The U.S. Preventive Services Task Force now recommends adults ages 40 to 75 with no history of heart disease — but who nevertheless have at least one risk factor and an elevated risk of cardiovascular disease — take a low- to moderate-dose statin.
The independent panel of experts in prevention and evidence-based medicine issued the recommendation in the Nov. 15 issue of JAMA.
An estimated 505,000 adults died of coronary heart and cerebrovascular disease in 2011. The prevalence of heart disease increases with, ranging from about 7 percent in adults ages 45-64 to 20 percent in those 65 and older. It is somewhat higher in men than in women.
We ask Owens some questions about the new guideline:
Q: What prompted this new recommendation by the task force?
Owens: Cardiovascular disease is the leading cause of death in the United States, accounting for 1 in 3 deaths among adults due to heart attack and stroke. And statins can provide an important benefit to people at elevated risk of cardiovascular disease. But in order to know whether statins are going to be beneficial, it’s important to know something about the patient’s cardiovascular risk.
We reviewed the literature comprehensively — including 19 randomized clinical trials involving more than 73,340 patients, as well as additional observational studies — to understand both the benefits and the harms of statins. We concluded that the benefits outweigh the harms in appropriate patients at increased risk of cardiovascular disease. The primary benefit of statins is a reduction in your chance of having a heart attack or stroke.
Q: What are statins and why do they offer such benefit?
Owens: A statin is a drug that reduces the production of cholesterol by the liver. High cholesterol is a significant risk factor for cardiovascular disease and stroke, and statins help prevent the formation of the so-called bad cholesterol. Statin drugs also help lower triglycerides, or blood fats, and raise the so-called good cholesterol, HDL.
While there are some reported side effects from the use of statins, such as muscle and joint aches, most people tolerate statins fairly well. There is mixed evidence about whether statins may result in a modest increase in the chance of diabetes, but the task force assessed the benefits to clearly outweigh harms in patients at increased risk of cardiovascular disease.
Q: Who should be taking low- to moderate-dose statins?
Owens: The task force recommends that clinicians offer statins to adults who are 40 to 75 years old and have at least one existing cardiovascular disease risk, such as diabetes, hypertension, high cholesterol or smoking. They also must have a calculated risk of 10 percent or more that they will experience a heart attack or stroke in the next decade.
The task force recommends clinicians use the American College of Cardiology/American Heart Association risk calculator to estimate cardiovascular risk because it provides gender- and race-specific estimates of heart disease and stroke.
For people with a risk of 7.5 to 10 percent of heart attack or stroke over the next decade, the task force recommends individual decision-making, as the benefits of statins are less in this age group because these people have a lower baseline risk of having a cardiovascular event.
The task force also looked at the initiation of statins in people 75 or older and found there wasn’t enough evidence to determine whether people in this age group who have not previously been on a statin would benefit from starting a statin. So the task force suggests people in this age group consult their physicians about whether a statin may be beneficial.
Q: Do these new statin guidelines override the task force recommendation in 2008 that adults be screened for lipid disorders due to high cholesterol?
Owens: Yes, this recommendation replaces the 2008 recommendation on screening for lipid disorders in adults.
The accumulating evidence on the role of statins in preventing heart disease has now led the task force to reframe its main clinical question from “Who should be screened for dyslipidemia?” to “Which population should be prescribed statin therapy?”
We recommend that physicians go beyond screening for elevated lipid levels and assess the overall cardiovascular risk to identify adults ages 40 to 75 years who will benefit most from statin use.
Q: What does the task force hope to accomplish with the new recommendation?
Owens: We hope this guideline will help both clinicians and patients decide what their cardiovascular risk is and what steps they can take to reduce those risks, which include a healthy lifestyle, a healthy diet and exercise, and for appropriate patients at elevated risk for cardiovascular disease, potentially a statin.
We also hope to highlight areas that would benefit from additional research. Further research on the long-term harms of statin therapy, and on the balance of benefits and harms of statin use in adults 76 years and older, would be helpful in informing clinicians and patients.
Health policy expert Bob Kocher likes to show a slide of the signature page of the Affordable Care Act, which he helped draft when he worked in the White House.
The mottled page shows an official time stamp of March 23, 2010, and the choppy signature of President Obama, who had to use the 22 pens he would later gift each member of Congress who helped him pass the landmark health-care law.
“We thought it would be pretty simple,” Kocher recalled with a grin. “We had 60 Democrats in the Senate and a huge majority in the House, a popular president. But then you saw what happened.”
“Everything that you could imagine that would throw a monkey wrench into it, did,” said Kocher, a physician and partner at the Silicon Valley venture capital firm, Venrock, which invests in health-care and technology startups.
