Health policy
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China has been making efforts to establish a universal health care coverage system through multiple social health insurance schemes. As these insurance schemes cover different populations with different financing and reimbursement levels, large disparities remain in health care access and health outcomes among people covered. The government has launched an urban-rural integration policy for social health insurance to reduce disparities in access and health outcomes. We adopt a difference-in-differences propensity score matching approach to estimate the effects of this integration policy on health care utilization, financial risk protection, and health status, using nationally representative Chinese household survey data.

The results show that the integration policy has significantly improved the financial risk protection and self-assessed health of rural residents in China, which could be attributed to a decline in out-of-pocket payment. The low-income rural residents benefit most from this policy. There is no evidence that it has pronounced effects among urban residents. Greater efforts to increase reimbursement rates and to expand beneficiary populations could help to mitigate remaining urban-rural disparities. The findings in this study would contribute to a better understanding of the impacts of health insurance expansion in low- and middle-income countries.

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Journal Articles
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Impact on Health Care Utilization, Financial Risk Protection, and Health Status
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Applied Economics
Authors
Qin Zhou
Qing He
Karen Eggleston
Gordon G. Liu
Authors
Noa Ronkin
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While the coronavirus pandemic has captured the world’s attention, non-communicable chronic diseases (NCDs) such as hypertension, heart diseases, and diabetes continue to be the leading cause of mortality worldwide, accounting for about two-thirds of deaths globally. Their financial and social burden is also immense, as individuals with chronic diseases face high medical spending, limited ability to work, and financial insecurity. Primary health care (PHC) is a crucial avenue for managing and preventing chronic diseases, yet many health systems, especially in low- and middle-income countries (LMICs), lack robust primary health care settings. How can policymakers improve PHC to reduce illness and death from chronic diseases?

There is little rigorous evidence from LMICs about the effectiveness of programs seeking to improve the capacity of PHC for controlling chronic disease. Now a new study, published by the Journal of Health Economics, helps fill in this gap. It offers empirical evidence on China’s efforts to promote PHC management, showing that better PHC management of chronic diseases in rural areas can reduce spending while contributing to better health. We sat down with APARC’s Asia Health Policy Program Director Karen Eggleston, one of the study co-authors, to discuss the research and its implications beyond China. Watch:

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Challenges for Primary Health Care Services

China, a large and rapidly developing middle-income country with a hospital-based service delivery system for its aging population, makes a suitable case study of efforts to promote PHC management. Over the past several decades, PHC use in China has significantly decreased relative to hospital-based care. This trend is a natural consequence of the country’s unprecedented increases in living standards and improvements in financial risk protection, which increase patients’ demand for quality care and spur self-referral to providers with higher-perceived quality like hospital outpatient departments.

The performance differences between PHC and hospital-based care are especially stark in China’s rural areas, where management of chronic diseases relies heavily on grassroots physicians, who have limited medical education and training. That is why Eggleston and her colleagues set out to provide new empirical evidence about the effectiveness of a program that promotes PHC management of hypertension and diabetes for rural Chinese. Part of the National Basic Public Health Service Program for rural Chinese, it financially rewards PHC grassroots physicians for managing residents with chronic diseases.

Collaborative Research in the Era of Great Power Competition

Eggleston’s co-authors include her colleagues at the Zhejiang Provincial Center for Disease Control and Prevention (Zhejiang CDC). Their study is the culmination of Eggleston’s multiyear collaborative research project with the Zhejiang CDC team, "Addressing Health Disparities in China," which looks to Tongxiang county in Zhejiang as a case study of China's responses to healthcare inequalities and population aging challenges in rural and urban areas. The project also involved two Stanford doctoral students who worked with Eggleston.

The team worked together to develop the quantitative analysis even during a time of sometimes-tense bilateral relations. “We found it very important to be able to communicate directly and collaborate on an important question not only for rural China but for many other parts of the world,” says Eggleston.
Karen Eggleston speaking to staff at Zhejiang Provincial CDC, China
Eggleston with her colleagues at the Zhejiang CDC during a field visit in 2018.

“This kind of collaboration, where we utilize the data that's available to answer an important question while respecting the privacy of the individuals and hopefully delivering benefits to them through more effective or affordable programs in the future perhaps is a promising model for researchers here and elsewhere to undertake,” she notes.

Disentangling the Effect of Primary Health Care Management

To study the program’s effectiveness, the researchers assembled a unique dataset linking individual-level administrative and health information between 2011 and 2015 for rural Chinese diagnosed with hypertension or diabetes in Tongxiang, a mostly rural county of Zhejiang province in southeast China. Collected by the Tongxiang CDC and Zhejiang CDC, the compiled database links basic demographic information, health insurance claims, PHC service logs, and health check-up records — four sets of data that are rarely linked and analyzed in combination in China healthcare research.

