In the summer of 2018, the Asia Health Policy Program (AHPP) at the Shorenstein Asia-Pacific Research Center (co)hosted two conferences in Beijing. From June 25-26, AHPP hosted “Healthy Aging and Chronic Disease Management in China and India in International Comparison” at the Stanford Center at Peking University in Beijing. Immediately following the event, June 26-27 AHPP cohosted, along with Professor Fang Hai, Peking University China Center for Health Development Studies, the “Fourth Annual Conference on Primary Care and China’s Health System Reform”, focused this year on China’s family doctor system.

Healthy Aging and Chronic Disease

Day one of the Healthy Aging and Chronic Disease Management conference combined discussions of chronic disease control in India and China (part of an ongoing SCPKU Team Innovation faculty fellowship) with a workshop focused on assessing net value of diabetes management across Asia.

Research teams from Hong Kong, South Korea, India, Taiwan, and the United States convened to discuss research on net value analysis of diabetes in their respective countries. The Net Value in Diabetes Management project seeks to develop a method for measuring net value of diabetes internationally­–based on previous methods discussed in an 2009 study by Karen Eggleston and Joseph Newhouse with data from the Mayo Clinic for Type 2 Diabetes.

The research teams provided updates to their calculations from the gathering last year and explained the strengths and weaknesses of their data sets, the risk prediction model they employed or created for their specific population, and the cost effectiveness analyses conducted with their data.

Participants included Kavita Singh from the Public Health Foundation of India, Janet Lam from Hong Kong University, Hongsoo Kim and Wankyo Chung from Seoul National University, Rachel Lu and Ying Isabel Chen of Chang Gung University Taiwan, and Kyueun Lee and Karen Eggleston of Stanford University.

Non-communicable/Chronic Disease Control

The afternoon of day one featured presentations by various representatives from provincial and national-level Centers for Disease Control and Prevention (CDC) in China regarding non-communicable disease (NCD) control initiatives.

Dong Jianqun from the People’s Republic of China CDC presented the “Effect of Community-Based 5+1 staged diabetes management.” This research project–fielded in sites in three different provinces–involved staged diabetes targeting management. Results showed that examination rates for complications management increased. Fang Le from the Zhejiang Provincial CDC presented updates on community management of NCDs in Zhejiang, including the intensive follow-up system for high risk diabetes patients. Representatives from Shandong University and the Shandong CDC, including Dr. WANG Yan, presented “The Status, Problems, and Determinants of community management and control of diabetes in Shandong Province” while also discussing current policy and implementation.

The afternoon ended in a session comparing health care systems and ongoing initiatives for chronic disease control in China and India. Kavita Singh discussed issues in India’s health system, including high out of pocket expenditure, over-privatization, and large health inequities across states and between urban and rural areas. Singh introduced existing innovations being used, including smartphone-based decision support software in heart disease monitoring. Dong Jianqun and colleagues discussed NCD control in China, including the demonstration areas that have integrated initiatives including better surveillance and management of diabetes and hypertension, and prevention education.

The first conference closed the next morning by bringing together representatives from various Chinese organizations to discuss the current state of primary care, family doctor system, and health care reform within the country. During a highly immersive classroom session for the Diabetes Net Value Teams, Dr. Sanjay Basu shared insights regarding best practices in predictive risk modeling.

China’s Family Doctor System

Beginning the afternoon of June 26, the second conference was devoted to China’s family doctor system, primary care, and health care reforms.  The event opened with remarks from Zhuang Ning, Deputy Director of the State Department of Health, System Reform Department, about the importance of community health and greater recognition of primary health providers in China.

The director’s remarks were followed by an opening keynote address by Professor MENG Qingyue, Dean of the Peking University School of Public Health and Director of the China Center for Health Development Studies at Peking University. Professor Meng reflected on the role of primary care in the development of China’s health system. Qin Jiangmei, Director of the Community Health Research Center, National Health and Family Planning Commission Health Development Research Center, next introduced the necessity of comprehensive health reform in China as well as funding challenges.

Afterwards, representatives from the Beijing Dongcheng district, Shanghai Changning district,  Xiamen City, and Shenzhen Luohu Hospital Group shared their experiences constructing family doctor systems within their respective regions. Important points stressed by the presenters included consolidation, maintaining a good evaluation system, and establishing trust with their patients.

The day ended with a Primary Medical Care Roundtable Discussion featuring four directors of district-level community health centers. The panelists answered questions concerning the future model of primary care in China, as well as changes they would like to see at the community and policy levels. The district directors advocated that more funds be allocated to general practitioners, believing that they will be the dominant form of primary care in China. Participants also spoke of the additional need for clearer targets to ensure that primary care providers are better funded (so that, with enough time, patients will begin to recognize the importance of the family physician).

