African-American doctors could help reduce cardiovascular mortality among black men by 19 percent — if there was more racial diversity among physicians, according to a new study led by Stanford Health Policy’s Marcella Alsan.

After conducting a randomized clinical trial among 1,300 black men in Oakland, the researchers found that the men sought more preventive services after they were randomly seen by black doctors for a free health-care screening compared to non-black doctors.

“We found that, once African-American men were at the clinic, even though all services were free, those assigned to a black doctor took up more services,” such as flu shots and diabetes and cholesterol screenings, said Alsan, an economist and infectious disease physician who focuses on  health and socioeconomic disparities here at home and around the world.

“It was surprising to see the results,” said Alsan, an associate professor of medicine at Stanford Medicine, a faculty fellow at the Stanford Institute for Economic Policy Research, and an investigator at the VA Palo Alto Health Care System. “Prior to doing the study, we really were not sure if there would be any effect, much less the magnitude. The signal in our data ended up being quite strong.”

Those signals include the men were 29 percent more likely to talk with black doctors about other health problems and seeking more invasive screenings that likely required more trust in the person providing the service. They found subjects assigned to black doctors increased their uptake of diabetes and cholesterol screenings by 47 percent and 72 percent, respectively.

The researchers calculated that black doctors could reduce cardiovascular mortality by 16 deaths per 100,000 per year, accounting for 19 percent of the black-white gap in cardiovascular-related deaths. They believe that the results would be even larger if extrapolated to other leading causes of death that are amenable to prevention, such as cancer and HIV/AIDS. 

“I was definitely surprised,” said Owen Garrick, president and COO of Bridge Clinical Research, an Oakland-based organization that helps clinical researchers find patients from targeted ethnic groups. “If you ask most people, they feel that there is some impact of black men seeing black doctors — but it has never been quantified using an experimental design.”

Alsan and Garrick, along with U.C. Berkeley graduate student Grant Graziani, published their findings in this working paper for the National Bureau of Economic Research.

Garrick, himself an African-American physician, said black doctors tend to present themselves in a manner that puts a black patient at ease, making him more willing to open up and agree to certain care. “The black doctor might explain the medical services in a way that the black patient more clearly understands.”

Garrick called the findings “astounding,” but he warned that increasing the number of black doctors and getting black men to routinely see them are no small tasks.

There is a yawning gap between white physicians and those of color. While African-Americans comprise about 13 percent of the population, only 4 percent of physicians and less than 6 percent of medical school graduates are black, according to the study.

This is compounded by African-American men having the lowest life-expectancy in the country, due to lack of health insurance, lower socioeconomic status and structural racism. 

And there remains a distrust of the U.S. healthcare system at least partially attributed to the infamous Tuskegee study that began in 1932, when the U.S. Public Health Service began following about 600 African-American men in Tuskegee, Alabama. Some two-thirds of the men had syphilis, and USPHS declined to inform those afflicted by the disease. Even after penicillin became the standard of care for syphilis treatment in the mid-1940s, the USPHS continued to withhold treatment. The study was finally halted when a whistleblower went to the press in 1972.

Alsan— with her colleague Marianne Wanamaker at the University of Tennessee — published a study in The Quarterly Journal of Economics in February that found the 1972 Tuskegee study revelation was correlated with a reduction in health-seeking behavior and increases in medical mistrust and mortality among African-American men.

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The men who participated in the recent study were recruited from barbershops and flea markets in Oakland, a city known for its diversity, yet plagued by a 20 percent rate of poverty.

Field officers —including minority and low-income pre-med students from around the Bay Area — approached men to enroll in the study. After obtaining written consent, the men were given a short survey about socio-demographics, health care and mistrust. For completing the survey, the men received a voucher with up to $25 for their haircut or, in the flea market, a cash incentive.

The men were also given a coupon to receive a free health-care screening for blood pressure, BMI, cholesterol and diabetes at the clinic where the Stanford team operated on Saturdays in the fall and winter of 2017-2018. The patients who did not have transport to the clinic were given free rides courtesy of Uber. Attendance at the clinic was encouraged with another $50 incentive.

Subjects and the 14 participating doctors were told that they were taking part in a Stanford study designed to improve preventive health-care for African-American men.

On top of the significant increases in patients who agreed to diabetes or cholesterol screenings if suggested by a black doctor, the researchers found that the men were 56 percent more likely to get a flu vaccine if randomized to one of the African-American doctors.

The results suggested the more invasive the test, the greater the advantage of being assigned a black doctor. And the findings were even stronger among subjects who had a high mistrust of the medical system as well as those who had limited prior experience with routine medical care.

