A team of SHP faculty and researchers, together with Stanford Medicine graduate and medical students and in collaboration with colleagues at CIDE in Mexico, have launched a modeling framework to investigate the epidemiology of COVID-19 and to support pro-active resource planning and policy evaluations for diverse populations and geographies — including California, Mexico and India.

The Stanford-CIDE Coronavirus Simulation Model — or SC-COSMO — incorporates realistic demography and patterns of contacts sufficient for transmission of the virus that has infected more than 2 million people worldwide and claimed more than 125,600 lives, according to the widely used Johns Hopkins COVID-19 map which is updated several times a day.

The SC-COSMO model also incorporates non-pharmaceutical interventions, such as social distancing, timing and effects on reductions in contacts which may differ by demography.

Jeremy Goldhaber-Fiebert, an associate professor of medicine at Stanford Health Policy, is the principal investigator of the project, along with Fernando Alarid-Escudero, an assistant professor at the Center for Research and Teaching in Economics (CIDE) in Mexico and Jason Andrews, an assistant professor of medicine (infectious diseases) at Stanford Medicine. Other SHP faculty among the 20 investigators and staff members who are working on the project are Joshua Salomon and David Studdert, both professors of medicine.

The SC-COSMO team is a multi-disciplinary, multi-institutional team including expertise and experience in infectious disease, epidemiology, mathematical modeling and simulation, statistics, decision science, health policy, health law and health economics.

“As COVID-19 transmission occurs throughout the world’s diverse populations, it is critical to efficiently model and forecast its future spread between and within these populations and to appropriately reflect uncertainty in modeled outcomes,” Goldhaber-Fiebert said. “Doing so supports timely resource planning and decision making between potentially appropriate and effective interventions that balance the trade-offs they embody.”

The team is currently working on three projects:

1. The researchers are providing California with county-level COVID-19 estimates for such things as the number of infections, detected cases and projections of future needs for hospital and ICU beds, personal protective equipment (PPE) and ventilators.
2. The project is working on potential strategies to mitigate the COVID-19 pandemic in Mexico by focusing on three specific objectives: collecting, synthesizing and openly sharing the most relevant and useful data; accelerating the development of the SC-COSMO model and its adaptation to the Mexican situation; and identifying a set of mitigation strategies, comparing the health and economic consequences in the population in the medium and long term.
3. They are developing forecast models of the COVID-19 epidemic in India with the Wadhwani Institute of Artificial Intelligence and its Indian government partners, providing a rapid response to urgent needs for planning and resource allocation.

Half of the medical students in the United States are women, as are two-thirds of the health-care workers taking care of patients in hospitals, clinics and residential communities.

And the majority of the nurses on the frontlines of the COVID-19 pandemic? Women.

Yet gender bias and workplace harassment continue to plague women who have dedicated their careers to taking care of others.

A classic example given by Michelle Mello in a Perspective published in this week’s New England Journal of Medicine goes like this: A female attending physician and a male resident respond to a call to the emergency department. The ED staff direct questions about medical decisions to the man, addressing the logistics to the woman.

“The resident looks awkwardly at the attending but says nothing,” Mello writes. “Gesturing at the attending, the patient says he hopes `the hot new nurse is going to be mine.’ Everyone ignores the comment.”

Sexual harassment and gender bias remain highly prevalent in medicine, ranging from the banal comments by the patient in the scenario above to aggressive misconduct that can damage female health professionals’ well-being, careers and quality of care.

Healthcare organizations have formal processes in place to respond to complaints of workplace discrimination, but these processes “are insufficient to transform cultures,” writes Mello, a professor of medicine with Stanford Health Policy and a professor of law with Stanford Law, and her co-author Reshma Jagsi, director of the Center for Bioethics and Social Sciences at the University of Michigan.

Health-care professionals of both genders must speak up.

“We believe health professionals have a moral duty to practice `upstanding’ — intervening as bystanders — in response to sexual harassment and general bias and that this obligation should be described in codes of medical professional ethics and supported within institutional training,” the authors write.

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While many medical professional societies now mention sexual harassment in their ethical codes, these guidelines fall short in that they do not encourage professionals to respond to the behaviors and intervene when they become aware of discrimination or harassment. The only large specialty society whose guidelines contain “aspirational advice” to stop sexual harassment in its tracks is the American Association of Orthopaedic Surgeons.

