The U.S. Preventive Services Task Force has adopted decision modeling as one of its methods in developing its evidence-based recommendations about preventive health care.

The USPSTF has developed a framework that will help the independent body of medical experts determine when to use modeling as a complementary, quantitative approach as they deliberate on their recommendations for clinical practice and medical policy. 

“This is methodologically important because it describes a framework the Task Force can use to assess when decision models may aid in the development of recommendations,” said Douglas K. Owens, who led the decision-modeling group at the USPSTF.

Owens, of the VA Palo Alto Health Care System, and a professor of medicine at Stanford Medicine and a leader at Stanford Health Policy, said the task force spent three years developing the framework.

“Modeling can be a very useful tool to complement empiric studies and can enable you to answer questions that you couldn’t otherwise answer,” he said. “For example, what’s the implication of starting mammography screening at 40 versus 50, or colorectal cancer screenings at 50 versus 45? How might a preventive intervention perform in a population that is slightly different from the ones that have been studied?”

Modeling provides insights about how benefits and harms of an intervention may vary in such circumstances, he said.

The framework for using modeling was described in the July 5, 2016, online edition of the Annals of Internal Medicine, the journal of the American College of Physicians.

The article emphasizes how decision modeling can be useful in answering important medical questions that have not been addressed in clinical trials.

“Decision models are a formal methodological approach for simulating the effects of different interventions — such as screening and treatment — on health outcomes,” the authors write. “Unlike epidemiologic models that project the course of disease or seek to make inferences about the cause of disease, decision models assess the benefits and harms of intervention strategies by examining the effect of specific interventions.”

The USPSTF has used decision models in the development of recommendations for screening colorectal, breast, cervical, and lung cancer. It’s also used modeling in recommendations for use of aspirin to prevent cardiovascular disease and colorectal cancer.

For these services, decision models allowed the USPSTF to consider the lifetime effect of different screening programs in specific populations and at various ages.

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For example, the effect of HIV screening on mortality has not been directly assessed in clinical trials. But there is evidence that HIV can be diagnosed accurately and that early treatment reduces mortality and HIV transmission.

In contrast, a recent assessment of screening for thyroid dysfunction found that the evidence was insufficient to assess benefits and harms, so this topic would not be a candidate for modeling.

Models are also useful for weighing the harms and benefits of an intervention. Clinical studies have shown, for example, that aspirin can prevent non-fatal heart attacks and strokes. But it also causes intracranial and gastrointestinal bleeding.

“How do you weigh these different benefits and harms? Modeling can be very useful in understanding the tradeoff between benefits and harms,” Owens said.

The Task Force is a leader in evidence-based methods for guideline development, Owens noted. “I hope this work will also be useful to the broader community that is developing clinical guidelines.”

A key concern weighing heavily on those attending this week’s global conference on AIDS is the diminishing donor support to fight the communicable disease, which has claimed an estimated 35 million lives since the beginning of the epidemic.

“That’s on everybody’s mind now — how to continue facing the epidemic with the shrinking resources,” said Eran Bendavid, a core faculty member at Stanford Health Policy and assistant professor at Stanford Medicine attending the conference in Durban, South Africa.

Donor government funding to support HIV efforts in low- and middle-income countries fell for the first time in 2015, decreasing from $8.6 billion in 2014 to $7.5 billion last year, according to a new report by the Kaiser Family Foundation and UNAIDS.

Funding for HIV treatment declined for 13 of 14 major donor governments, with the U.S. continuing to provide more donor funding for HIV than any other country or organization.

“There’s a sense of panic about how we’re going to fill the shortfall in funding,” Bendavid said. “All the major donors are here, PEPFAR, the Global Fund, and everyone is saying `We need more to continue the fight.’

“But, in my mind,” Bendavid continued, “the conversation that is mostly missing is the one between the organizations on the front lines and the national ministries of health and finance. See what they can do to get domestic resources to fill the gap.”

PEPFAR — the President’s Emergency Plan for AIDS Release — is the U.S. government initiative to help those suffering from HIV/AIDS.

Bendavid, an infectious disease physician, joins 18,000 global leaders, researchers, activists and front-line health workers attending the conference July 18-22.

The U.N. General Assembly last month pledged to end the AIDS epidemic by 2030. But more than half of the nearly 37 million people around the world infected with HIV still have no access to the antiretroviral therapy that is saving so many lives.