Six years after its rocky start — and ongoing threats to repeal the law by Republicans — Kocher still believes the ACA has had a tremendously important impact on the nation.
“Despite the single worst launch of a website in the history of the internet,” he said, 20 million more Americans now have access to health care; 13 million more are privately insured by their companies; and 7 million more are enrolled in Medicaid.
“I believe the ACA is working better than expected by virtue of the fact that there’s nobody in the ecosystem who is not behaving differently,” Kocher said.
Large employers have been forced to engage with their employees about the costs and quality of their health plans, and hospitals are adopting new technology by “liberating their data” with electronic medical records and embracing telemedicine, Kocher said.
“And for the first time, you see patients beginning to engage with new technologies and their doctors willing to entertain new models.”
Kocher, who specializes in investing in healthcare IT and services, said technology would eventually strip away some of the cost of patient care.
“One of the fun parts of my job as a venture capitalist is that I get to see a lot of these embryonic ideas and many of them have powerful ways to pull down costs without hurting quality,” he said. “We’ll have the technology and coordinated care, and data that helps guide the care, so I’m more hopeful than ever about being a patient.”
Kocher, a consulting professor at Stanford Medicine, was one of 15 speakers at the symposium to launch Stanford Health Policy, a community of faculty, physicians, scholars and students across the campus who are focused on improving health care and policy here at home and around the world.
Precision Health
Stanford School of Medicine Dean Lloyd B. Minor shared what he called “some surprising statistics” with the 200 people at the symposium on Oct. 14.
When looking at a pie chart representing the determinants of health, Minor said, only 5 percent are genetically based, 20 percent are based on health care and another 20 percent are due to behavioral factors.
But a full 55 percent of the determinants of health are socially and environmentally determined, Minor said, and that presents challenges for academic medical centers.
“I’m really excited in that I believe that we are beginning to come up with some ways we can address that need, as a leading academic medical center, to chart the future for how we can improve the delivery of health care in our country and then ultimately around the world,” Minor said. “For us, that vision for how we fulfill that need begins with what we describe as precision health.”
Minor said precision medicine, now embraced by the Obama administration, is about using genomics, big data science and personalization in order to individualize the treatment of acute diseases such as cancer, heart and neurological diseases.
“It’s about understanding the determinants and predisposing factors of disease in being able to more effectively intervene earlier,” he said. “And of course there’s no better place to do that than at Stanford because our academic medical center is such an integral part of this great research university.”
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The ACA Moving Forward
Kocher, who often lectures in health economics and policy courses at Stanford, conceded there are serious problems with Obamacare and offered some solutions moving forward.
But the climbing cost of health care and prescription drugs in the United States — which continue to outpace the economy and job growth — is his first concern.
Health insurance on average costs a family of four is $18,000 a year.
“That’s the price of a Corolla,” he said, referring to Toyota’s compact car. “The idea that you’re effectively buying a new car every year doesn’t feel like we’re getting the right amount of cost pressure on the system that we need. So I think that’s going to be the most fundamental problem going forward.”
Despite the gnashing of teeth over what would become of the ACA under a Trump or Clinton administration, Kocher predicted few changes.
“If Hillary Clinton wins, her priorities are actually going to be totally separate from ACA tweaks,” he said, adding that she likely would first focus on K-through-12 education, work on infrastructure spending and then international affairs.
“The odds that she wants to relive 1993 seems implausible to me,” he said.
As first lady, she pushed President Bill Clinton’s universal health-care plan with a mandate for all employers to provide health insurance coverage to all employees. The Health Security Act was widely condemned by conservatives and the health insurance industry and after a rancorous year of debate and counter-proposals, it died.
And what happens to the ACA if Donald Trump is elected president on Nov. 8?
“I can’t bring myself to comment,” Kocher said, lowering his head and chuckling.
He quickly moved on to some suggestions to make health care work better and faster.
“The first thing we need is to make these adolescent exchanges grow into adults and be stable and work better,” Kocher said of the health insurance marketplaces, which have foundered in some states and thrived in others.
He said the Covered California exchange, which insures some 1.7 million Californians, is the only exchange working really well because it has large bidding regions, doesn’t let all insurance providers into the system and does great outreach to young, healthy people.
Secondly, he said, the market power of hospitals has become too strong.
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“I realize there are some hospital leaders in the room and I salute you — you’ve done many things right, including getting market power,” Kocher said, addressing David Entwistle and Chris Dawes, the CEOs of Stanford Health Care and Lucile Packard Children’s Hospital, respectively, who also spoke at the symposium.
“But we need to figure out how to make the demand side of the equation more balanced with the supply side.”
