely, the benefit of its alleviation. 
3. Cost-effectiveness evaluations traditionally are concerned with how efficiently health-care resources are utilized by asking questions like: How many lives can I save per million dollars invested? But society may care about other benefits that go beyond efficient use of resources, such as reducing disparities by helping the most vulnerable sections of society and alleviating poverty.

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Mark Sculpher, one of the leading health economists in the world, gave the keynote address about his efforts in the UK to use cost-effectiveness analysis to inform decisions at the National Institute for Health and Care Excellence.

He said there are two big challenges today: defining cost-effectiveness thresholds that are meaningful, and determining how policymakers, donors and payers make decisions when there are multiple criteria and perspectives.

“The realities of decision-making inevitably involve a whole host of considerations,” said Sculpher, who is director of the Program on Economics Evaluation and Health Technology Assessment at the University of York. “Ultimately it’s about what is this measure of benefit that we want to maximize — and how do we invest in it.”

Stanford Health Policy’s Douglas K. Owens, director of the Center for Health Policy at the Freeman Spogli Institute for International Studies and the Center for Primary Care and Outcomes Research at the Department of Medicine, presented his influential economic modeling research about the need for routine HIV screening.

“We determined that HIV screening is cost-effective in virtually all health-care settings,” Owens told the audience, noting that the findings became policy at the Centers for Disease Control and Prevention and other national health policy organizations. It has become an example of how economic modeling can inform crucial policy decisions — and help save lives.

There were also robust panel discussions about the challenges of doing cost-effectiveness analysis in developing countries with limited resources; the difficult paths to universal health care; and how economics can help address disparities in health care and financial protection.

“The consortium is particularly valuable because it fosters collaborations among a broad group of global health experts,” Owens said.

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This season, “Downton Abbey's” plot line has health policy wonks on the edge of their seats: a heated debate about hospital consolidation that closely parallels what’s going on in the U.S. health care system today.

If you’re not a Downton fan, here’s a quick plot recap by Kaiser Health News reporter Jenny Gold: It’s 1925 for the lords and ladies at Downton Abbey. Think flapper dresses, cocktail parties and women’s rights. And a big hospital in the nearby city of York is making a play to take over the Downton Cottage Hospital next to the posh estate.

As Maggie Smith’s character, the Dowager Countess of Grantham, sees it, “The Royal Yorkshire county hospital wants to take over our little hospital, which is outrageous!”

Stanford Health Policy’s Kathy McDonald — an unabashed fan of the popular PBS period piece — says things haven’t changed that much today. There has been an uptick in hospital consolidations since 2010, with about 100 taking place each year, she says.

You can listen to McDonald’s interview with Gold, who took the Downton debate to the American Public Media radio show, “Marketplace.”

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The prestigious panel of medical experts who provoked a nationwide debate when it suggested fewer mammograms is standing by its recommendation that women 50 and older only get the screening every other year.

The U.S. Preventive Services Task Force issued an update of its 2009 guidelines on Tuesday, noting that women in their 40s with an average risk of breast cancer should discuss mammography with their clinicians and make individual decisions about whether to have the screening.

When the panel made the panel first made the recommendation, it provoked an outcry from some medical associations and cancer-awareness advocates who feared the advice would lead some women to delay having mammograms and put them at greater risk of death.

“In 2015, contentious discussions about breast cancer screening and prevention continued, with physicians, advocates, lawmakers, and scientists all lending their voices to the debate,” the Task Force said in an editorial on its website.

“Many of these stakeholders focused on the need for women to be able to make more informed health care choices about when to start screening without having to worry about the cost of an insurance copayment,” said the panel of experts, including Stanford Health Policy’s Douglas K. Owens, director of the Center for Health Policy and the Center for Primary Care and Outcomes Research.

“The role of the U.S. Preventive Services Task Force (USPSTF) in these discussions has remained unchanged: to empower women with the best scientific data about the benefits and harms associated with breast cancer screening, so they can make an informed decision with their doctor.”

Breast cancer is the second-leading cause of cancer death among women in the United States, according to the National Cancer Institute. In 2015, an estimated 232,000 women were diagnosed with the disease and 40,000 women died. It is most frequently diagnosed among women aged 55 to 64 years, and the median age of death from breast cancer is 68 years.

The task force determined that while screening mammography in women aged 40 to 49 may reduce the risk for breast cancer death, the number of deaths averted is smaller than that in older women and the number of false-positive results and unnecessary biopsies is larger.

The balance of benefits and harms is likely to improve as women move from their early to late 40s, the task force said.

“In addition to false-positive results and unnecessary biopsies, all women undergoing regular screening mammography are at risk for the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to their health, or even apparent, during their lifetime,” the Task Force said. “Beginning mammography screening at a younger age and screening more frequently may increase the risk for over-diagnosis and subsequent overtreatment.”

The independent panel of medical experts from around the nation said that women with a parent, sibling, or child with breast cancer are at higher risk for breast cancer and thus may benefit more than average-risk women from beginning screening in their 40s.

Not everyone is pleased with the recommendations.