U.S. Secretary-General Ban Ki-moon said on the opening day of AIDS2016 that when the conference was last held in Durban 16 years ago, less than 1 percent of all people living with HIV in developing countries had access to treatment.

“Today, the world has proven that when we come together, we can transform lives,” Ban said, noting that of the 36.7 million people living with HIV today, about 46 percent of infected adults have access to antiretroviral treatment.

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“In addition, medicines are more effective and less toxic, technology allows diagnosis in 20 minutes or less, generic medicines reduced the cost of treatment to just a dollar a day and great international finance has been made available,” Ban said.

Still, the secretary-general warned, “the gains are inadequate — and fragile,” when you consider that more than half of all people living with HIV still lack access to treatment.

Bendavid, who spoke by telephone from Durban, gave a symposium at the conference on Tuesday that summarizes his research and provides his conclusions on the most effective approaches to use donor resources.

He said the while the global burden of noncommunicable diseases, such as heart disease and cancer, is greater than HIV, malaria, or TB, the interventions available to combat infectious diseases are more cost-effective. 

“Basically, the resource constraints are forcing us to think carefully about what to invest in, and we want to invest in what works,” Bendavid said, adding that donor funding typically goes straight to the disease rather than the local health system infrastructure.

“The scarce donor resources should not be directed towards interventions that are either inefficacious or costly,” he argued. “The opportunity cost of investing in costly or ineffective interventions is very high when you consider the millions who could benefit from inexpensive, simple interventions such as bed nets and drugs for TB.”

He conceded that he typically gets push back on this line of reasoning.

“But when you’re talking about what you can do with very limited resources, investing in noncommunicable diseases, in my mind, jeopardizes the premise of donor funding: There are many people who would be happy to shut down PEPFAR and the Global Fund if they were shown to be ineffective.”

He published a paper earlier this year that found the U.S. government has invested $1.4 billion in HIV prevention programs that promote sexual abstinence and marital fidelity. But there is no evidence that the programs have been effective at changing sexual behavior and reducing HIV Risk.

Bendavid said his presentation at the symposium was received with a mix of understanding and concern.

“People mentioned that funding health systems could have averted Ebola, and that the fight against HIV needs to address health systems,” he said. “I agree, but also think governments should step up and help fill some of those gaps.”

The Asia Health Policy Program at Stanford’s Shorenstein Asia-Pacific Research Center, in collaboration with scholars from Stanford Health Policy's Center on Demography and Economics of Health and Aging, the Stanford Institute for Economic Policy Research, and the Next World Program, is soliciting papers for the third annual workshop on the economics of ageing titled Financing Longevity: The Economics of Pensions, Health Insurance, Long-term Care and Disability Insurance held at Stanford from April 24-25, 2017, and for a related special issue of the Journal of the Economics of Ageing.

The triumph of longevity can pose a challenge to the fiscal integrity of public and private pension systems and other social support programs disproportionately used by older adults. High-income countries offer lessons – frequently cautionary tales – for low- and middle-income countries about how to design social protection programs to be sustainable in the face of population ageing. Technological change and income inequality interact with population ageing to threaten the sustainability and perceived fairness of conventional financing for many social programs. Promoting longer working lives and savings for retirement are obvious policy priorities; but in many cases the fiscal challenges are even more acute for other social programs, such as insurance systems for medical care, long-term care, and disability. Reform of entitlement programs is also often politically difficult, further highlighting how important it is for developing countries putting in place comprehensive social security systems to take account of the macroeconomic implications of population ageing.

The objective of the workshop is to explore the economics of ageing from the perspective of sustainable financing for longer lives. The workshop will bring together researchers to present recent empirical and theoretical research on the economics of ageing with special (yet not exclusive) foci on the following topics:

• Public and private roles in savings and retirement security
• Living and working in an Age of Longevity: Lessons for Finance
• Defined benefit, defined contribution, and innovations in design of pension programs
• Intergenerational and equity implications of different financing mechanisms for pensions and social insurance
• The impact of population aging on health insurance financing
• Economic incentives of long-term care insurance and disability insurance systems
• Precautionary savings and social protection system generosity
• Elderly cognitive function and financial planning
• Evaluation of policies aimed at increasing health and productivity of older adults
• Population ageing and financing economic growth
• Tax policies’ implications for capital deepening and investment in human capital
• The relationship between population age structure and capital market returns
• Evidence on policies designed to address disparities – gender, ethnic/racial, inter-regional, urban/rural – in old-age support
• The political economy of reforming pension systems as well as health, long-term care and disability insurance programs

Submission for the workshop

Interested authors are invited to submit a 1-page abstract by Sept. 30, 2016, to Karen Eggleston at karene@stanford.edu. The authors of accepted abstracts will be notified by Oct. 15, 2016, and completed draft papers will be expected by April 1, 2017.

