The three women who are the first doctoral candidates in the School of Medicine’s new PhD in Health Policy program have one guiding belief: economics, decision science and data are now key to improving health care.
Stanford Health Policy, through the Department of Health Research and Policy at the School of Medicine, launched the PhD program to educate the next generation of scholarly leaders in the field of health policy.
And the first crop of candidates is taking their backgrounds in science and economics to pursue health policy careers based on medical information technology, data and analytics.
“We live in an era where information in health care is more rapidly and readily available than ever before,” said Catherine Lei, who will focus on the industrial organization of health care, the effects of insurance costs and the impact of regulation on health insurance markets.
Image
“The burgeoning ‘big data’ revolution is beginning to collectively help researchers tackle long-standing issues of health care spread and quality, determinants of health, and how policies could best improve health,” said the recent Princeton University graduate who majored in economics and finance.
“Whether it be the digitization of medical records, the aggregation of pharmaceutical companies’ research into electronic databases, or the increased transparency of the health-care sector as a whole — stakeholders from every corner of the industry recognize that this is a critical turning point in health care,” said Lei.
Kyu Eun Lee, who worked as a research assistant at the Harvard Center for Health Decision Science before joining Stanford, intends to develop mathematical models for health interventions in Asia and other parts of the developing world.
“I am seeking advanced training in quantitative methodology and the application of those skills to support decision-making in a global health context,” said Lee, who graduated from Pohang University of Science and Technology in South Korea and then got her master’s of science at the University of Minnesota.
“I am particularly interested in model-based, cost-effectiveness analysis of cancer interventions in South or Southeast Asia, where the risks of communicable and noncommunicable diseases compete under limited resources,” she said.
The new program offers coursework in two tracks: Health Economics, including the economic behavior of individuals, providers, insurers and governments and how their actions affect health and medical care; and Decision Sciences, which uses quantitative techniques to assess the effectiveness and value of medical treatments.
“The new PhD program really developed because of our aim to offer premier educational programs that will train the next generation of health policy leaders,” said Laurence Baker, professor of Health Research and Policy and chief of Health Services Research in the department of Health Research and Policy.
“One of the real strengths of the program is its context at Stanford, with a rich set of opportunities for health policy students to interact with the clinicians and scientists from around the school of medicine and the university,” said Baker, who is also an affiliated faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research (CHP/PCOR).
Yiqun Chen, who will focus on the supply and demand of health care both in the United States and China, said her double major in economics and medicine at Peking University made her aware of the integral role that economics plays in providing an analytic framework for studying the meaty issues in health care today.Chen, who went on to get her master’s in economics at Duke University, has published several papers and intends to investigate whether Medicaid payment increases to nursing homes result in cost offsets.
“The utilization of hospital services is high among nursing home residents; yet a large proportion of stays are documented to be avoidable through provision of better quality of nursing home care,” Chen said.
Image
She will also research the recent consolidation of health insurers and of health care providers and how that is impacting the consumer.
“As a result of such consolidation, not only is there a potential loss of consumer choice, but it gives the pricing power to insurers and health-care service suppliers,” Chen said. And those who argue health-care and insurance consolidation results in greater efficiencies have yet to document these gains or losses — something she intends to do.
Faculty belonging to the health policy centers will advise the PhD candidates. The students will take courses in health economics, health insurance and government program operations, health financing, international health policy and economic development, as well as the cost-effectiveness analysis of new medical technologies.
Coursework in the new program will also cover relevant statistical and methodological approaches to public health concerns such as obesity and chronic disease.
"Our PhD students will learn from faculty across the University who bring perspectives from economics, medicine, law, decision science, business and other disciplines," said Michelle Mello, a professor of law and professor of health research and policy at the School of Medicine. "They will become truly cross-disciplinary thinkers and problem solvers."
MUMBAI, India – India’s colors, crowd and noises can overpower a newcomer. And the unfathomable wealth and crushing poverty that are both on display reinforce the sense that this is a country of extremes.