The American Medical Association (AMA) Code of Ethics Opinion 9.1.3 requires only that physicians “promote and adhere to strict sexual harassment policies in medical workplaces.” Mello and Jagsi note a striking contrast to the AMA’s approach to physicians who appear to be impaired (for example, due to substance use or mental health problems): Opinion 9.3.2. requires that physicians “intervene in a timely manner” to ensure that impaired colleagues stop practicing and get help.

“Absent stronger exhortation from within the profession, the norm will continue to be that clinicians are lauded when they stand up to harassment or bias but do not feel obligated — and they are not trained and equipped — to do so,” the authors write.

They recommend formal training in bystander intervention and peer-to-peer coaching, using tip sheets describing various courses of action, like this one adapted from Mary Rowe, an adjunct professor of negotiation and management at MIT Sloan.

(This is excerpted from a story from The Mercury News.)

Long motorcades of volunteers converged at three Stanford University research sites this week, donating blood for a new test that identifies the prevalence of coronavirus in our community – and could help reveal the full scope of Santa Clara County’s epidemic.

The 2,500 test slots on Friday and Saturday filled up within hours, as news of the project — the first large scale study of its type in the U.S. — spread quickly through the county, according to this Mercury News story.

The test detects protective antibodies to the virus rather than the virus itself. This gives scientists a snapshot of how many people in the county have already been infected, but weren’t seriously sick and didn’t realize it. And it tells residents whether they carry potentially protective antibodies – so may be immune to future infection.

“This is critical information,” said principal investigator Eran Bendavid, an infectious disease specialist and associate professor of medicine with Stanford Health Policy. “We will show the country what to do and how to do it,” he said.

The project, coordinated with the Santa Clara County Department of Health, was applauded by Gov. Gavin Newsom during a Saturday press conference in Sacramento, who called it “the first home-grown serum test in the state of California.”

Read The Mercury News Story

A team of Stanford experts has produced a series of videos aimed at benefiting children detained at the U.S. border. Intended for lawyers who work with detained migrants, the videos describe how to interview young people using techniques informed by scientific knowledge on trauma. 

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To ask such questions in a sensitive way, the videos recommend giving children and teens as much control as possible: For example, attorneys are encouraged to explain that they want to help; familiarize themselves beforehand with what they need to say so that they can speak warmly instead of reading from a list; praise interviewees for their effort rather than the content of their answers; and tell kids they can take breaks or end the interview at any time, or skip answering questions if they wish.

Many primary-care physicians continue to join multispecialty group practices, such as the Palo Alto Medical Foundation and Stanford Health Care, instead of working in their own solo practices or in practices with only other primary care doctors.

Physicians in practices of nine or fewer dropped from 40% in 2013 to 35% in 2015; the rate of those in practices of 100 or more increased from 30% to 35% during the same period.

But is this growing trend having a positive impact on health-care use and spending?

Stanford Health Policy’s Loren Baker and Kate Bundorf set out to find a few answers.

In their new working paper published by the National Bureau of Economic Research, they focused on Medicare beneficiaries who changed their primary care physician when they moved from one area to another. They focused on people who switched from a doctor in a primary-care-only practice to one in a multispecialty practice, and those who made the opposite switch.

They then compared changes in health-care use and spending before and after the move — and among patients who switch practice types and those who do not.

“We wanted to look at people who experienced an abrupt change in their primary care physician for reasons other than an explicit choice to change their physician,” Bundorf said.

“A weakness of this approach is that they may differ from people who don’t move,” said Bundorf, an associate professor of health research and policy at Stanford Medicine and a senior fellow at the Stanford Institute for Economic Policy Research (SIEPR). “But our descriptive statistics suggest that we capture a broad cross-section of types of people.”

They identified 119,272 patients who moved from one area to another and used data from Medicare claims from 1999 to 2010.

The results were striking

The results of the analysis show that multispecialty practice decreased annual medical spending by $1,600 per Medicare beneficiary — a 35% reduction in spending.

“The size of the result is very intriguing,” said Baker, a professor of health research and policy at Stanford Medicine and also a SIEPR senior fellow. “We are often happy when a change in health-care delivery can help achieve savings of even a few percentage points, but our results suggest the potential here is much larger than that.”