Economy-class travel and accommodation costs for one author of each accepted paper will be covered by the organizers.

Invited authors are expected to submit their paper to the Journal of the Economics of Ageing. A selection of these papers will (assuming successful completion of the review process) be published in a special issue.

Submission to the special issue

Authors (also those interested who are not attending the workshop) are invited to submit papers for the special issue in the Journal of the Economics of Ageing by Aug. 1, 2017. Submissions should be made online. Please select article type “SI Financing Longevity.”

About the Next World Program

The Next World Program is a joint initiative of Harvard University’s Program on the Global Demography of Aging, the WDA Forum, Stanford’s Asia Health Policy Program, and Fudan University’s Working Group on Comparative Ageing Societies. These institutions organize an annual workshop and a special issue in the Journal of the Economics of Ageing on an important economic theme related to ageing societies.

More information can be found in the PDF below.

Studying the microorganisms that live in our gut is a relatively new field, one that has only really taken off in the last decade. In fact, it is estimated that half of the microbes that live in and around our GI track have yet to be discovered.

“This means there is a huge amount of this dark matter within us,” said Ami S. Bhatt, an assistant professor of medicine and genetics who runs the Bhatt Lab at the Stanford School of Medicine. The lab is devoted to exploiting disease vulnerabilities by cataloguing the human microbiome, the trillions of microbes living in and on our bodies.

“I think if we fast-forward to the impact of some these findings in 10 years, we’re going to learn that modifying the microbiota is a potent way to modulate health,” Bhatt said. “Humans are not only made up of human cells, but are a complex mixture of human cells and the microbes that live within us and among us — and these microorganisms are as critical to our well-being as we are to theirs.”

Bhatt, along with key collaborators at the University of Witwatersrand in Johannesburg, and the INDEPTH research consortium, now intends to take this research to Africa.

She is this year’s winner of the of the Rosenkranz Prize for Health Care Research in Developing Countries, awarded by Stanford Health Policy to promising young Stanford researchers who are investigating ways to improve health care in developing countries.

The $100,000 prize is targeted at Stanford’s emerging researchers who are dedicated to improving health care in poorer parts of the world, but may lack the financial resources.

Bhatt, MD, PhD, intends to take the prize money to execute the first multi-country microbiome research project focused on non-communicable disease risk in Africa. The project intends to explore the relationship between the gut microbiome composition and body mass index (BMI) in patients who are either severely malnourished or obese.

“As a rapidly developing continent with extremes of resource access, Africa is simultaneously faced with challenges relating to the extremes of metabolic status,” Bhatt wrote in her Rosenkranz project proposal. The Bay Area native, who is also the director of global oncology at Stanford, came to the School of Medicine in 2014 to focus on how changes in the microbiome are associated with cancer.

In this new project, Bhatt and members of her lab will team up with colleagues in Africa, first in South Africa, and then in Ghana, Burkina Faso, and Kenya. They will leverage the infrastructure already in place at the INDEPTH Network of researchers, using an existing cohort of 12,000 patients at within those four countries. The patients have already consented to be involved in DNA testing and have given blood and urine specimens.

Identifying alterations of the microbiome that are associated with severe malnutrition or obesity could pave the way for interventions that may mitigate the severity or prevalence of these disorders, Bhatt said.

“These organisms are critical to our health in that they are in a delicate balance with one another and their human hosts,” she said. “Alterations in the microbiome are associated with various diseases — but have mostly been studied in Western populations. Unfortunately, little is known about the generalizability of these findings to low- and middle-income countries – where most of the world’s population lives.”

Bhatt said that as Africa rapidly continues to develop, the continent is simultaneous faced with challenges relating to extreme weight gain and loss. While the wealthy are facing obesity and its associated disease such as stroke, heart failure and diabetes, many people are still faced with issues related to food insecurity, hunger and malnutrition.

The research, she hopes, could lead to aggressive behavioral, dietary and lifestyle modifications targeted at maintaining healthy BMI in at-risk individuals.