The second conference concluded on June 27 by way of a highly engaging classroom session on the continuing collaboration between the Zhejiang Provincial CDC and Stanford University Asia Health Policy Program.

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

There is a wealth of data that could help hospitals cut costs while still providing high-quality service for patients, if physicians were willing to join forces with administrators to truly understand how much their services cost, according to a new article by Stanford researchers.

The Centers for Medicare and Medicaid Services (CMS) has been pushing physicians and providers toward population-based payment, which requires that providers reduce their internal costs below payment levels.

In this effort, the beleaguered health-care payer for the elderly has been undertaking innovative payment models, such as accountable care organizations (ACOs) and bundled payment that require providers to better coordinate care and reduce reimbursements and unnecessary or redundant patient procedures.

“However, it has proven challenging for the models, which focus on costs from the payer perspective, to achieve the desired effect of reduced Medicare spending,” writes Merle Ederhof, PhD, in this Health Affairs Blog. The researcher who focuses on issues at the intersection of health-care and accounting is with Stanford’s Clinical Excellence Research Center.

Her co-authors, Alexander L. Chin, MD, MBA and Jeffrey K. Jopling, MD, MSHS, are also at the center, which is dedicated to discovering, testing and evaluating cost-saving innovations in clinical care.

Changing old patterns at hospitals and among physicians

“Highly detailed cost data generated by internal cost accounting systems already exist in a large, and growing, number of health-care organizations,” says Ederhof. 

As Ederhof wrote in this New England Journal of paper last year, the data collected by the Healthcare Information and Management Systems Society shows that more than 1,300 U.S. hospitals have adopted sophisticated internal cost accounting systems.

The authors argue that the cost data produced by these accounting systems can be used in hospitals internally to lower their costs of providing services to all their patients, both within and outside the Medicare system. But physicians must get on board.

“The high adoption rate of these cost-measurement systems is not surprising, considering that the systems are designed around the existing data infrastructure that providers must have in place for billing purposes,” the authors write. “However, while provider administrators have used such cost accounting systems for some time, we are only now beginning to see them being used by interdisciplinary teams involving physicians to restructure clinical processes.”

Some large health-care systems have already started using these accounting systems alongside teams of physicians.

Partners HealthCare in Boston has started to use this approach to analyze costs for a set of services, for example, in a recent project a team of spine surgeons reviewed and discussed unblinded comparisons at the episode and cost-category levels. 

“Analysis of the costs in the individual categories revealed variation in clinical processes across surgeons, which was very illuminating to the team,” the authors wrote.

Leaders at NYU Langone Health have also started to use the cost data in the organization’s “Value-Based Management” initiative. A key feature of the initiative, the authors write, is a dashboard that is accessible to all physicians. For each specific diagnosis-related group (DRG), the dashboard shows cost averages for each physician performing the procedure, at the procedure level and at the level of individual cost categories, such as the ICU, laboratory, operating room and therapies.

“Physicians have been highly engaged and interested in the dashboard since it allows them to compare their costs to their peers and external benchmarks, and to learn how they can restructure clinical processes to lower their costs,” the authors write.

This Value Based Management initiative at NYU, which incorporates cost savings targets, development-level incentives and quality components, has apparently resulted in substantial cost savings for the organization.

Stanford Health Care has also joined the movement to promote value-based care, recently launching its Cost Savings Reinvestment Program. 

Compare, for example, the average cost for a hip replacement surgery among five surgeons who perform the surgery in the same hospital. Then take the “positive outlier,” or the surgeon with the lowest cost for the surgery.

“Once positive outliers are identified, detailed analysis that combines physicians’ clinical expertise and administrators’ insight can uncover ways in which clinical processes can be restructured to deliver high-quality care at lower total episode cost,” the authors wrote.

Then the interdisciplinary team of physicians and administrators must try to understand why that surgeon’s costs are lower and what he or she does differently. Did she order physical therapy sooner after the hip-replacement surgery? Did he use a different anesthesia approach that resulted in a shorter recovery for the patient? 

But you still have to get those four, more expensive surgeons to adopt the less-expensive treatments. And that can go to the heart of a physician’s identity.

“Even just a few years ago concern for the cost of providing health-care services still heavily clashed with physicians’ professional identity,” Ederhof said in an interview. 

The authors believe there is no turning back.

“In my view, the shift in recent years is attributable to the fact that physicians are starting to realize that the rising costs of the U.S. health-care system are no longer sustainable and that things will have to change — with or without their collaboration,” Ederhof said.