He called health care today “massively inefficient” and “insanely unaffordable,” and said the average hospital stay is now $6,000 in the United States.
Kocher said he recently took his daughter to an emergency room and was charged $52 for a Tylenol. He told them he was a doctor and offered a Tylenol from his backpack.
“But I was told I couldn’t because of the safety of the hospital,” he said, shaking his head.
Kocher said hospitals must be accountable for their quality of the care and fined for failure to achieve promised quality indicators. As hospitals continue to bundle services and acquire private practices and physicians, costs have not gone down as expected.
Instead, hospital prices nationally have risen 6 to 9 percent in the last five years, faster than the rate of inflation. Perhaps, he suggested, some procedures and services should be tied to Medicare rates above a certain percentage of market share. And federally subsidized drug prices should be tied to patient income, not the facilities they use.
Kocher said there continues to be great debate over how high the penalty should be for those who decline to join a health exchange if they are uninsured by an employer.
The annual fee for not having insurance in 2016 is $695 per adult and $347.50 per child.
A higher mandate, he said, would get a lot more people into the system.
“But there’s no chance Congress is going to think about that.”
As health-care costs climb ever upward, controlling expenses without sacrificing high-quality care becomes increasingly important. Payment systems based on the value of care are emerging as a way to combat rising costs.
Many researchers like Jason Wang, an associate professor of pediatrics and a Stanford Health Policy core faculty member, have found that bundled payment systems may help health-care institutions achieve better value of care.
In a new study in the Journal of the American Medical Association Oncology, Wang and his co-authors show that a value-based bundled payment system is associated with cost containment and improvement in care, even improving chances for survival.
The study examined Taiwan’s bundled pay-for-performance (PFP) system for breast cancer. Instead of the traditional fee-for-service (FFS) system that is typical in the United States — in which every test, surgery and exam is billed individually — this system includes all aspects of treatment in a single established cost, or bundled payment.
Based on guidelines set by Taiwan’s National Health Insurance Administration (NHIA), the pilot program reimbursed health-care institutions’ costs for breast cancer treatment based on the patient’s cancer stage, 0 to IV. Institutions that exceeded the NHIA’s standards received a financial bonus as an incentive for better performance.
The study followed 4,215 patients in the bundled-care system over a five-year period, comparing the quality of their care, the cost of their treatment and the outcomes of their treatment to 12,506 similar patients in the traditional FFS system.
The authors found that patients in the bundled-payment system received better care throughout treatment, were more likely to survive, and contained medical costs over time, compared to their peers in the FFS system.
Costs for patients in the bundled payment system remained about the same throughout the study. However, the cost of treatment for those in the FFS system steadily increased throughout the study period. By the end, even health-care institutions receiving the maximum bonus incentive would incur lower costs than those in the FFS system.
Yet even though their treatment was cheaper, patients in the bundled system experienced better results. Patients using the bundled system had significantly higher survival rates for cancer stages 0 to III, and they were more likely to receive higher quality care based on quality indicators.
This is largely due to the better coordination of care made necessary by the bundled system, according to Wang.
“When you play in an orchestra, the whole group needs to play together, so it plays the right tune,” said Wang. “Focusing on value for the patient and the health-care system forces people to play the same tune.”
Wang believes the lessons learned from Taiwan’s program could be applied in other parts of the world, including the United States, which is currently moving toward bundled cancer care.
Though the U.S. already bundles care for conditions like appendicitis and chemotherapy — in which costs are fairly predictable — many hospital administrators fear that broadening the use of bundled payments for more complex conditions is too risky, financially.
Wang does not share their misgivings.
“People say, ‘We can’t do this for a very complex disease.’ It’s not true,” he said. “When we went outside of the U.S., we started to find systems that work.”
Wang found that when institutions can coordinate care for patients — that is, when a single institution manages all aspects of a patient’s care — the patient is more likely to have better outcomes.
“If institutions take the leadership of providing the infrastructure to coordinate care, they can really deliver better care with the same or lower costs.”
There are benefits for the institutions, too. Right now, because health insurance providers may accept or reject particular costs in an unpredictable way, care institutions never know how much they’re going to get paid for a service. But in a bundled payment system, costs are much more stable and revenue easier to predict.
Considering the benefits, Wang hopes the Taiwan breast cancer study will show institutions in the United States and around the world that bundled payments for cancer can be done on a broad scale.
Many people dread dealing with health insurance. Choosing the right plan, navigating benefits and understanding premiums, copays and deductibles can leave you frustrated and confused. Even in economic research, health insurance markets pose some of the most challenging questions.