Video by Ankur Bhatt

Grant Miller, an associate professor of medicine and core faculty member at Stanford Health Policy who chaired the Rosenkranz Prize committee this year, believes Bhatt’s research could eventually break new ground.

“The entire Rosenkranz Prize selection committee was highly impressed with Ami and the innovation of her project,” Miller said. “Ami’s work on the human microbiome in the extremes of nutritional status in developing countries — including its potential link to obesity, an emerging challenge in low income countries — is potentially path-breaking.”

The award’s namesake, George Rosenkranz, first synthesized cortisone in 1951, and later progestin, the active ingredient in oral birth control pills. He went on to establish the Mexican National Institute for Genomic Medicine, and his family created the Rosenkranz Prize in 2009.

The award embodies Dr. Rosenkranz’s belief that young scientists hold the curiosity and drive necessary to find alternative solutions to longstanding health-care dilemmas.

The Supreme Court struck down parts of a Texas law that imposed standards on abortion providers that had the effect of reducing the number of abortion facilities in the state by at least half.  In a 5-3 ruling in which Justice Anthony Kennedy joined the liberal wing of the Court, the justices said the restrictions placed an undue burden on a woman’s constitutional right to seek an abortion. The 2013 law  required all abortion facilities to meet state standards for ambulatory surgical centers (ASCs) and required doctors performing abortions to have admitting privileges at a nearby hospital.

Justice Stephen G. Breyer wrote in the majority opinion, “We conclude that neither of these provisions offers medical benefits sufficient to justify the burdens upon access that each imposes. Each places a substantial obstacle in the path of women seeking a pre-viability abortion, each constitutes an undue burden on abortion access, and each violates the Federal Constitution.”

Michelle Mello, a professor of health research and policy at the Stanford School of Medicine and professor of law at Stanford Law School, as well a core faculty member of Stanford Health Policy, was a signatory to a brief submitted to the Supreme Court by public health academics and the American Public Health Association in support of the abortion providers’ challenge.

What was the main argument of the amici curiae brief submitted to the Supreme Court by public health academics and organizations?

There were two critical factual points that had to be made. First, although the Texas law’s provisions were putatively adopted to benefit women’s health, they actually had no medical benefit.  Second, the law had a rapid, dramatic effect on access to abortion in Texas.  Particularly because in Texas several other restrictions already limited access to abortion and funding for family planning services was scant, this poses a real threat to public health.

Can you say more about why the provisions of the law did not protect women’s health?

The standards were completely unnecessary.  Abortion is an extremely safe procedure; complications rarely occur.  The facilities already had protocols in place to ensure safe transfer to hospitals in the event of an emergency.  But when complications do occur, they usually arise after the woman returns home, so transfer from the facility to the hospital isn’t an issue.  And there’s no reason a woman needs to receive emergency care from the same doctor who performed the abortion. 

Many of the standards for ASCs are simply irrelevant to providing safe abortions.  Many abortions aren’t surgical, they’re medical (chemical).  And standards relating to things like providing general anesthesia, avoiding infections to open wounds, having an advanced heating and air condition system, and having a particular traffic pattern from the operating room to the recovery room just don’t apply.  The state’s argument about protecting women’s health was just a pretext. 

It was a dangerous pretext, in fact, because these were standards that most abortion facilities clearly were not going to be able to meet.  Many hospitals require doctors to admit a minimum number of patients in order to maintain admitting privileges, but abortion is so safe that abortion providers generally can’t do that.  And fitting out a clinic to meet ASCs is prohibitively expensive.  ASCs can afford it because they charge for expensive operations like cosmetic surgeries, hysterectomies, and hernia repairs; abortion providers can’t.

Why do you and the other signatories consider this a public health issue?

More than 60,000 Texas women per year obtain legal abortions.  While we’d all like to see this number go down, you can’t restrict access to abortion while also failing to provide adequate support for other methods of family planning.  History makes it abundantly clear that the result will be greater numbers of women resorting to illegal, unsafe abortions or facing the mental and physical health risks of carrying unwanted pregnancies to term.

Does the Supreme Court’s holding have implications beyond this case?

Yes, because the Court clarified how it will apply the “undue burden” standard of Planned Parenthood v. Casey in future cases.  The majority said that courts must balance “the burdens a law imposes on abortion access” against “the benefits those laws confer.”  The justices also clarified that appellate courts can take a deep dive into the factual evidence about a law’s effects presented earlier in the case.  These holdings collectively make it harder for states to adopt abortion restrictions based on flimsy arguments about how they will benefit women. 

