Yiqun Chen and Tess Ryckman are the first students in the Stanford Health Policy PhD program to win research grants. Their projects could improve health outcomes in the United States and in the developing world.

“Awards like these are a recognition of the quality of our very young PhD program,” said Corinna Haberland, director of education for the PhD program that launched in 2015.

Yiqun Chen, Predoctoral Student

A member of the first class of doctoral candidates and currently in her second year, Chen received a seed grant from the Center on the Demography and Economics of Health and Aging (CDEHA). Funded by the National Institute on Aging (NIA), CDEHA studies how best to modify health care systems to adapt to aging populations.

Chen will study the Hospital Readmission Reduction Program. A component of the Affordable Care Act (ACA), the program encourages hospitals to keep readmission rates low, but the financial incentives do not extend to doctors. Chen will evaluate the program’s effectiveness for Medicare patients.

“Yiqun is well positioned to offer new insights into the ways that the organization of physicians and hospitals will influence quality improvement programs,” said Laurence Baker, chair of the Department of Health Research and Policy and the grant’s primary investigator.

Tess Ryckman, Predoctoral Student

She plans to study nutrition in developing countries, focusing on the cost-effectiveness of programs that address stunting as compared to wasting. Two important public health indicators, stunting measures short height for age and wasting measures low weight for height.

“Wasting is more likely to result in death, but in a lot of countries the prevalence of wasting isn’t actually that high,” said Ryckman. “I suspect that in some cases they’re sacrificing funding that could go for stunting because wasting is more visible.”

The fellowship will allow Ryckman to focus on the research that inspires her. Instead of working as a TA or research assistant, she can pursue her own project while still drawing on faculty expertise.

“All of the faculty are really supportive,” she said. “They’re a helpful sounding board and give good advice.”

Pandemics are a growing health concern in the United States and abroad. But as global health specialists are ramping up efforts to prevent them, funding may be slipping away.

President Trump's proposed budget would eliminate the National Institutes of Health's Fogarty International Center, a key player in the fight against diseases worldwide.

According to a USA Today column by Michele Barry, Director of the Center for Innovation in Global Health and a Stanford Health Policy affiliate, and David Yach, a former cabinet director at the World Health Organization, Fogarty's global health research benefits the United States along with other countries. The center has produced insights into Alzheimer's research, is looking into the genetics of obesity and diabetes, and has started developing early warning systems for pandemics.

But its most important accomplishment, according to Barry and Yach, is training scientists in more than 100 low- and middle-income countries. These experts have emerged as leaders in their own countries and around the world.

Their contributions have not only improved health but have influenced the World Health Organization and leading global health donors.

Said Barry and Yach, "To eliminate the Fogarty Center now would undermine progress, erode trust in America’s leadership in global health, and increase the risk of a devastating and preventable epidemic in the U.S. Keeping Fogarty would preserve health, both of Americans and populations all over the world."

Read the full article.

When Americans think of gun violence, we typically think of homicide and the never-ending debate over Second Amendment rights. But we rarely consider gun violence —and the growing rate of suicide by firearms — as a public health epidemic.

There were 36,252 gun deaths in the United States in 2015, according to the Centers for Disease Control and Prevention. America’s firearms homicide rate is 25 times greater than the average of other high-income countries.

In fact, guns have killed more Americans since 1968 than in all the combined deaths on the battlefields of all American wars. These numbers are astounding.

Yet audience members at the recent symposium on “Race, Policing and Public Health,” sponsored by the Stanford schools of law and medicine, learned that the Centers for Disease Control and Prevention haven’t funded research into gun violence since 1997, when Congress passed a bill barring the agency from funding any research that would “advocate or promote gun control.”

It’s just too much of a political hot potato.

The audience of the daylong symposium on March 6 also learned that twice as many Americans commit suicide using a gun than there are homicides in this nation. While black men are 14 times more likely than white men to be shot and killed with guns, older, middle-aged white men have the highest rate of firearm suicide.

“Who knew that firearm violence was increasingly an old white guy problem?” said Garen Wintemute, an emergency physician, and director of the Violence Prevention Research Program at UC Davis School of Medicine.