Intrigued by the shifting dynamics of the industry and inspired partly by her own experience of finding health care coverage during graduate school, Polyakova has joined a small group of health economists who are at the forefront of examining the increasing complexities surrounding the provision of medical insurance.
Changes under the Affordable Care Act have deepened the connection between public and private players, Polyakova says. There’s a rise in health care plans that are publicly funded but privately run. And many people using public plans, like Medicare, are supplementing their coverage with private add-on insurance.
The intertwined relationship raises a host of policy challenges, which Polyakova outlines in this detailed policy brief.
“We're moving toward this world where we think competition in health insurance is good because that somehow increases efficiencies and provides consumers with choices that they like,” Polyakova says. “But on the other hand, there has been a lot of debate on whether health insurance is the right place to have choice.”
Polyakova, an assistant professor of health research and policy at the School of Medicine, joined Stanford in 2014. Her ongoing economic research looks at the impact of government policies in social insurance on consumer behavior, insurer behavior and market outcomes, including risk protection and redistribution.
By investigating the design of health insurance systems, Polyakova’s work could inform policymakers on the extent the government should facilitate competition among insurers that are providing social insurance benefits, or the steps public and private insurers can take to reduce risks and costs for consumers. Her early forays have gained recognition.
For her doctoral thesis on Medicare Part D — the prescription drug component of the federal health insurance program — Polyakova won the 2015 Ernst-Meyer Prize, which recognizes original research about risk and health insurance economics. She also received the John Heinz Dissertation Award from the National Academy of Social Insurance in 2015.
Her findings included evidence of substantial inertia among enrollees, despite significant changes in about 40 plans under Medicare Part D.
“If no one actually ever reacts to changes in products,” Polyakova says, “it could defeat the purpose of having competition.”
Polyakova continues to drill into details where answers may lie. Her empirical research in progress ranges from examining new ways of calculating risk to the effects of word choice in insurance plan descriptions.
“Policies are labeled silver, gold, platinum — theoretically to simplify the plans. But in reality, those simplifications may lead people to choose plans that are not the best for them,” she says. “Assessing the implications of their choices for the overall efficiency of the health insurance system is tricky”
The health care system appeared much more straightforward in Germany, where she worked for a year after graduating in 2008 from Yale with a bachelor’s degree in economics and mathematics.
Then while attending graduate school at the Massachusetts Institute of Technology, Polyakova went through the hassles of figuring out the health insurance system and how insurers reimburse medical providers. She recalls thinking, “Why is this so complicated?”
Polyakova turned her focus to health economics after taking some courses with MIT Professor Amy Finkelstein, a pioneer in the field who became Polyakova’s primary advisor.
As he explained during the recent Rosenkranz Prize Symposium, Stefano M. Bertozzi used this slogan to promote health reform in the Mexico City prison system. By encouraging inmates to step up and get themselves tested for HIV and other chronic illnesses, Bertozzi, dean and professor of health policy and management at the UC Berkeley School of Public Health, was able to decrease the spread of illnesses in Mexican prisons and the surrounding communities.
The Rosenkranz Prize Symposium celebrated research projects that—like Bertozzi’s—address the health care needs of the world’s most vulnerable populations. With support from the Rosenkranz Prize for Health Care Research in Developing Countries, Stanford scholars have stepped up to tackle health issues in regions in need.
Since 2010, the award has funded six young Stanford researchers who aim to improve health in developing countries. The symposium celebrated their achievements.
The award honors the work of Dr. George Rosenkranz who spent his career reducing health disparities around the globe. Rosenkranz, who was the first to synthesize cortisone and the active ingredient in the first oral contraceptive, also celebrated his 100th birthday at the symposium.
Producing research that will increase care for vulnerable populations globally is the ultimate goal of the Rosenkranz Prize.
Andrés Moreno-Estrada, the 2012 winner, has used the award to study genetics in Latin American and Caribbean populations, aiming to increase knowledge of potential genetic illnesses. He said, “The Rosenkranz Prize is a clear, important step forward to demonstrate that we can do cutting edge science in developing countries that is of international relevance.”
Other winners include Eran Bendavid, Sanjay Basu, Marcella Alsan, Jason Andrews and Ami Bhatt. Their projects range from the effect of AIDS relief efforts on health care delivery to the treatment of diabetes in India to low-cost diagnostic tools for regions lacking infrastructure.
“I can’t think of a better way to celebrate (my father’s) birthday than listening to the bright future of science,” said Ricardo T. Rosenkranz, son of Dr. George Rosenkranz and a prize donor. “We can’t wait to hear what the next Rosenkranz Prize winners tell us.”