Colorectal cancer is the second leading cause of death from cancer in the United States, after lung cancer, yet many Americans are still loathe to be screened for the disease.

The U.S. Preventive Services Task Force strongly recommended adults ages 50 to 75 to be screened for colon cancer and suggested adults 76 to 85  make individual decisions about whether to be screened, depending on their overall health and prior screening history. The recommendation and several accompanying editorials were published Wednesay in the Journal of the American Medical Association (JAMA).

The independent body of national experts in prevention and evidence-based medicine emphasized colonoscopy is not the only valid test out there. There are multiple screening options available to the one-third of Americans over 50 who have never been screened.

We pose five key questions about the Task Force recommendations to Douglas K. Owens, the Henry J. Kaiser, Jr., Professor of Medicine at Stanford and director of the Center for Health Policy and Center for Primary Care and Outcomes Research. He is an author of the recommendation and was a member of the Task Force when the guidelines were developed.

What is the most significant finding of this final recommendation?

Colorectal cancer is the second leading cause of death from cancer in the United States. The good news is that evidence convincingly shows screening for colorectal cancer works. The Task Force strongly recommends screening adults 50 to 75 for colorectal cancer, as it reduces the risk of dying from the disease. Unfortunately, one-third of people 50 to 75 have never been screened, so we are missing an important opportunity to prevent deaths from colorectal cancer.

There are multiple screening options for colorectal cancer. What are they and how should individuals decide which is best for them?

What really matters is that people get screened. There are several options that are effective, so we recommend that people discuss the options with their clinician. There are direct visualization tests, like colonoscopy, and stool-based tests, like fecal immunochemical testing (FIT). Each test has different strengths and limitations, and people may prefer one approach over another. For example, colonoscopy can be done every 10 years, but FIT testing should be done every year. But the real message is, choose an approach in consultation with your clinician and get screened.

The Task Force found that once adults reach 76 years old, the benefits of screening become smaller and the potential for harm is greater. Why is this and how should older Americans determine which test is best for them?

We recommend individual decision making for patients 76 to 85. The benefits are smaller because a person’s chance of dying of other causes goes up as they get older. The harms are still small but increase with age, primarily because the risks of the potential complications of colonoscopy (bleeding, perforation, and infection) go up with age. Still, some people in this age group will benefit from screening. People most likely to benefit are those who have not been screened before, people who are healthy enough to undergo treatment for CRC should it be found, and people who do not have other diseases or conditions that limit their life expectancy substantially.

Owens explains the Task Force's recommendations to JAMA

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JAMA Network | JAMA | USPSTF Recommendation Statement: Screening for Colorectal Cancer

African-Americans have the highest incidence of and mortality rates from colorectal cancer among all racial and ethnic subgroups. Why are African-Americans more susceptible and does this mean that the screening recommendations differ for them?

The Task Force recognizes the burden that colorectal cancer has on African-Americans, who are at higher risk of being diagnosed with and dying from the disease than other racial/ethnic subgroups. We don’t know why this is — more research is needed in this area. The Task Force did not find enough evidence to conclusively support that making a different recommendation specific to African-Americans would result in a greater net benefit for this population. So our recommendations are intended to apply to all racial/ethnic groups. More robust efforts are needed to ensure that at-risk populations actually receive the screening tests and the follow-up treatments or interventions they need, as people are dying unnecessarily from this disease.

What data did the Task Force use to come to its conclusions?

The Task Force commissioned a comprehensive systematic review of the available evidence on the benefits and harms of colorectal cancer screening. The Task Force also commissioned a modeling study from the Cancer Intervention and Surveillance Modeling Network (CISNET) to help it better understand different screening strategies, such as the optimal age to start or stop screening, and the length of time between screenings. The evidence is convincing that screening reduces the risk of dying from colorectal cancer.

The number of uninsured Americans has dropped to a historic 9.1 percent since the enactment of the Affordable Care Act six years ago.

According to the U.S. Department of Health & Human Services, an estimated 20 million people have gained health insurance coverage between the passage of the law in 2010 and March of this year.

“Our country has made undeniable and historic strides thanks to the Affordable Care Act,” HHS Secretary Sylvia M. Burwell said earlier this month, noting that for the first time in our history, fewer than one in 10 Americans lacked health insurance.