Wintemute, one of the country’s leading experts on the public health crisis of gun violence, said the aggregate annual cost of firearm deaths is about $229 billion per year after considering the full range of costs: prison terms, lost wages and the law enforcement costs to the American taxpayer.

“So far we have taken a traditional risk-based focus on the problem,” he said. “But there is a complementary approach, the population health approach, which suggests perhaps we should look at the burden of illness.”

Wintemute added the problem is so widespread that “elements of our society who do not think they have a stake in the problem — are so wrong.”

David Studdert, a faculty member at Stanford Health Policy and a professor of law and professor of medicine, moderated the panel. In a special communication in JAMA Internal Medicine, Studdert and colleagues analyzed the federal laws that protect firearm dealers and makers from tort litigation.

“Garen made the crucial point that gun violence is not one epidemic, but several sub-epidemics, each with very different properties and racial profiles,” Studdert said. “While firearm homicide rates are highest among young black men, rates of firearm suicide are highest among middle-aged and elderly white men. These different sub-epidemics clearly call for different policy responses.”

Also speaking at the conference attended by health and law faculty and students from Stanford, UC San Francisco and UC Berkeley, were Marcella Alsan, a physician and economist at Stanford Health Policy; Charles H. Ramsey, the former police commissioner of the Philadelphia Police Department who is now a visiting fellow at Drexel University; Suzy Loftus, assistant legal counsel at the San Francisco Sherriff’s Department; and Jeff Rosen, the district attorney for the County of Santa Clara.

“It was terrific opportunity to get the perspectives of both public health researchers and law enforcement leaders on the problem of gun violence,” Studdert said. “These perspectives don’t intersect as often as they should.”

Ramsey, who also worked in the Chicago Police Department before heading up the departments in Washington, D.C. and then Philadelphia, was asked whether the fatal shooting of black men by white police officers is new and on the rise.

“No, it’s not new,” said Ramsey. “I think what’s new is social media and cable news; those things are new. Now you have video that’s played over and over and over again on cable news, so it does give the impression that things are more severe now than they have been in the past.”

According to the Washington Post’s Fatal Force tracker of deadly shootings by police, 963 people were shot and killed last year, down from 992 in 2015. While 40 percent of those killed were black, African-American men make up a mere 6 percent of the nation’s population.

A student asked Ramsey whether there was implicit bias against African-American men by white police officers who target black communities.

“There’s not a person in this room who doesn’t have implicit bias, we all have it,” he said.

There were 277 murders in Philadelphia last year, down from 391 a decade earlier.

“But 85 percent of the homicides victims in Philly were African-American, due to poverty, poor housing, high unemployment and drug use,” Ramsey said. “They’re in these concentrated pockets. So I’m trying to make a decision about where I should deploy my assets. Where do you think I should put them, in Chinatown?”

Ramsey finds it disturbing that neither the FBI nor the Centers for Disease Control and Prevention keep up-do-date statistics on the number of police-involved shootings, limiting transparency about the extent of the problem.

As Co-Chair of the President’s Task Force on 21^st Century Policing, convened by President Barack Obama in 2014, Ramsey said community policing is key to ending the mistrust and fatalities among officers and civilians.

“Every cop in Philly starts on foot patrol, they’re on the ground and when they’re out there and you start to meet Miss Jones and Miss Smith, who are afraid to come out, you start to get a more balanced sense of who is actually a threat to that community.”

All the videos from the daylong symposium can be watched here.

Like any energetic 7-year-old, your daughter loves running around outside, playing with her friends and kicking around a soccer ball. So you’re concerned when she starts losing energy. She looks pale and refuses to eat. You take her to the pediatrician, and her test results show the worst: she has leukemia. Once you work through the shock, you do you what any parent would do: find the best possible care to get her through it. But where do you go?

Health care for children is different from care for adults. Treating kids requires doctors who are experienced with their unique needs, and according to Stanford pediatricians Paul Wise and Lisa Chamberlain, this experience is developed and lives in children’s hospitals.

And these facilities are highly dependent on Medicaid.

“Children are the poorest segment of the United States population,” said Wise, a Stanford Health Policy core faculty member.

Nearly one out of every five children lives below the poverty line, according to the United States Census Bureau. Very few children need extensive health care, but of those that do, about 44 percent rely on Medicaid or other public insurance programs.