With their co-author Anne B. Royalty of Indiana University-Purdue University Indianapolis, they found the results were driven primarily by changes in hospital expenditures and are concentrated among patients with two or more chronic condition. This suggests multispecialty practices improve care delivery by reducing hospitalizations among relatively sick patients.

“The results imply that, while research has shown the potential for physician consolidation to increase prices in some settings, large multispecialty groups also have the potential to lower costs,” the authors wrote.

Baker said when they set out to do this research, they were not sure what they would find. 

“The results suggest that the way care is organized can be important for health-care delivery and that there may be organizational changes that could help us better manage spending.”

Larger practices don’t always lead to better health outcomes

While the pervasive view underlying the move toward consolidated practices is that larger, more integrated organizations provide care more efficiently through greater coordination of care, the literature on physician integration largely does not support this view. 

The authors point to a study that looked at data from the 1970s to 2013, which found little evidence that these larger practices improve the quality and lower the cost of health care. 

“The hope of many policymakers was that the larger, multispecialty organizations could organize care more efficiently,” Bundorf said. “Yet there is little evidence to date that larger practices have generated these types of benefits for patients. Since the literature has not taken a hard look at the single or multispecialty side of things, we wanted to investigate that here.”

While the trend is toward these big multispecialty practices, many physicians choose to remain in smaller or solo ones.

The Kaiser Family Foundation estimates that there are some 139,000 primary care physicians in the United States. Despite the transition to multispecialty practices, some 40% of physicians continue to work in solo practice or a small group of two-to-nine physicians.

It’s important, they said, to continue examining the health-care spending of all practice sizes.

“We are very curious to continue work on ways to learn more about how organizations achieve savings,” Baker said. “We are also excited to continue thinking about opportunities for policies that would encourage the formation of effective practices, for example through payment policy reforms.

People today can generally expect to live longer and, in some parts of the world, healthier lives. The substantial increases in life expectancy underlying these global demographic shifts represent a human triumph over disease, hunger, and deprivation, but also pose difficult challenges across multiple sectors. Population aging will have dramatic effects on labor supply, patterns of work and retirement, family and social structures, healthcare services, savings, and, of course, pension systems and other social support programs used by older adults. Individuals, communities, and nations around the world must adapt quickly to the demographic reality facing us and design new approaches to financing the many needs that come with longer lives.

This imperative is the focus of a newly published special issue of The Journal of the Economics of Ageing, entitled Financing Longevity: The Economics of Pensions, Health and Long-term Care. The special issue collects articles originally written for and discussed at a conference that was dedicated to the same topic and held at Stanford in April 2017 to mark the tenth anniversary of APARC’s Asia Health Policy Program (AHPP). The conference convened top experts in health economics and policy to examine empirical and theoretical research on a range of problems pertinent to the economics of aging from the perspective of sustainable financing for long lives. The economics of the demographic transition is one of the research areas that Karen Eggleston, APARC’s deputy director and AHPP director, studies. She co-edited the special issue with Anita Mukherjee, a Stanford graduate now assistant professor in the Department of Risk and Insurance at the Wisconsin School of Business, University of Wisconsin-Madison.

The Financing Longevity conference was organized by The Next World Program, a Consortium composed of partners from Harvard University, Fudan University, Stanford University, and the World Demographic and Aging Forum, and was cosponsored by AHPP, the Stanford Institute for Economic Policy Research, and the Stanford Center on the Demography and Economics of Aging.

The contributions that originated from the conference and are collected in the Journal’s special issue cover comparative research on more than 30 European countries and 17 Latin American countries, as well as studies on Australia, the United States, India, China, and Japan. They analyze a variety of questions pertinent to financing longevity, including how pension structures may exacerbate existing social inequalities; how formal and informal insurance interact in securing long-term care needs; the ways in which the elderly cope with caregiving and cognitive decline; and what new approaches might help extend old-age financial security to those working outside the formal sector, which is a major concern in low-income countries.

Another challenge of utmost importance is the global pension crisis, caused due to committed payments that far exceed the saved resources. It is a problem that Eggleston and Mukherjee highlight in their introduction to the special issue. By 2050, they note, the pension gap facing the world’s eight largest pension systems is expected to reach nearly US $400 trillion. The problem cannot be ignored, as “the financial security of people leading longer lives is in serious jeopardy.” Indeed four of the eight research papers in the special issue shed light on pensions and inequality in income support for older adults. The other four research papers focus on health and its interaction with labor force participation, savings, and long-term care.