Four Stanford students embraced this savory sensory overload while navigating the labyrinthine Indian health-care system during seven weeks of research in the poor communities outside the financial capital, Mumbai, this summer.
“I think this experience has just hammered into me that it’s a very diverse country with a range of experiences,” said Lina Vadlamani, a Human Biology major just starting her senior year. “As one pharmaceutical owner said to us, ‘India might be poor — but the Indian people are not.’ There’s just so much going on here.”
One day they whizzed by bright Bollywood movie posters in belching auto-rickshaws and gaped up at Antilia, the 27-story mansion of a business tycoon considered the world’s most expensive home after Buckingham Palace.
The next, the students were talking to mothers of one Dalit community — members of the so-called “untouchable” Hindu caste — in the slums on the outskirts of Mumbai. They sat on the floor of a one-room community center taking notes as the women told them about their struggles to get access to medicine and doctors.
And yet another day, the students and their Indian colleagues and translators crouched in a small stucco pharmacy in the heat and humidity of the monsoon season while talking to a doctor about the procurement of traditional medicines.
The three Stanford seniors and one School of Medicine student were tracking access to health care, the quality of that care, and the way pharmaceutical networks impact medical practices in India. The Stanford India Health Policy Initiative fellows saw for themselves that the world’s largest democracy has become a microcosm of humanity’s bustling economic prosperity and yawning stretches of poverty.
“I think Mumbai is the place to see the extremes of inequality,” says Mark Walsh, an Economics major starting his senior year and a coterm who already has a Master’s in Public Policy with a focus on international development. “I’m just trying to think about how some of this great prosperity can be applied to the health problems that are affecting some of the most disadvantaged members of Indian society.”
Hadley Reid, another HumBio senior, and Pooja Makhijani, who just began her second year at the Stanford School of Medicine, are the other fellows. The students spent six days a week in the field for seven weeks and then would debrief one another every night back in their rooms on what they had learned that day.
“I’ve always thought I might be interested in doing international field work,” said Reid. “And I thought this fellowship would be a good way to experience that and see what’s really happening on the ground versus what you learn in the classroom.”
Navigating the three medical practices in India
Grant Miller, an associate professor of medicine and core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research, directs the India Health Policy Initiative. The program, now in its third year, aims to work on the ground to identify obstacles to health-care delivery in the South Asian nation.
Miller gave the four fellows a mission: Spend your summer investigating the pharmaceutical networks that cater to the three main branches of Indian medicine:
The more mainstream Western practice of allopathy;
The traditional AYUSH system of medicine: ayurveda, yoga, unani, siddha and homeopathy.
And the large network of providers who have no formal medical training.
“The fellowship has two objectives,” said Miller, also a senior fellow at the Freeman Spogli Institute for International Studies. “One is to develop a nuanced, on-the-ground understanding of the practical realities that often cause otherwise promising health programs in India to fail. The other is to provide in-depth, non-clinical field experience to Stanford students interested in global health.”
Nomita Divi, program manager of the initiative, said the fellowship is designed to be demanding. During the preparatory spring quarter, the students brainstormed with a design-thinking expert about how to formulate their research and work toward specific goals. When the students return to Stanford later this month, they will focus on unpacking and analyzing the data and then writing a full report.
“Our aim is to expose students to the realities of field research in India and provide them sufficient time to grasp the realities on the ground, as well as provide them with the tools to assimilate their observations into a final report,” said Divi.
When they arrived in Mumbai in early July, the fellows went through a week of training with Veena Das, the renowned social anthropologist from Johns Hopkins University who is on the executive board of the New Delhi-based Institute of Socio-Economic Research on Development and Democracy (ISERDD). She taught the students how to conduct field research and compose discussion guides before they crossed the thresholds of more than 100 homes of patients and offices of physicians, pharmacists and drug wholesalers.
ISERDD is a nonprofit organization devoted to research on social and economic issues and is the leading partner of the Stanford initiative, providing decades of qualitative and quantitative data sets as well as field researchers who worked alongside the students all summer.