Because so many of their patients use Medicaid, these children’s hospitals need reimbursements from the program to support their services. Without this income, some might have to downsize or even shut down, and if they do, services would suffer for all children.

“If you want to kill rich kids, cut Medicaid,” said Wise. “If you’re a rich kid with a serious chronic problem, you’re going to want facilities that provide high-quality care. Those facilities are intensely dependent on Medicaid.”

If the American Health Care Act (the Republican replacement for Obamacare) passes Congress, Medicaid will convert to a per capita cap system. Instead of providing coverage to all who meet its criteria — which is primarily based on income and need — the federal government would cap how much money the federal government could provide each person.

Wise and Chamberlain worry that a set amount allocated for states or individuals would not be able to keep up with health industry inflation, causing payments to effectively decrease over time. They are also concerned that children would be particularly affected by these changes because their medical needs are so different from adults’.

“Caring for seriously ill children requires a wide range of services and specialists, from pediatric surgeons to speech therapists to hospital teachers who make sure kids don’t fall behind,” said Chamberlain. “In pediatrics we work as a team — and cutting Medicaid will reduce our ability to do that.”

Not only would the funds available for child health coverage erode, but according to Wise, the focus on adult health concerns in the emerging Medicaid changes could, without immediate attention, undermine 40 years of progress in developing strong, regionalized child health systems.

Providing for children’s needs should be simple because their expenditures are relatively low. Child health care makes up less than nine percent of all federal health expenditures in the United States.

But because the health policy debate in the United States focuses on older populations, children are often left out.

“I think it’s really important that we have these conversations about the unique needs of children,” said Chamberlain.

Wise and Chamberlain hope to alert policy-makers to the fiscal needs of children and how they affect care for all kids.

“Our elected officials have to cope with a wide range of issues, and they welcome engaged professionals exchanging ideas about active legislation,” said Chamberlain. “Those conversations really matter – now is the time to let them hear what we think.”

To hear more from Wise and Chamberlain about child health and Medicaid, listen to their podcast on World Class:

About two-thirds of American patients see doctors who receive payments from drug companies, but almost none of them know it.

In a collaborative study between Drexel, Stanford and Harvard, researchers found that 65 percent of participants had visited a doctor within the last year who had received payments or gifts from pharmaceutical or medical device firms.

Payments to physicians can take the form of meals, travel, gifts, speaking fees and research.

Only 5 percent of participants knew that their doctor had received these payments.

“The concern is that physicians with financial ties to drug and device companies may be more likely to recommend those companies' products to their patients, even when other choices would be better for the patient, or just as good but less costly,” said Michelle Mello, the Stanford author and a professor of law and of health research and policy.

Open Payments, which reports pharmaceutical and device industry payments to physicians, was set up as part of the Physician Payment Sunshine Act, a provision of the Affordable Care Act (ACA). The website exists to make industry payment information available to the public.

But the study found that only 12 percent of patients knew this information was accessible. The authors stated that the act’s impact is highly dependent on whether patients know about it.

“Transparency can act as a deterrent for doctors to refrain from behaviors that reflect badly on them and are also not good for their patients,” said Genevieve Pham-Kanter, the lead author and an assistant professor at Drexel’s Dornsife School of Public Health.

Drug and device companies tend to target “key opinion leaders” who are likely to influence the choices of other physicians. During the year studied, the average American physician received $193 in payments. However, the median payment for doctors visited by patients in the study was much higher, $510 for the year.

“We may be lulled into thinking this isn’t a big deal because the average payment amount across all doctors is low,” said Pham-Kanter. “But that obscures the fact that most people are seeing doctors who receive the largest payments.”

Payments vary widely across specialties. Among patients surveyed, 85 percent of those who saw an orthopedic surgeon saw a doctor who had received payments. The next highest was obstetrics and gynecology physicians at 77 percent.

“Drug companies have long known that even small gifts to physicians can be influential, and research validates the notion that they tend to induce feelings of reciprocity,” said Mello.

Despite potential changes to the ACA, Mello believes the Sunshine Act is here to stay. The current version of the American Health Care bill, which would repeal and replace the ACA, does not dismantle it.