Florida Congresswoman and chair of the Democratic National Committee, Debbie Wasserman Schultz, issued a statement that suggested the Task Force recommendations could put younger women at risk because their insurance companies may stop paying for their screenings.

“These guidelines indicate that screening for women under 50 is less beneficial in detecting breast cancer than for older women,” said Wasserman Schultz, herself a breast-cancer survivor. “However, because insurance companies often use these guidelines to determine coverage for these critical life-saving screenings, these new recommendations could potentially bar millions of women from getting coverage for screenings they need.”

Judy Salerno, president and CEO of the Susan G. Komen breast cancer charity, said she worries the recommendation could target African-American women in particular.

“A lack of coverage would be most harshly felt in high-risk and underserved populations,” Salerno said. “African-American women, for example, are often diagnosed at younger ages with aggressive forms of breast cancer – and die of breast cancer at rates over 40 percent higher than white women. Screening at younger ages is a critical tool for these women.”

Members of the Task Force, however, emphasized that it was their role to evaluate scientific evidence and not make insurance coverage decisions.

“The USPSTF acknowledges the important role that insurance coverage plays in access to and use of preventive services,” the Task Force said in its editorial. “Coverage decisions are the domain of payers, regulators and legislators. Whatever we may believe about the importance of coverage in shared decision-making about mammography, we cannot exaggerate our interpretation of the science to ensure coverage for a service. This would lead to confusion regarding the state of science versus the politics of coverage.”

The U.S. Preventive Services Task Force recommends adults between the ages of 40 and 75 take a cholesterol-lowering statin drug to help prevent heart attacks and strokes if they are at risk of cardiovascular disease.

One in three Americans die of heart attacks or strokes. And those with no signs or symptoms, as well as no past history of cardiovascular disease, can still be at risk.

The independent panel of medical experts from around the nation said in a news release that statins could help those who have a risk factor for cardiovascular disease — such as high cholesterol or blood pressure, diabetes or those who smoke — and have at least a 7.5 percent risk of having a cardiovascular event in the next 10 years.

The task force also called for more research on the use of prescribing statins for children and adolescents who are at risk of heart disease.

The American Heart Association and American College of Cardiology have been recommending statins in adults for several years. The task force is now making a similar recommendation for primary prevention based on the latest clinical trials and research.

“The task force looked carefully at current data to identify who can benefit the most from taking statins,” said task force chair Albert L. Siu, MD, MSPH, who is also chair of the Ellen and Howard C. Katz Mount Sinai Health System.

“People with no signs, symptoms, or history of cardiovascular disease can still be at risk of heart attack or stroke,” said task force member Douglas K. Owens, MD, a Stanford professor of medicine and director of the Center for Health Policy and Center for Primary Care and Outcomes Research at Stanford Health Policy.

“Fortunately, for certain people at increased risk, statins can be very effective at preventing these events,” said Owens, who emphasizes that adults who fall into those risk and age groups must first consult with their physicians.

The task force said all adults could reduce their risk of cardiovascular disease by not smoking, eating a healthy diet, engaging in physical activity and limiting alcohol use. Managing high blood pressure and high cholesterol and taking aspirin when indicated can also help prevent heart attacks and strokes.

Based on the current evidence, the task force said, it is not yet clear whether taking statins is beneficial for people who are older than 75. But they did find the effectiveness of statins is the same for both men and women.

This is the first time the task force has changed its fundamental approach since 2008, when it recommended screening for abnormal amount of lipids in the blood. While screening remains key, most adults are now routinely screened as part of an overall cardiovascular risk assessment.

Therefore, the task force found the more relevant clinical question is no longer whom to screen for elevated cholesterol, but rather whom to treat with preventive medication once increased cardiovascular risk has been identified in an individual.

The Preventive Services Task Force also announced that there is not enough data and evidence to assess the balance of benefits and harms in screening for high cholesterol in children and adolescents up to age 20.

While some experts have recommended lipid screening in children and teens, the task force found that the evidence shows it’s difficult to predict which children who have high cholesterol will continue to have it as they age.

“There is currently not enough research to determine whether screening all average-risk children and adolescents without symptoms leads to better cardiovascular health in adulthood.” said Task Force Vice Chair David C. Grossman, MD, MPH. “In addition, the potential harms of long-term use of cholesterol-lowering medication by children and adolescents are not yet understood.”

The public can review the findings and comment on the task force website.

Other articles on the recommendation include:

The Associated Press

MedPage Today

Reuters

HealthDay

The cold and flu season is upon us — and with that comes the potential overuse of antibiotics. All too often, physicians prescribe antibiotics for viral infections, which typically is ineffectual and can even be dangerous for elderly Medicare patients.

An estimated 2 million Americans are infected with drug-resistant organisms each year, resulting in 23,000 deaths and more than $20 billion in excess costs, according to the Centers for Disease Control and Prevention.

Excessive antibiotic use in cold and flu season is not only costly, but it also contributes to antibiotic resistance, writes Stanford Health Policy's Marcella Alsan and her co-authors in a study published in the December edition of Medical Care. The study’s objective was to develop an index of excessive antibiotic use in cold and flu season and determine its correlation with other indicators of clinically appropriate or inappropriate prescribing.