“Our country ought to be proud of how far we’ve come and where we’re going.”

But 19 states still refuse to expand Medicaid for the poorest of the uninsured. And many low- and middle-income families still find that participating in state exchanges is out of their reach or that the process is just too complex.

Stanford health policy experts, state government officials, mobile health and private health-care executives recently gathered on campus to look at the impact of the Affordable Care Act, six years after its adoption.

The consensus was the Act has done more to grant access to health care for Americans than any other government program since Medicaid was adopted in 1965 to help the poor, and Medicare to subsidize the elderly in 1985.

Yet the law’s initial technical missteps, continuing red tape and opposing provisions — as well as the lack of support by so many states and members of Congress — continue to undermine the Act.

“As most of you know, the heath-care sector in the U.S. is large and extremely complex,” said Mark Duggan, director of the Stanford Institute for Economic Policy Research, which sponsored the conference. He said total health-care spending in 2016 would amount to $3.4 trillion, an average of more than $10,000 per person.

Yet one-third of those health-care costs go to waste, said Thomas Goetz, co-founder and CEO of the health-care startup Iodine, which uses apps and data visualization to better inform consumers about their health-care and drug choices.

Goetz told the audience of faculty and students that medication — for depression and anxiety, chronic pain and autoimmune diseases — are typically ineffective up to 50 percent of the time.

“The solution isn’t more randomized clinical trials,” said Goetz, whose company recently launched an app that allows users to take a depression test and decide which antidepressant might work best for them. “The goal is to look at patients as consumers and catalysts — versus patients as passive.”

But has the ACA been effective? It seems the reviews are still mixed.

Kate Bundorf, associate professor of health research and policy at the School of Medicine, noted that this an exciting time for policymakers because the evidence on the effects of the Affordable Care Act is starting to emerge.

She said the Congressional Budget Office estimates that the coverage provisions of the ACA increased government spending by $110 billion and reduced the number of uninsured by 22 million in 2016.

While many analysts were concerned that employers might drop health insurance for workers in response to the subsidies for coverage available through the exchanges, employment-based coverage has remained stable.

Whether the ACA has slowed the rate of growth of health-care spending is still up for debate.

While spending did slow down around the time of the Act’s implementation, it is difficult to determine whether the lag was caused by the ACA’s provisions or other factors such as the recession or increases in cost-sharing for private insurance. And the most recent estimates indicate the rates of growth in spending have begun to increase, possibly signaling a return to historical levels, Bundorf said.

“The big surprise was that not all states expanded Medicaid, with the Court ruling allowing states to opt out,” said Bundorf, who is also a senior SIEPR fellow.

The Supreme Court ruled in 2012 that states could decide individually whether to expand the Medicaid insurance program for the poor.

John Bertko, chief actuary for California’s health exchange, Covered California, describes the Affordable Care Act “as actuarial puzzle to work on every day.”

He should know. Bertko worked on the Obamacare actuarial tables for three years.

One of the most significant changes to the American health-insurance system, he said, are those 32 states that expanded Medicaid under the the ACA. Americans who earn less than 138 percent of the federal poverty level now qualified for Medicaid and the Children’s Health Insurance Program.

Just as the Medicaid expansion went into effect in 2014, a provision of ACA also increased payments for primary care physicians who accepted Medicaid. However, for budgetary reasons, those increased payments only lasted for two years.

“So you have this huge expansion of the number of people qualifying for Medicaid and at the same time payments for suppliers dropped down,” he said. “So lots of Medicaid card carriers were left floating around looking for providers.”

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“When you insure people, you’re going to increase costs and the costs have gone up,” said Bhattacharya, a core faculty member of Stanford Health Policy and senior fellow at SIEPR and the Freeman Spogli Institute for International Studies.

“The total expenditure on the poor, the costs have gone up,” Bhattacharya said. He added here has been no change in the mortality rate of Americans since adoption of the Act. “It’s difficult to find mortality benefits from the social benefits.

Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation, reminded the audience the main goal of the ACA was to expand insurance coverage for Americans.

“And it certainly has been a success at doing that,” he said.

Still, Levitt added, roughly 30 million non-elderly Americans remain uninsured. And many of those who are insured are opting for high-deductible plans to keep their monthly premiums down.