This leaves the question of how policymakers can make information about payments to physicians more visible to patients. The authors suggested that the Centers for Medicare and Medicaid Services (CMS) could provide a one-stop shop for patients to view industry payments and other information about their providers online. Mello added that private insurers could make this information available on their “Find a Physician” websites.

“Finding the physician who is right for you depends on a lot of factors,” said Mello. “Whether a physician accepts money from industry may or may not be important to you, but my general view is that the more informed these choices are, the better they will be for patients.”

If there is such a person as a universally respected and universally loved scholar, Professor Arrow was such a man. I have been trying to think of what I might write to pay tribute to him that somebody else could not say better.  I will give it a shot, though I am not qualified to do this task full justice.

Prof. Arrow was a great genius whose work will be spoken about for as long as economics remains a subject of interest. But I am sure that other economists, even someone who did not know him personally, could do an excellent job of recounting his genius. At the very least, Prof. Arrow’s impossibility theorem and his groundbreaking work on general equilibrium models will be part of the standard curriculum of economics, I believe forever. He had an incredibly wide-ranging curiosity, which led him to work that has revolutionized many empirical fields, including my field of health economics.

Let me focus instead on Prof. Arrow’s reputation for being a kind and humble man, about which I can give some specifics. The main thing I have to say about this is that his reputation was well deserved. There are many stories I could tell, but I’ll just tell one here.

In 1989, during the fall of my senior year in college, Prof. Arrow offered a class on economic inequality for undergraduate economics majors. To my surprise, the class was not oversubscribed, and so I signed up. Prof. Arrow was quietly brilliant the whole quarter. In his hands, the economics of inequality touched on an astonishing array of topics, and to this day, I cannot think about the subject except with the framework he presented there.

He was not an outstanding speaker – there was nothing flashy about his style, but there was nothing false either. His aim as a teacher was to focus his students on the material, not himself. Even when he presented his impossibility theorem, I do not remember him saying that it was his theorem.

The next part is embarrassing. The impossibility theorem says, very roughly, that in a society where there is broad disagreement about social policy, democratic processes can produce incoherent social outcomes. When Prof. Arrow taught it in the class, however, I misunderstood and thought the theorem said that democratic processes always lead to incoherent social outcomes. That evening, I found an easy – too easy! – counter-example to the incorrectly understood theorem. So I scheduled a time to go meet with Prof. Arrow to see where I had gone astray.

When we met, Prof. Arrow was very kind as he explained my error. He even apologized for being unclear in his explanation, even though I am sure most of the rest of the class had it right.

He spent the bulk of the time that day trying to find out what I wanted to do with my life. When I told him I wanted to be a doctor and not an economist, he seemed disappointed (this genuinely surprised me) and he encouraged me to think some more about it. That meeting led me for the first time to think really seriously about a career as an economist. That brief meeting with Prof. Arrow changed my life.

It is easy to be sad when someone of Prof. Arrow’s character and genius dies. I am grateful that I had the opportunity to get to know him. I will always count his touch on my life a blessing from God and I will miss him.

When drug prices go up, does demand decrease? Not necessarily said Maria Polyakova, a professor of health research and policy and Stanford Health Policy core faculty member. In her study, "Out of Pocket Cost and Utilization of Healthcare among Elderly and Pre-elderly Adults," Polyakova used data from Medicare Part D — the prescription drug branch of Medicare, covered by private insurance companies — to determine how older people respond to price changes. In her preliminary findings, Polyakova discovered that people with acute conditions were less likely than patients with chronic conditions to change their drug usage when prices increased.

As the leading cause of death for young people in the United States, traffic accidents are a major risk to health. Around the world, they kill 1.3 million people per year and seriously injure more than 80 million. David Studdert, a professor of medicine and law and a Stanford Health Policy core faculty member, wanted to bring those numbers down. In his study, "Exploring the relationship between traffic citation history and crash risk among elderly drivers in Florida," Studdert looked for a way to find high-risk drivers based on demographics and driving records. He found that drivers who have a quick succession of traffic violations or have particular types of violations may be at a higher risk to cause serious accidents. Studdert hopes to use the study's results to make driving safer without encroaching on civil liberties.