“In curative care, the patient feels ill and then may seek out medical care to fix the problem,” Alsan said. “But in preventive care, the patient may feel just fine — but must trust the doctor when he is told that certain measures must be taken to safeguard health.” 

The policy implications would suggest that medical schools need to open the pipeline to students from diverse backgrounds who are training for health-care professionals. 

Garrick recommends exposing more young people of color to the field of medicine and helping them to become more competitive applicants through tutoring and interview prep.

“And you need advocates,” he said. “Since much of the medical school selection process is subjective, you need to get people on the selection committees who will relate and see the potential of black applicants as much as people relate to other applicants.”

Some links to other media outlets that have written about this research: 

The New York Times

Harvard Business Review

The Daily Mail

ColorLines

At age 94, with an extensive collection of health policy research and publications under his belt, Victor Fuchs has a lot to say about the health care system.

The high cost. The uninsured. The fragmentation.

During a speech at the Stanford Institute for Economic Policy Research (SIEPR), the pioneering health economist narrowed his gaze to whether a single-payer system is the fix to those problems.

The answer is complicated, and it depends on the questions behind the question, said Fuchs, a SIEPR Senior Fellow and the Henry J. Kaiser, Jr., Professor of Economics and Health Research and Policy, emeritus. He is also a senior fellow at the Freeman Spogli Institute for International Studies and a core faculty member at Stanford Health Policy.

Recent challenges to the Affordable Care Act have rekindled a debate over the merits of a single-payer health care system — where one entity, namely the federal government, would foot the bill for essential services for all — and Fuchs spoke at SIEPR to succinctly explain what a single-payer system could achieve, what would probably never happen, and why.

The problem, Fuchs pointed out, is that the United States spends the most of any high-income country on health care, yet Americans are not achieving better health outcomes. Part of the solution would have to address the nation’s higher administrative costs, higher prices for prescription drugs, and the expensive increasing mix of services and specialists.

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Fuchs contended a single-payer system would lower costs. For one, it would create the bargaining power needed to offset the monopolistic powers of those providing the drugs, medical services and equipment.

To control costs, “we must move to something like a single-payer plan, but that alone will not be sufficient,” Fuchs said. “It will depend on what kind of single-payer plan it is.”

Even as it provides for universal health care insurance coverage, a single-payer system could take on various forms, including a blend of private and public controls.

And to have any chance at success, Fuchs said, the single-payer system would have to be simple, require minimum bureaucracy, and provide choice.

Then comes the rub, of course: The political will has historically tread against single-payer.

Americans are not willing to provide subsidies for those too poor to afford health insurance; neither do they have a compulsion for everyone to acquire coverage and contribute to those subsidies.

“The country as a whole has not been willing to fully embrace these two principles,” he said. “And I feel you need to have a strong majority of both if you’re going to have universal coverage.”

And unfortunately, Fuchs added, he does not believe universal health coverage would necessarily improve health outcomes. Many other socio-economic and environmental factors also play a role there.

In leading a brief discussion with Fuchs, Mark Cullen, a SIEPR Senior Fellow and professor of medicine, asked what makes him think the federal government would work to control costs under a single-payer system — when it has thus far chosen to exert little buying power under the current structure.

“I have not discussed the political feasibility of this, deliberately,” Fuchs quipped.

You can learn more about Fuchs’ viewpoint in The Journal of the American Medical Association.

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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.

The value, he said, is worth the risk.

Could out of pocket drug costs be responsible for pandemics? In this Public Health Perspectives article, Marcella Alsan discusses how copayments for antibiotics can cause people in poor areas to turn to unregulated markets.

On May 26, 2016, researchers at the Walter Reed National Military Medical Center reported the first case of what they called a “truly pan-drug resistant bacteria.” By now, the story has been well-covered in the media: a month earlier, a 49 year old woman walked into a clinic in Pennsylvania with what seemed to be a urinary tract infection. But tests revealed something far scarier—both for her and public health officials. The strain of E. Coli that infiltrated her body has a gene that makes it bulletproof to colistin, the so-called last resort antibiotic.

Most have pinned the blame for the impending doom of a “post-antibiotic world” on the overuse of antibiotics and a lack of new ones in the development pipeline. But there’s another superbug incubator that hasn’t gotten the attention it deserves: poverty.

Last month at the IMF meeting in Washington, D.C., UK Chancellor George Osborne warned about the potentially devastating human and economic cost of antimicrobial resistance. He called for “the world’s governments and industry leaders to work together in radical new ways.” But Gerry Bloom, a physician and economist at the Institute for Development Studies, argued that any measures to stop overuse and concoct new drugs must be “complemented by investments in measures to ensure universal access to effective antibiotic treatment of common infections.”