Dr. George Rosenkranz celebrated his 100th birthday at the symposium. The first to synthesize cortisone as well as the active ingredient in the first oral contraceptive, Rosenkranz spent his life reducing health disparities around the globe.
An independent panel of medical experts has updated 20-year-old guidelines for evaluating cost-effectiveness in health and medicine, in an effort to help everyone from policymakers to patients make more informed decisions about tests and treatments.
Released in a special communication in the Journal of the American Medical Association, the panelists spent more than three years building on the work of the 1996 Panel on Cost-Effectiveness in Health and Medicine, originally convened by the U.S. Public Health Service. They developed recommendations by consensus.
The new recommendations are intended to guide decision-makers in using new methods for analyzing evidence, reporting standardized results, incorporating both health-care system and societal perspectives, as well as weighing ethical issues in the use of cost-effectiveness analysis (CEA).
“Some people question the use of economic analyses in health care, but cost-effective analysis is a way to ensure that we are proving high-value care,” said Stanford Health Policy’s Douglas K. Owens, a professor of medicine and senior investigator of the VA Palo Alto Heath Care System, who sat on the panel.
“If we do interventions without understanding their value, we may well spend money on something that may not really be worth it,” said Owens. “Cost effectiveness analysis is one approach to understanding how we can help control health-care costs and provide high-value health care.”
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The panel was led by co-chairs Gillian D. Sanders, Professor in the Department of Medicine and a member of both the Duke Clinical Research Institute and the Duke-Margolis Center for Health Policy, and Peter J. Neumann, Director, Center for the Evaluation of Value and Risk in Health at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center and Professor of Medicine at Tufts University.
Sanders said CEA could help inform decisions about how to apply new or existing medical tests, therapies, and prevention techniques so that decision-makers use health-care resources wisely.
“As health-care costs continue to rise at unsustainable rates, these recommendations provide a framework for comparing the relative value of different health-care interventions, and help decision-makers across the spectrum from policymakers to patients sort through alternatives and decide what tests and treatments make sense,” she said.
Neumann noted that in the 20 years since the original panel’s report, the field of cost-effectiveness analysis has advanced, as has the need to deliver health-care efficiently.
“Updating the guidelines provides an opportunity to reflect on the evolution of cost-effectiveness analysis and to provide guidance for the next generation of practitioners and consumers,” he said.
Primarily funded by grants from the Robert Wood Johnson Foundation and the Bill & Melinda Gates Foundation, the panel recommends several key changes to the guidelines, while confirming other principles from the first panel, including:
Broadening the scope and number of reference cases in a cost analysis, which describe standard methodology that should be followed to ensure quality analysis by creating comparable measurements. The panel is recommending that all CEAs should not report two reference cases: one based on a health-care sector perspective and another based on a societal perspective.
Using an “impact inventory” that lists the health and non-health effects of a health-care intervention to ensure that all consequences are considered, including those to patients, caregivers, social services and others outside the health-care sector. This tool also allows analysts to look at categories of impacts that may be most important to stakeholders.
Measuring health effects in terms of quality adjusted life years, a common measure used by health researchers that includes both the quality and quantity of life lived.
Including both costs reimbursed by third-party payers and those paid for out-of-pocket by patients in health-care sector analyses.
Including a reporting checklist and guidelines for transparency that includes assumptions in any analysis and the disclosure of potential conflicts of interest.
The complete report of the so-called Second Panel will be published in October.
The panelists noted that the field of CEA has emerged dramatically since the last guidelines 20 years ago. For example, the Advisory Committee for Immunization Practices, which establishes national immunization policy recommendations on behalf of the Centers for Disease Control and Prevention, now uses CEA in its calculations.
“The need to deliver health-care efficiently and the importance of using analytic techniques to understand clinical and economic consequences of strategies to improve health, have only increased,” the Second Panel authors wrote in the JAMA paper.
Health-care spending in the United States comprised 13 percent of GDP in 1995; today it approaches 18 percent. And the total national health expenditures have tripled during that period, jumping to more than $3 trillion in 2014, according to the Kaiser Family Foundation.
“The goal of the Second Panel is to promote the continued evolution of CEA and its use to support judicious, efficient, and fair decisions regarding the use of health-care resources,” the experts wrote in the JAMA article.
Imagine there’s a new pill on the market. It promises you a one in 200 chance of avoiding a heart attack, stroke, heart failure or death over the next year — if you take it religiously.
It also promises a one in 60 chance of landing you in the hospital for some serious complication: Maybe you passed out. Maybe the pill affected your kidney function. Maybe you developed a severe electrolyte imbalance.
Would you take it? How would you decide?