“Primary care in poor parts of India is centered around drugs,” Miller said. “This summer, our fellows focused on the relationship between pharmaceutical suppliers and health providers, many of whom work in the informal sector — that is, they lack formal clinical training of any kind.”
Only 1.3 percent of India’s GDP was devoted to public health in 2014, one of the lowest rates in the world, according to the World Bank. India still accounts for 21 percent of the world’s burden of disease, yet the amount of public funds India invests in health care is quite small compared to other emerging economies.
Most of the cost of health care falls to the patient in India, where 86 percent of the 1.2 billion people must pay for health care and medications on their own. While the private sector caters to Indians who can pay, the poor are left to rely on the often less-than-optimal public health care system and a network of family and friends.
Unproductive spending and corruption also cripple the system.
Image
In the Field
Jaya Jadhav, a young mother in the Dalit community, explained to the students that they rely on a government nurse who comes once a month to hand out paracetamol. They have no local doctor to treat the more serious cases of typhoid and malaria, so must travel to the next settlement to see a doctor.
The women also turn to poorly trained practitioners who purchase wholesale drugs from small manufacturers and dispense these cheaper, unlabeled and often diluted pills to their patients.
As the students interviewed the women, a dozen children sat on the floor eating government-donated puffed rice and boiled gram from tiffin pots; mothers nursed beneath their saris and politely answered questions. At the end, the women asked shyly if the Stanford students had any medications they could share.
The students explained they were not doctors, but hoped that learning about the women’s daily lives would help them with their findings.
“Well, if it will one day benefit the women in the area, then this exchange of ideas about health is a good thing,” says Jadhav.
But the students weren’t always so sure.
“One of the things that I’m struggling with is the frustration of being able to do so little for these people, who basically have nothing but are ready to give us all their time,” says Makhijani, an American whose parents are from Mumbai. “But I realize I have the potential to be able to do that in the future, so I’m considering coming back to work here one day.”
Hoping for Results
Vadlamani — one of the HumBio majors who this fall also begins the Department of Medicine’s new coterm Master’s Program in Community Health and Prevention Research — applied for the fellowship because of its emphasis on field work.
““It makes us feel like detectives in a way,” said Vadlamani, who was born in the southern India city of Hyderabad and moved to the States with her parents when she was an infant. “I hope we would leave this experience with a couple of concrete areas that need to be focused on that would, down the road, lead to a policy change.”
Reid also believes their summer-long research will yield results.
“I’m not saying we’re painting the broadest, most accurate picture of the situation in India,” she said. “I know we’re taking a very small sample outside of Mumbai. But the hope is our findings will decrease some of the obstacles to effective policymaking for the health care system in India one day.”
Some of the key trends the students observed include the murky government regulations on certain classes of drugs, and the lack of knowledge about the current restrictions of antibiotic and steroid use among AYUSH doctors.
And compounding communicable diseases, such as tuberculosis and HIV/AIDS, Indians are increasingly suffering from non-communicable diseases as well.
“That’s happening across the developing world, these chronic lifestyle diseases such as diabetes and hypertension,” said Walsh. “And these families aren’t used to having to deal with these kinds of chronic diseases.”
The rural poor cannot afford to see a primary care physician who would school them in lifestyle changes to fight a potentially deadly disease such as diabetes.
And those who can afford a doctor in rural India often can’t find one.
India currently has some 840,000 doctors, or about seven physicians for every 10,000 people, according to the World Health Organization. That compares with about 25 in the United States and 16 in India’s economic rival, China.
The doctors the students did meet were generally overworked and struggling to keep up with all their patients and the shifting laws and regulations. But the students were forced to let go of some of their preconceived notions.
“Although there’s definitely a lot of gaps in knowledge, I’ve been surprised at how much doctors do know and how well trained they are,” said Makhijani, who often visits family in Mumbai, but had never ventured out into the poorer communities where her grandfather once ran a government hospital.
“I’ve never had such personal interactions with people living in the slums, with the doctors who are working here,” she said. “It really turns your perspective around, how resilient and creative they are.”