Alsan and senior author, Dartmouth economist Jonathan Skinner, concluded that flu-related antibiotic use was correlated with prescribing high-risk medications to the elderly.

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A new federal proposal would ban smoking in public housing homes — a move that could impact some 1.2 million households across the nation.

Cigarette smoking kills 480,000 Americans each year, making it the leading preventable cause of death in the United States, according to the Center for Disease Control and Prevention.

The Department of Housing and Urban Development announced last week that the proposal is intended to protect residents from secondhand smoke in their homes, common areas and administrative offices on public housing property.

“We have a responsibility to protect public housing residents from the harmful effects of secondhand smoke, especially the elderly and children who suffer from asthma and other respiratory diseases,” said HUD Secretary Julián Castro in a statement, adding the proposed rule would help public housing agencies save $153 million every year in health-care, repairs and preventable fires.

Stanford Law School professor Michelle Mello, who is also a professor of health research and policy and a core faculty member at Stanford Health Policy, has researched and written about this issue extensively, including in this article in The New England Journal of Medicine.

We asked Mello about her views on the federal smoking ban proposal.

What would be the greatest benefit to banning smoking in public housing?

There are lots of benefits, but to me the greatest benefit is to the 760,000 children living in public housing. Although everyone knows that secondhand smoke exposure is extremely toxic, not everyone knows how much children in multiunit housing are exposed — even when no one in their household smokes. Research shows that smoke travels along ducts, hallways, elevator shafts, and other passages, undercutting parents' efforts to maintain smoke-free homes. Also, chemicals from cigarette smoke linger in carpets and curtains, creating hazardous "third-hand smoke" exposure that especially affects babies and small children.

Do most public housing residents want a ban on smoking?

Yes. Exposure to cigarette smoke is a perennial complaint among public housing residents and surveys of residents show that strong majorities support smoke-free policies. They also show residents frequently report smoke incursions into their living spaces, and that these reports are much lower when multiunit housing buildings have 100 percent smoke-free policies than when they have only partial smoke-free policies or no policies. Secondhand smoke in public housing is also a problem because these residents have few housing choices; they generally can't "vote with their feet" by moving to a smoke-free environment.

Could this help tenants who don't have the political will, time, or financial ability, to sue landlords who ignore their claims of respiratory concerns?

Absolutely — not to mention that those lawsuits, even if they were brought, often would fail.  Generally, tenants' rights are whatever local housing codes and lease agreements say they are, and smoke-free buildings aren't typically part of that package. Smoke-free policies aren't a guarantee, of course, and there have been difficulties enforcing them among some of the local public housing authorities that have implemented them.  But when they're in place, housing authorities have more mechanisms and reason to ensure that residents are protected from smoke exposure than they do without the policies.

Many argue that what they do in their own home is their own business.

That argument fails as soon as a puff of smoke escapes their home and wafts into someone else's air supply.  It also fails whenever there's a dependent in the house, whether a child or an adult relative, who doesn't smoke. Let's not forget, nearly half of all public housing households include children. Finally, most smokers desire to quit. About 7 in 10 say they want to quit completely, and in one study, over 90 percent said they wished they had never started. When we're talking about an addiction, particularly one people generally want to kick, the trope of autonomy doesn't have a lot of traction.

There are those who will say this is another attack on low-income Americans — such as banning sugary drinks or limits to what people can buy with their food stamps — and that this smacks of government shaming the poor.

Although it's reasonable to question policies that disproportionately burden the poor, I don't think this is such a policy. The reason is that only a minority of public housing residents are smokers; most of these low-income residents are benefitted, not burdened, by smoke-free policies.  The majority are vulnerable people, including children and the elderly, who have a higher-than-average incidence of respiratory and other health problems — and who want to breathe clean air in and around their homes.

Could this proposal lead to fewer kids smoking that first cigarette?

Yes. Part of the "tobacco endgame" is to further denormalize smoking, to the point that the next generation of kids will not grow up seeing it as something adults do. This is a hard argument to make when a kid smells smoke every time he walks into the hallway of his building and sees groups of residents smoking on stoops. Smoking bans have really helped to marginalize smoking behavior in other settings, like airports, restaurants, hospitals and schools.  Multiunit housing is the next logical step.

California’s measles epidemic was no fluke; between 2007 and 2013 the percentage of kindergarteners using a “personal belief” exemption to enroll in school without vaccinations doubled.

In that year, 3 percent of kindergarteners entered school unvaccinated. In some schools, the percentage of vaccinated children was so low that it threatened herd immunity, or the ability for a population to keep a pathogen at bay, according to Stanford health-policy researcher Michelle Mello, PhD, JD.

To understand the rapid increase, Mello worked with a team led by Tony Yang, ScD, with George Mason University. Their research is published on Nov. 12 in the American Journal of Public Health.

They found the highest resistance to vaccinations among white, affluent communities. In contrast to previous studies, however, they did not find a correlation between higher levels of education and vaccine exemptions.

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