This question is confronting some patients with hypertension as well as their health-care providers who, like me, help manage their blood pressure. The “pill” is not a pill per se, but a treatment strategy.
In November of 2015, researchers published results of a large NIH-sponsored trial known as SPRINT, which compared two systolic blood pressure treatment targets for hypertensive adults: a higher, conventional target of 140 mm mercury compared to a more stringent target of 120. Participants in the trial were older, did not have diabetes, and were generally at high risk of developing cardiovascular disease. They were prescribed commonly used blood pressure medications, which were carefully adjusted by investigators to achieve target blood pressures.
The trial demonstrated a large relative benefit: Those in the lower target group had about a 25 percent reduction in the rate of cardiovascular disease or death. The absolute benefit, though, was small, with only about one in 200 patients avoiding cardiovascular disease or death as a result of treatment. The trial also showed that complications in the lower target group were relatively common.
As a physician, I’d love to be able to tell the patient in my exam room whether she will be the lucky one out of 200 who will benefit. That dream is still a few years off. I can, though, answer a related question. If I treat a large group of patients, on the whole, will my patients benefit? Or will the harms of treatment outweigh the benefits? And if the treatment is overall beneficial, what investment will we need to achieve this gain in health?
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To answer this question, I teamed up with a group of researchers at Stanford. Our team included experts in cost-effectiveness analysis as well as students developing clinical and analytic expertise in this area. We used data from SPRINT along with other published sources to project the expected benefits, harms and costs from targeting a lower or higher blood pressure over the course of a lifetime.
Results of our study were published this week in JAMA Cardiology. We found that targeting a lower blood pressure results in a substantial net benefit, even after accounting for harms from common, serious adverse events. This net benefit, though, doesn’t come free: An investment of about $23,777 is required for every year of life gained from this strategy.
Is $23,777 “worth it?” It’s a hard question to answer and it depends, in part, on who is paying. But in the spectrum of medical interventions that we routinely use here in the United States, this would be considered a good deal, a bargain even.
So should we go all in? Should we push stringent blood pressure targets for everyone?
No. There are a number of other considerations. SPRINT answered a specific question about hypertension treatment in a specific group of patients. Whether other groups of patients, like those at lower risk of cardiovascular disease, would benefit is unclear. There were also methodological quirks that have left the trial open to criticism.
But if we believe that the findings from SPRINT are generally correct, a lower blood pressure target seems to provide significant health gains for a reasonable cost in patients who are at high risk of developing cardiovascular disease.
Ilana B. Richman, MD, is a VA Health Services Research and Development Fellow at Stanford Health Policy.
Sex differences in mortality vary over time and place as a function of social, health, and medical circumstances. The magnitude of these variations, and their response to large socioeconomic changes, suggest that biological differences cannot fully account for sex differences in survival. Drawing on a wide swath of mortality data across countries and over time, we develop a set of empiric observations with which any theory about excess male mortality and its correlates will have to contend. We show that as societies develop, M/F survival first declines and then increases, a “sex difference in mortality transition” embedded within the demographic and epidemiologic transitions. After the onset of this transition, cross-sectional variation in excess male mortality exhibits a consistent pattern of greater female resilience to mortality under socio-economic adversity. The causal mechanisms underlying these associations merit further research.
This event has reached capacity. Please join us to watch the live-stream at this link.
The symposium will focus on the key questions that impact health through the year 2020. How could the 2016 election affect health care in the U.S.? How will payment reform affect health systems, physicians and patients? Are the insurance exchanges viable? What challenges pose the biggest threat to global health? Experts from Stanford and beyond address these topics and more as they discuss the future of health policy.
Lloyd Minor, Dean, Stanford University School of Medicine
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Minor, MD, is a scientist, surgeon and academic leader. He is the Carl and Elizabeth Naumann Dean of the Stanford University School of Medicine, a position he has held since December 2012. Minor leads more than 1,500 faculty and 1,000 students at the oldest medical school in the West and has made precision health — the prevention of disease before it strikes — a hallmark of research, education and patient care at Stanford Medicine.
Bob Kocher,a partner at the Silicon Valley venture capital firm, Venrock
Bob Kocher
Kocher, MD, is a partner at Venrock who focuses on healthcare IT and services investments and is a consulting professor at Stanford University School of Medicine. He served in the Obama Administration as special assistant to the president for health care and economic policy and was one of the key shapers of the Affordable Care Act.
David Entwistle, President and CEO, Stanford Health Care
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Entwistle joined Stanford Health Care as its President and CEO in July, bringing extensive executive experience at leading academic medical centers. Most recently he served as CEO of the University of Utah Hospitals & Clinics, the only academic medical center in the Intermountain West region. While serving at UUHC, Entwistle received the Modern Healthcare “Up and Comers Award,” for significant contributions in health-care administration, management or policy.