“In many countries, poor people obtain these drugs in unregulated markets,” Bloom said. “They often take a partial course and the products may be sub-standard. This increases the risk of resistance.”

For at least fifteen years, we’ve known about these socioeconomic origins of antimicrobial resistance. Other studies have revealed problems with mislabeled or expired or counterfeit drugs. But the clearest link between poverty and the rise of antimicrobial resistance is that poor people may not see a qualified health care provider or complete a course of quality antibiotics. Instead, they might turn to unregulated markets for substandard drugs.

But why do people resort to unregulated markets or take drugs that aren’t that great if they are available? Marcella Alsan, an assistant professor of medicine at the Stanford School of Medicine who studies the relationship between socioeconomic disparities and infectious diseases, led a study that answered this question. In last October’s Lancet Infectious Diseases, Alsan and her colleagues showed that it might have a lot to do with requiring copayments in the public sector. To show this, they analyzed the WHO’s 2014 Antibacterial Resistance Global Surveillance report with an eye toward the usual suspects, such as antibiotic consumption and antibiotic-flooded livestock.

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A substantial share of all malpractice claims in the United States is attributable to a small number of physicians, according to a study led by researchers at Stanford University and the University of Melbourne.

The team found that just 1 percent of practicing physicians accounted for 32 percent of paid malpractice claims over a decade. The study also found that claim-prone physicians had a number of distinctive characteristics, such as practicing specialities that are riskier than others.

“The fact that these frequent flyers looked quite different from their colleagues — in terms of specialty, gender, age and several other characteristics — was the most exciting finding,” said David Studdert, professor of medicine and of law at Stanford. “It suggests that it may be possible to identify high-risk physicians before they accumulate troubling track records, and then do something to stop that happening.”

Studdert is also a core faculty member at Stanford Health Policy and the lead author of the study published in The New England Journal of Medicine.

Concentrated among a small group

“The degree to which the claims were concentrated among a small group of physicians was really striking,” added Studdert, an expert in the fields of health law and empirical legal research.

The researchers analyzed information from the U.S. National Practitioner Data Bank, a data repository established by Congress in 1986 to improve health-care quality. Their study covered 66,426 malpractice claims paid against 54,099 physicians between January 2005 and December 2014.

Almost one-third of the claims related to patient deaths; another 54 percent related to serious physical injury. Only 3 percent of the claims were litigated to verdicts for the plaintiff. The remainder resulted in out-of-court settlements. Settlements and court-ordered payments averaged $371,054.

“The concentration of malpractice claims among physicians we observed is larger than has been found in the few previous studies that have looked at this distributional question,” said Michelle Mello, a co-author of the study and professor of law and of health research and policy at Stanford.

“It’s difficult to say why that is,” Mello added. “The earlier estimates come from studies of single insurers or single states, whereas ours is national in scope. Also, the earlier numbers are more than 25 years old now, and claim-prone physicians may be a bigger problem today than they were then.”

Encouraging greater awareness

The authors recommend that all institutions that handle large numbers of patient complaints and claims develop a greater awareness of how these events are distributed among clinicians.

“In our experience, few do,” they write in the paper. “With notable exceptions, fewer still systematically identify and intervene with practitioners who are at high risk for future claims.”

The most important predictor of incurring repeated claims was a physician’s claim history. Compared to physicians with only one prior paid claim, physicians who had two paid claims had almost twice the risk of another one; physicians with three paid claims had three times the risk of recurrence; and physicians with six or more paid claims had more than 12 times the risk of recurrence.

“Risk also varied widely according to specialty,” the authors noted. “As compared with the risk of recurrence among internal medicine physicians, the risk of recurrence was approximately double among neurosurgeons, orthopedic surgeons, general surgeons, plastic surgeons and obstetrician-gynecologists.”

The lowest risks of recurrence occurred among psychiatrists and pediatricians.

Male physicians had a 40 percent higher risk of recurrence than female physicians, and the risk of recurrence among physicians younger than 35 was about one-third the risk among their older colleagues, the study found.

“If it turns out to be feasible to predict accurately which physicians are going to become frequent flyers, that is something liability insurers and hospitals would be very interested in doing,” Studdert said.

“But institutions will then face a choice,” he added. “One option is to kick out the high-risk clinicians, essentially making them someone else’s problem. Our hope is that the knowledge would be used in a more constructive way, to target measures like peer counseling, retraining, and enhanced supervision. These are interventions that have real potential both to protect patients and reduce litigation risks.”

Other stories about the study:

The New York Times Well Blog

The Huffington Post

KQED Public Radio

U.S. News & World Report

CBS News

Reuters

Medscape