An Honor and Duty
Dr. Masood Ahmed Khan, a physician and pharmacist, spent nearly two hours with the students, with no prior knowledge that they would show up at his door and pepper him with questions about how he runs his unani practice.
When asked why he would give so much of his time, he said it was his “honor and duty” to help the students better understand the ups and downs of his medical community in one of the poor Muslim corners of Mumbai.
Dr. Khan then bid farewell with a cup of masala chai and this advice as they embark on their careers: “Go with empathy, go with humanity — and go with humility.”
View the photo gallery by clicking here or on the arrows below:
Beth Duff-Brown is the communications manager for the Center for Health Policy/Center for Primary Care and Outcomes Research. She joined the students in Mumbai for a week to blog about their research. You can read the blog postings here.
Hero Image
A young boy in an impoverished Dalit community on the outskirts of Mumbai.
Video of A career in Economics...it's much more than you think
Marcella Alsan, an assistant professor of Medicine and CHP/PCOR core faculty member, shows how economics is a broader field than most people realize in this video produced by the American Economic Association (AEA). Along with other top economists, she discusses the interdisciplinary nature of economics, specifically as it relates to global health. Alsan states that "without understanding economic principals and economic forces, [there is] a real gaping hole in actually practicing medicine." Understanding economics can help us to understand policy decisions and to tackle the broad problems of society.
Although the expansion of Medicaid under the Affordable Care Act has made millions of low-income and rural Americans eligible for health insurance, many states don’t provide dental coverage for adults under their Medicaid programs.
Paying for dental insurance on the individual market or paying for dental services out of pocket is cost-prohibitive for Medicaid beneficiaries, many of whom are at or beneath the federal poverty level.
So many have turned to emergency rooms for such care.
The researchers said Medicaid dental coverage could help reduce the need for many low-income Americans to visit emergency departments for dental conditions that may have otherwise been prevented with adequate access to basic dental care.
“It is likely that EDs will continue to provide care to individuals without adequate access to community-based dental care unless new dental service delivery models are developed to expand access in underserved areas, and unless more dental providers begin to accept Medicaid under the ACA,” the researchers wrote in their study, which was published today in Health Affairs.
BACKGROUND: Current guidelines for economic evaluations of health interventions define relevant outcomes as those accruing to individuals receiving interventions. Little consensus exists on counting health impacts on current and future fertility and childbearing. Our objective was to characterize current practices for counting such health outcomes. METHODS: We developed a framework characterizing health interventions with direct and/or indirect effects on fertility and childbearing and how such outcomes are reported. We identified interventions spanning the framework and performed a targeted literature review for economic evaluations of these interventions. For each article, we characterized how the potential health outcomes from each intervention were considered, focusing on quality-adjusted life-years (QALYs) associated with fertility and childbearing. RESULTS: We reviewed 108 studies, identifying 7 themes: 1) Studies were heterogeneous in reporting outcomes. 2) Studies often selected outcomes for inclusion that tend to bias toward finding the intervention to be cost-effective. 3) Studies often avoided the challenges of assigning QALYs for pregnancy and fertility by instead considering cost per intermediate outcome. 4) Even for the same intervention, studies took heterogeneous approaches to outcome evaluation. 5) Studies used multiple, competing rationales for whether and how to include fertility-related QALYs and whose QALYs to include. 6) Studies examining interventions with indirect effects on fertility typically ignored such QALYs. 7) Even recent studies had these shortcomings. Limitations include that the review was targeted rather than systematic. CONCLUSIONS: Economic evaluations inconsistently consider QALYs from current and future fertility and childbearing in ways that frequently appear biased toward the interventions considered. As the Panel on Cost-Effectiveness in Health and Medicine updates its guidelines, making the practice of cost-effectiveness analysis more consistent is a priority. Our study contributes to harmonizing methods in this respect.
Despite potential legal and enforcement challenges, California’s new vaccination law may set a precedent for other states, according to Stanford scholars.