“Twenty percent of people who are insured say they have a problem paying their medical bills because they don’t have a lot of money in the bank and have large deductibles,” he said.

If the other states would follow the lead of the top 10 states leading the way on ACA enrollment, Levitt said, there would be a great improvement overall.

Bundorf said the so-called Cadillac Tax would raise some revenue and the incentive to create more employee-sponsored insurance plans.

But the highly contentious levy that was supposed to go into effect in 2018 has bene delayed to 2020 while Congress, the IRS, unions and big business debate its fairness.

The provision of Obamacare would impose a 40 percent excise tax on the portion of most employer-sponsored health coverage that exceed $10,200 a year and $27,500 for families. The goal is to control the growth of health-care spending by eliminating pricier benefit plans and curtail excessive health-care use.

“The problem with the Cadillac Tax is that, with time, it becomes the Chevy tax,” said Levitt. “I don’t think it will ever go into effect — but it will precipitate something that can replace it.”

Triage nurses typically assign patients to emergency room doctors who are on call or working a shift. But what if the doctors themselves determine whom among them is better suited to take on the next patient?

Classic economic theory predicts “moral hazard” in teams, which means one member behaves inefficiently because in the end someone else will pay the consequences. Yet many successful organizations promote teamwork.

So how does this puzzle relate to health care?

This is the question that Assistant Professor of Medicine David Chan, a core faculty member at Stanford Health Policy, tackles in his new study in the Journal of Political Economy.

Emergency departments (ED) nationwide cost a combined $136 billion to run each year, significantly impacting the growing health-care sector of the U.S. economy. Visits to the emergency rooms are increasing despite the implementation of the Affordable Care Act, causing them to be overcrowded and underfunded.

Chan studied two organizational models: one in which physicians are assigned patients in a nurse-managed system and one in which the doctors divide patients among themselves in a self-managed system.

“I find evidence that physicians in the same location have better information about each other and that, in the self-managed system, they use this information to assign patients,” Chan writes.

He said that by simply allowing physicians to choose patients, a self-managed system reduces emergency room lengths of stay by 11-15 percent, relative to the nurse-managed system.

“This effect occurs primarily by reducing a `foot-dragging’ moral hazard, in which physicians delay patient discharge to forestall new work,” Chan writes. A triage nurse is often in another room and has a difficult time observing true physician workload, whereas peer physicians who work together can.

“So, for example, if there are two physicians working at a time when there are a whole bunch of patients in the waiting room, then each physician knows that the minute he discharges a patient, he is more likely to get another one,” Chan said in an interview. This might lead the physician to dilly-dally on the release of that patient, knowing that he’ll immediately be signed another before he gets a break.

However, two physicians who can observe how busy the other one truly is will be less likely to stall, even if they want to avoid new patients.

Chan studied a large, academic emergency room that treated 380,699 patients over a six-year period. He looked at length of stay, measuring each physician’s individual contribution. He also observed patient demographics and used the Emergency Severity Index, an ED triage algorithm based on a patient’s pain level, mental status, vital signs and medical condition.

Besides measuring the effect of the self-managed system in this large hospital, Chan combined evidence to support the hypothesis that teamwork improves outcomes because of mutual management with better information.

He found that the only difference in outcomes between the two organizational systems was foot-dragging. Clinical outcomes or even the number of tests ordered were about the same under a self-managed or nurse-managed system.

Moreover, the foot-dragging behavior grows as physicians may anticipate future work by the number of patients in the waiting room, even if they end up seeing the same number of patients.

Finally, physicians refrain from this behavior when being watched by another physician in the same location, even in the nurse-managed system, when that other physician does not otherwise have any role in the physician’s patient care.

“I think the biggest takeaway is that such efficiency gains can be widespread in health care, particularly because there is so much at stake hidden behind information in patient care that is not transparent,” Chan said.

“Even if we don’t fully anticipate all of these gains, we could still achieve a lot by tinkering and using these changes as natural experiments to figure out what works and what doesn’t,” Chan said. “We can further use these results, particularly the evidence pointing at a mechanism, to think of what other innovations might work.”

The U.S. government has invested $1.4 billion in HIV prevention programs that promote sexual abstinence and marital fidelity, but there is no evidence that these programs have been effective at changing sexual behavior and reducing HIV risk, according to a new Stanford University School of Medicine study.

Previously: PEPFAR has saved lives – and not just from HIV/AIDS, Stanford study finds