Chris Dawes, President and CEO, Lucile Packard Children’s Hospital
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Christopher G. Dawes became President and Chief Executive Officer of Lucile Packard Children’s Hospital Stanford in 1997 after five years of service as Chief Operating Officer. Under his guidance, the hospital, research center and regional medical network has been ranked as one of the best in the nation, as an industry leader in patient safety and innovation in providing a full complement of services for children and expectant mothers.
Panelists:
Marcella Alsan, Assistant Professor of Medicine, Stanford University
Marcella Alsan’s research focuses on the relationship between health and socioeconomic disparities with a focus on infectious disease. Another vein of research focuses on the microfoundations of antibiotic overuse and resistance. She received a BA degree in cognitive neuroscience from Harvard University, a master’s degree in international public health from Harvard School of Public Health, a medical degree from Loyola University, and a PhD in economics from Harvard University. She is board-certified in both internal medicine and infectious disease. She trained at Brigham and Women’s Hospital, completing the Hiatt Global Health Equity Residency Fellowship in internal medicine. She combined her PhD with an Infectious Disease Fellowship at Massachusetts General Hospital. She currently is an infectious disease specialist at the Department of Veterans Affairs, Palo Alto.
Laurence Baker, Chair of Health Research and Policy, Stanford University
Laurence Baker is an economist interested in the organization and economic performance of the U.S. health-care system, and his research has investigated a range of topics including financial incentives in health care, competition in health-care markets, health insurance and managed care and health-care technology adoption. Baker is a past recipient of the ASHE medal from ASHEcon and the Alice Hersch Award from AcademyHealth. He received his BA from Calvin College, and his MA and PhD in economics from Princeton University.
Eran Bendavid, Assistant Professor of Medicine, Stanford University
Eran Bendavid is an infectious diseases physician. His research interests involve understanding the relationship between policies and health outcomes in developing countries. He explores how decisions about foreign assistance for health are made, and how those decisions affect the health of those whom assistance aims to serve. Dr. Bendavid is also a disease modeler, and uses that skill to explore issues of resource allocation in low and middle-income countries with cost-effectiveness analyses. His recent research projects include an impact evaluation of the US assistance program for HIV in Africa, and an exploration of the association between drug prices, aid and health outcomes in countries heavily affected by HIV.
Jay Bhattacharya, Professor of Medicine, Stanford University
Jay Bhattacharya’s research focuses on the constraints that vulnerable populations face in making decisions that affect their health status, as well as the effects of government policies and programs designed to benefit vulnerable populations. He has published empirical economics and health services research on the elderly, adolescents, HIV/AIDS and managed care. Most recently, he has researched the regulation of the viatical-settlements market (a secondary life-insurance market that often targets HIV patients) and summer/winter differences in nutritional outcomes for low-income American families. He is also working on a project examining the labor-market conditions that help determine why some U.S. employers do not provide health insurance.
M. Kate Bundorf, Associate Professor of Medicine, Stanford University
M. Kate Bundorf is a Faculty Research Fellow at the National Bureau of Economic Research. She received her M.B.A. and M.P.H. degrees from The University of California at Berkeley and her Ph.D. from The Wharton School. She was a Fulbright Lecturer and Visiting Professor at Fudan School of Public Health in Shanghai, China in 2009 and 2010. Her research, which focuses on health insurance markets, has been published in leading economics and health policy journals and has received funding from the U.S. National Institutes of Health, the Agency for Health Care Research and Quality and the Robert Wood Johnson Foundation. She received the 13th Annual Health Care Research Award from The National Institute for Health Care Management in 2007.
David Chan, Assistant Professor of Medicine, Stanford University
David Chan is a physician and economist whose research focuses on productivity in US health care. His research draws on insights from labor and organizational economics. He is particularly interested in studying what drives physician behavior, how this explains differences in productivity in health care delivery, and what the implications are for the design of health care. He is the recipient of the 2014 NIH Director’s High-Risk, High-Reward Early Independence Award to study the optimal balance of information in health information technology for patient care. David Chan is also an investigator at the Department of Veterans Affairs and a Faculty Research Fellow at the National Bureau of Economic Research.