The law, SB 277, ends exceptions to vaccination mandates based on religious and philosophical beliefs, leaving only medical exemptions as a path to avoid the vaccinations children are required to have before entering school.
Studdert, Mello, and Parmet discuss four factors that led to passage of the law. Strong advocacy by several members of the California legislature was one factor. Another was the state’s efforts to publicize data showing that personal belief exemptions have doubled since 2007, enough to endanger the community. In addition, there is mounting evidence that the recent measles outbreak at Disneyland could have been prevented by better vaccination compliance. Finally, supporters of SB 277 highlighted the risks unvaccinated school children pose to vulnerable classmates. According to the report, “the bill’s proponents focused on the specific threat to schoolchildren who are too medically fragile to receive vaccinations, effectively framing vaccine refusal as a decision that endangers others rather than a purely ‘personal’ one.”
SB 277 could place pressure on other states to tighten their exemptions for school-entry vaccination requirements. At this time, only West Virginia and Mississippi have legislation that prevents personal belief exemptions for vaccination. Adding California may give such laws national attention, and Studdert said that this development may be an “indication that politics are starting to shift.”
However, opponents of the law are likely to challenge it in court. Challengers may argue that the law impinges on their First Amendment rights to free exercise of religious beliefs or that it violates unvaccinated children’s right to access public schools. However, Studdert “would be very surprised if SB 277 ends up being struck down as a result of such challenges.” In the past, courts have ruled in favor of public health agencies in similar cases. “For over a century, appellate courts accepted arguments that mass vaccination is crucial to the well-being of the community.”
A more difficult challenge is enforcement of the law. Unvaccinated children can still attend school as long as their parents pledge to complete the children’s required vaccinations, and schools are not penalized for failing to follow up. The authors argue that “state laws should instead task health departments with enforcement responsibility for vaccination mandates” in order to boost compliance. “Willing providers,” or doctors who sympathize with vaccination opponents, may also undermine enforcement if they choose a broad interpretation of the medical exemption criteria. Other ways around the stricter requirements include home-schooling and nannies. This would not affect school safety but could have implications for the larger community.
Stanford Health Policy's David Studdert and Michelle Mello discuss SB 277, a new California law that ends exceptions to vaccination mandates based on religious and philosophical beliefs, leaving only medical exemptions as a path to avoid the vaccinations children are required to have before entering school. Their report highlights the factors that lead to the law's passage, potential legal and enforcement challenges the law may face, and the possibility that this law may set a precedent for similar laws in other states.
Foreign aid to the public health sectors of developing countries often appears to be allocated backwards: The global burden of non-communicable diseases such as diabetes or heart disease is enormous – yet they receive little health aid.
By comparison, the global burden of HIV is much smaller, yet it receives more health aid than any other single disease.
So will a wholesale reversal in health aid priorities improve global health? The answer, according to a new study by Stanford researchers, is that if the goal is to maximize the health benefits from each donor dollar, health aid is actually allocated pretty well.
Still, reallocating foreign aid to step up the fight against malaria and TB could lead to greater overall health improvements in developing nations. And it could be done without spending more money, the researchers have found.
Eran Bendavid, an assistant professor in the Department of Medicine and a core faculty member at the Center for Health Policy and Center for Primary Care and Outcomes Research, and three Stanford research assistants write in the July issue of Health Affairs that more health aid is going to disease categories with more cost-effective interventions.
"What we found, somewhat to our surprise, is that in nearly all countries, more aid was flowing to finance priorities with more cost-effective options,” Bendavid said in an interview. “That is partly because more aid was flowing to the treatment and prevention of infectious diseases such as HIV and malaria, and their management can be relatively inexpensive, even if the burden of these diseases is lower than that of non-communicable diseases.”
Bendavid, an infectious disease physician, added: “Conversely, even though the burden of non-communicable diseases is high and growing, addressing these chronic conditions such as diabetes and heart disease is, broadly, more costly than the unfinished infectious disease agenda.”
The authors also show that just because health aid is broadly allocated toward better cost-effectiveness does not mean that it cannot be better allocated.