The issue also features two special contributions. The first is an interview with Olivia S. Mitchell, a professor at the University of Pennsylvania’s Wharton School and worldwide expert on pensions and ageing. Mitchell explains the areas offering the most promise and excitement in her field; discusses ways to encourage delayed retirement and spur more saving; and suggests several priority areas for future research. The latter include applying behavioral insights to questions about retirement planning, improving financial literacy, and advancing innovations to help people imagine themselves at older ages and save more for their future selves.

The second unique contribution is a perspective on the challenges of financing longevity in Japan, based on the keynote address delivered at the 2017 Stanford conference by Mr. Hirotaka Unami, then senior Director for policy planning and research of the Minister’s secretariat of the Japan Ministry of Finance and currently deputy director general with the Ministry’s Budget Bureau.

In Japan, decades of improving life expectancy and falling birth rates have produced a rapidly aging and now shrinking population. Data released by Japan’s Statistics Bureau ahead of Children's Day on May 5, 2019 reveal that Japan’s child population (those younger than 15) ranks lowest among countries with a total population exceeding 40 million. In his piece, Unami focuses on the difficult tradeoffs Japan faces in responding to the increase in oldest-old population (people aged 75 and over) and the overall population decline. Japan aspires to do so through policies that are designed to restore financial sustainability for the country’s social security system, including the medical care and long-term care insurance systems.

Unami argues that Japan must simultaneously pursue a combination of increased tax revenues, reduced benefit growth, and accelerated economic growth. He notes that these three-pronged efforts require action in five areas: review Japan’s pension policies; reduce the scope of insurance coverage in low-risk areas; increase the effectiveness of health service providers; increase a beneficiary’s burden according to their means; and enhance policies for preventive health care for the elderly.

The aging of our world’s population is a defining issue of our time and there is pressing need for research to inform policies intended to improve the financial well-being of present and future generations. The articles collected in the Financing Longevity special issue and the ongoing work by APARC’s Asia Health Policy Program point to multiple areas ripe for such future research.

View the complete special issue >>

Learn more about Dr. Karen Eggleston’s work in the area of innovation for healthy aging >>

To prescribe or not prescribe? In the realm of the nation’s opioid epidemic, it’s an important question.

Research has shown that inappropriate use of prescription opioids is part of the reason behind a dramatic rise in opioid-related deaths since 2000. By 2015, the amount of opioids prescribed in the U.S. had tripled — enough for every American to be medicated around the clock for three weeks, at 5 milligrams of hydrocodone every four hours. 

Now, new research by a trio of Stanford scholars shows how different insurance strategies affect the volume of opioid use and could help stem inappropriate prescribing behaviors. 

The study, released in a working paper by the National Bureau of Economic Research, was co-authored by Stanford Health Policy’s Laurence C. Baker, M. Kate Bundorf, and Daniel P. Kessler. Baker and Bundorf are professors in the Department of Health Research and Policy at the Medical School; Kessler is a professor in the Law School and Graduate School of Business, and a senior fellow at the Hoover Institution.  All are also senior fellows at the Stanford Institute for Economic Policy Research (SIEPR).

Their study — the first to investigate the effect of the form of Medicare drug coverage on opioid use — found that enrollment in Medicare Advantage, a combined medical and drug insurance plan, significantly reduces the likelihood of beneficiaries filling an opioid prescription, as compared to enrollment in a stand-alone drug plan.

Compared to beneficiaries enrolled in stand-alone plans, those enrolled in the integrated Medicare Advantage plan were 37 percent less likely to get an opioid prescription, according to their analysis of drug claims from 2014.

The researchers also found that enrollment in integrated insurance coverage under Medicare Advantage had a disproportionate effect on the likelihood of filling an opioid prescription from the nation’s highest opioid-prescribing doctors — the top 1 percent of prescribers in Medicare Part D. The lower likelihood of prescriptions from these high prescribers to Medicare Advantage enrollees accounted for more than half of the reduction, according to their findings.

To understand the scope of this health plan-related effect and what’s at stake, consider the backdrop laid out in the study:

Since its implementation in 2006, Medicare Part D has become the nation’s largest purchaser of prescription opioids. More than 42 million Americans are enrolled in Medicare Part D — either under the stand-alone drug plan or the integrated Medicare Advantage plan.