Kathryn M. McDonald, Executive Director of the Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University
Kathryn McDonald, MM, is the Executive Director of the Center for Health Policy (CHP) and Center for Primary Care and Outcomes Research (PCOR) and a senior scholar at the Centers. She is also Associate Director of the Stanford-UCSF Evidence-based Practice Center (under RAND). Her work focuses on measures and interventions to achieve evidence-based patient-centered healthcare quality and patient safety. Mrs. McDonald has served as a project director and principal investigator on a number of research projects at the Stanford School of Medicine, including the development and ongoing enhancement of the Quality and Patient Safety Indicators for the Agency for Healthcare Research and Quality. She has authored numerous peer reviewed articles and government reports, including several with wide enough followership to merit recent updates: Care Coordination Measures Atlas, Closing the Quality Gap, and Patient Safety Practices.
Michelle Mello, Professor of Law and of Health Research and Policy, Stanford University
Michelle Mello is Professor of Law at Stanford Law School and Professor of Health Research and Policy at Stanford University School of Medicine. She conducts empirical research into issues at the intersection of law, ethics, and health policy. She is the author of more than 150 articles and book chapters on the medical malpractice system, medical errors and patient safety, public health law, research ethics, the obesity epidemic, pharmaceuticals, and other topics. From 2000 to 2014, Dr. Mello was a professor at the Harvard School of Public Health, where she directed the School’s Program in Law and Public Health. In 2013-14 she completed a Lab Fellowship at Harvard University’s Edmond J. Safra Center for Ethics. Dr. Mello teaches courses in torts and public health law. She holds a J.D. from the Yale Law School, a Ph.D. in Health Policy and Administration from the University of North Carolina at Chapel Hill, an M.Phil. from Oxford University, where she was a Marshall Scholar, and a B.A. from Stanford University. In 2013, she was elected to the National Academy of Medicine (formerly known as the Institute of Medicine).
Grant Miller, Associate Professor of Medicine, Stanford University
Grant Miller is Director of the Stanford Center for International Development, an Associate Professor of Medicine at the Stanford University School of Medicine, a Core Faculty Member at the Center for Health Policy/Primary Care and Outcomes Research, a Senior Fellow at the Freeman Spogli Institute for International Studies (FSI) and the Stanford Institute for Economic Policy Research (SIEPR), and a Research Associate at the National Bureau of Economic Research (NBER). His primary interests are health economics, development economics, and economic demography. As a health and development economist based at the Stanford Medical School, Dr. Miller’s overarching focus is research and teaching aimed at developing more effective health improvement strategies for developing countries. His agenda addresses three major interrelated themes. (1) First, what are the major causes of population health improvement around the world and over time? (2) Second, what are the behavioral underpinnings of the major determinants of population health improvement? (3) Third, how can programs and policies use these behavioral insights to improve population health more effectively?
Douglas K. Owens, Director of the Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University
Douglas K. Owens, MD, MS, is the Henry J. Kaiser, Jr., Professor at Stanford University, where he is a professor of medicine. He is director of the Center for Health Policy in the Freeman Spogli Institute for International Studies and director of the Center for Primary Care and Outcomes Research (PCOR) in the Department of Medicine. He is a general internist and associate director of the Center for Innovation to Implementation at the Veterans Affairs Palo Alto Health Care System. A past member of the U.S. Preventive Services Task Force, he has helped lead the development of national U.S. guidelines on screening for HIV, hepatitis C, hepatitis B, lung cancer, colorectal cancer, breast cancer, and use of aspirin and statins to prevent cardiovascular disease.
Maria Polyakova, Assistant Professor of Health Research and Policy, Stanford University
Maria Polyakova, PhD, is an Assistant Professor of Health Research and Policy at the Stanford University School of Medicine. Her research investigates questions surrounding the role of government in the design and financing of health insurance systems. She is especially interested in the relationships between public policies and individuals’ decision-making in health care and health insurance, as well as in the risk protection and re-distributive aspects of health insurance systems. She received a BA degree in Economics and Mathematics from Yale University and a PhD in Economics from MIT.
David M. Studdert, Professor of Medicine and of Law, Stanford University
David M. Studdert is a leading expert in the fields of health law and empirical legal research. His scholarship explores how the legal system influences the health and well-being of populations. A prolific scholar, he has authored more than 150 articles and book chapters, and his work appears frequently in leading international medical, law and health policy publications. Professor Studdert has received the Alice S. Hersh New Investigator Award from AcademyHealth, the leading organization for health services and health policy research in the United States. He was awarded a Federation Fellowship (2006) and a Laureate Fellowship (2011) by the Australian Research Council. He holds a law degree from University of Melbourne and a doctoral degree in health policy and public health from the Harvard School of Public Health.
Polyakova, an assistant professor of health research and policy at the School of Medicine, joined Stanford in 2014. Her ongoing economic research looks at the impact of government policies in social insurance on consumer behavior, insurer behavior and market outcomes, including risk protection and redistribution.
Bob Kocher