The biggest gains would come from taking some of the foreign aid earmarked for HIV or maternal, newborn or child health, and putting it toward programs to treat malaria and tuberculosis, they write.
The Stanford research team reviewed the literature for cost-effectiveness of interventions targeting five disease categories: HIV, malaria, tuberculosis, non-communicable disease and maternal, newborn and child health.
What they found was that aid from wealthy nations to developing ones might be allocated efficiently, but that the money is not always spent in the best interest of curbing the communicable diseases that would improve the overall health of a nation.
It is crucial, therefore, to further study the consequences of realignment of donor funds.
Public health aid is critical to most developing countries. Development assistance from high-income countries to public health sectors of low- and middle-income countries amounts to nearly 40 percent of public health spending in countries with a per capita GDP of less than $2,000.
The researchers focused on 20 countries that received the greatest total amount of aid between 2008 and 2011, a period of historically unprecedented growth in health aid. Development assistance has since flattened, however, so the authors believe it’s increasingly important to consider best value when investing limited resources.
The 20 countries studied – from Afghanistan to Zambia – received $58 billion out of the total $103.2 billion in recorded health aid disbursements to 170 countries between 2001 and 2011.
“Over the period of 2001-2011, a greater amount of disbursements flowed to HIV programs than any other disease category,” the authors write. “On average, interventions addressing malaria and had the lowest incremental cost-effectiveness ratio (ICER), which indicates that malaria interventions could yield greater health improvements from each dollar compared with the interventions having a higher ICER.”
The authors analyzed the data and determined that the alignment improves if up to 61 percent of HIV aid is reallocated for TB control and up to 80 percent is reallocated for malaria control.
“Our evidence suggests that the greatest improvements in the efficiency of global health dollars could result from reallocating funds to malaria and TB control programs,” the authors write.
“This study shows, for the first time, that the current allocation of health aid is generally aligned with the cost-effectiveness of targeted interventions. Contrary to common views that advocate for reprioritization toward non-communicable diseases, our data suggest that the alignment could best be improved by focusing on malaria and TB, especially where addressing those diseases is highly cost effective.”
The other authors of the study are Andrew Duong and Gillian Raikes, both research assistants in the Program of Human Biology; and Charlotte Sagan, a RA in the School of Medicine.
Development assistance from high-income countries to the health sectors of low- and middle-income countries (health aid) is an important source of funding for health in low- and middle-income countries. However, the relationship between health aid and the expected health improvements from those expenditures—the cost-effectiveness of targeted interventions—remains unknown. We reviewed the literature for cost-effectiveness of interventions targeting five disease categories: HIV; malaria; tuberculosis; noncommunicable diseases; and maternal, newborn, and child health. We measured the alignment between health aid and cost-effectiveness, and we examined the possibility of better alignment by simulating health aid reallocation. The relationship between health aid and incremental cost-effectiveness ratios is negative and significant: More health aid is going to disease categories with more cost-effective interventions. Changing the allocation of health aid earmarked funding could lead to greater health gains even without expanding overall disbursements. The greatest improvements in the alignment would be achieved by reallocating some aid from HIV or maternal, newborn, and child health to malaria or TB. We conclude that health aid is generally aligned with cost-effectiveness considerations, but in some countries this alignment could be improved.
David Studdert and colleagues explore how to balance publichealth, individual freedom, and good government when it comes to sugar-sweetened drinks. Over the last decade, many national, state, and local governments have introduced laws aimed at curbing consumption of sugar-sweetened beverages (SSBs), especially by children. The main regulatory approaches are taxes, restrictions on the availability of SSBs in schools, restrictions on advertising and marketing, labeling requirements, and government procurement and benefits standards. Efforts to regulate in this area often encounter stiff opposition, including claims that the laws are inequitable, do not achieve their goals, and have negative economic effects. Several lessons can be drawn from the international experience with SSB regulation to date, which may inform future design and implementation of legal interventions to combat noncommunicable disease.