What’s more, opioid prescriptions are concentrated among a relatively small group of “high prescribers.” 

According to research published in the 2016 edition of JAMA Internal Medicine, more than one-third of opioid prescriptions under Medicare Part D were made by about 8,000 doctors, making up the top 1 percent of prescribers. And according to the Office of the Inspector General of the Department of Health and Human Services, “extreme use” and “questionable prescribing” have put almost 90,000 beneficiaries at serious risk for opioid misuse or overdose.

Because the researchers did not examine patient health outcomes, they could not definitively determine that enrollment in Medicare Advantage reduced only inappropriate opioid use. However, because the reduction in opioid use came disproportionately from high prescribers, and previous work has found that Medicare Advantage enrollees had higher prescription drug use overall, the reduction in use that the researchers found was targeted rather than a result of a broader effort to restrict access to treatment.  

The researchers’ results support the conclusions of previous work that integration of prescription drug coverage with the other benefits provided by Medicare Advantage plans

improves the quality of care. Further study will be needed to drill deeper into the reasons behind the impact of Medicare Advantage plans, and whether a similar effect occurs in non-elderly populations, the researchers said.

The national opioid epidemic has grown at such breakneck speed that public health experts have been left scrambling to keep up. Though they understand the reasons behind the abuse — the solutions are complicated and costly.

Yet there appears to be some success at reducing at least one area of opioid abuse.

In new research by Health Research and Policy’s Eric Sun, the risk for chronic opioid use among patients with musculoskeletal pain actually decreased slightly between 2008 and 2014. 

The Stanford Medicine assistant professor of anesthesiology and pain medicine found that measures such as avoiding opioid use soon after diagnosis can further reduce the risk of addiction, especially among patients at highest risk for chronic opioid use.

"We found that early opioid use after diagnosis is predictive of opioid use longer term, suggesting that it may be prudent to minimize opioid use where possible for patients with musculoskeletal pain,” said Sun, whose research was published earlier this week in the Annals of Internal Medicine.

His co-authors are Jasmin Moshfegh, who is working on her PhD in health policy, and Steven Z. George, director of musculoskeletal research at Duke University School of Medicine.

Patients with lower back or chronic neck, shoulder and knee pain are at the highest risk for opioid abuse since pain meds are typically prescribed to help ease their spasms. 

Patients who suffer musculoskeletal pain may unwittingly transition to chronic opioid use, which means filling 10 or more prescriptions or having a supply for at least 120 days. The prescription drugs include hydrocodone, hydromorphone, methadone, morphine, oxymorphone, and/or oxycodone. Those don’t include heroin and synthetic opioids such as fentanyl.

Sun and his fellow researchers at the Stanford University School of Medicine used a large health-care database to assess the risk and risk factors for chronic opioid use among more than 400,000 “opioid-naïve” patients — those who have never been prescribed painkillers before — recently diagnosed with pain in the knee, neck, lower back or shoulder. 

The sample was restricted to privately insured patients, thereby excluding other policy-relevant populations, such as those who were prescribed pain medications under Medicare or Medicaid.

They found that risk for chronic opioid use ranged from 0.3 percent for knee pain to 1.5 percent for multiple-site pan and decreased for some anatomical regions during the timeframe studied. They discovered a relative decline of 25 to 50 percent across all pain types from 2008 to 2014.

Opioid Abuse

Opioid abuse has its roots in the late 1990s when pharmaceutical companies assured the medical community that patients would not become addicted to pain relievers. Clinicians began prescribing them at greater rates because they worked so well and seemed safe.

Today, more than 130 people die every day from opioid-related drug overdoses from prescription pain relievers, heroin and synthetic opioids such as fentanyl, according to the U.S. Department of Health and Human Services, From 2002 to 2017, there was more than a fourfold increase in opioid deaths, with some 49,000 people dying in 2017.

The Centers for Disease Control and Prevention estimates that the total economic burden of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of health care, lost productivity, addiction treatment and criminal justice involvement.

“While our research found that only about 1 percent of patients with musculoskeletal pain progress to chronic opioid use, this is potentially concerning because it’s an extremely common diagnosis,” Sun said. “By pointing out the scope of the issue and identifying factors that place patients at risk, we hope this research will guide further efforts aimed at reducing opioid use among patients with musculoskeletal pain.”