Focusing on neighboring border-straddling villages allows us to use only variation in PHC management within pairs of neighboring villages to identify the effect.
Karen Eggleston

Targeting the program’s effects on healthcare utilization, spending, and health outcomes, Eggleston and her colleagues compare residents in neighboring villages that straddle township boundaries. These residents are similar in their individual and environmental characteristics that shape health care use but are subject to different PHC management practices. This “border sampling” allows the researchers to disentangle the effects of PHC management from other underlying spatial differences that impact health care utilization. For each township, the researchers use a management intensity index that reflects the cumulative efforts of PHC physicians to screen their communities and keep patients within the PHC management programs for controlling hypertension and diabetes. Each township’s experience with PHC management over the 5-year study period is thus a case study for rural China.

Net Value in Chronic Disease Management

The results are encouraging for China's investment in primary care management of chronic diseases. Eggleston and her colleagues find that patients residing in a village within a township with more intensive PHC management had a relative increase in PHC visits, fewer specialist visits, fewer hospital admissions, and lower spending compared to neighbors with less intensive management. They also tend to have better medication adherence and better health outcomes as measured by blood pressure control.

If we can gradually scale up these kinds of effective programs at primary care then we can build more resilient, cost-effective, affordable health care systems for populations in many different settings.
Karen Eggleston

The results suggest that PHC chronic disease management in rural China improves net value in multiple ways — increasing PHC utilization, reducing avoidable hospitalizations, decreasing medical spending, and improving intermediate- and long-run health outcomes — all while leveraging existing resources rather than restricting care.

The findings also help inform investments in primary health care in LMICs. They highlight the latent potential of frontline healthcare workers in such settings to be more productive and show that financially rewarding these grassroots workers for managing residents with chronic diseases helps improve health outcomes. Moreover, they offer empirical evidence that supports the effectiveness of chronic disease management programs as part of broader regional initiatives to address population health.

Read the study by Eggleston et al

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Empirical evidence by Karen Eggleston and colleagues suggests that better primary health care management of chronic disease in rural China can reduce spending while contributing to better health.

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Sherri Rose, PhD  is an Associate Professor of Health Policy at the Stanford School of Medicine and Co-Director of the Health Policy Data Science Lab. Her research is centered on developing and integrating innovative statistical machine learning approaches to improve human health and health equity. Within health policy, Dr. Rose works on risk adjustment, ethical algorithms in health care, comparative effectiveness research, and health program evaluation. She has published interdisciplinary projects across varied outlets, including BiometricsJournal of the American Statistical AssociationJournal of Health EconomicsHealth Affairs, and New England Journal of Medicine. In 2011, Dr. Rose coauthored the first book on machine learning for causal inference, with a sequel text released in 2018. She has been Co-Editor-in-Chief of the journal Biostatistics since 2019.

Dr. Rose has been honored with an NIH Director's New Innovator Award, the ISPOR Bernie J. O'Brien New Investigator Award, and multiple mid-career awards, including the Gertrude M. Cox Award and the Mortimer Spiegelman Award, the nation’s highest honor in biostatistics, given to a statistician younger than 40 who has made the most significant contributions to public health statistics. She was named a Fellow of the American Statistical Association in 2020 and received the 2021 Mortimer Spiegelman Award, which recognizes the statistician under age 40 who has made the most significant contributions to public health statistics. Her research has been featured in The New York Times, USA Today, and The Boston Globe. 

Title: New and Ongoing Projects at the Interface of Machine Learning for Health Policy

 

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Encina Commons,
615 Crothers Way
Stanford, CA 94305-6006

 

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Professor, Health Policy
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PhD

Sherri Rose, PhD, is a Professor of Health Policy and Director of the Health Policy Data Science Lab at Stanford University. Her research is centered on developing and integrating innovative statistical machine learning approaches to improve human health and health equity. Within health policy, Dr. Rose works on ethical algorithms in health care, risk adjustment, chronic kidney disease, and health program evaluation. She has published interdisciplinary projects across varied outlets, including Biometrics, Journal of the American Statistical Association, Journal of Health Economics, Health Affairs, and New England Journal of Medicine. In 2011, Dr. Rose co-authored the first book on machine learning for causal inference, with a sequel text released in 2018.

Dr. Rose has been honored with an NIH Director’s Pioneer Award, NIH Director's New Innovator Award, the ISPOR Bernie J. O'Brien New Investigator Award, and multiple mid-career awards, including the Gertrude M. Cox Award. She is a Fellow of the American Statistical Association and received the Mortimer Spiegelman Award, which recognizes the statistician under age 40 who has made the most significant contributions to public health statistics. In 2024, she was recognized with both the ASHEcon Willard G. Manning Memorial Award for Best Research in Health Econometrics and the American Statistical Association Outstanding Statistical Application Award. Her research has been featured in The New York Times, USA Today, and The Boston Globe. She was Co-Editor-in-Chief of the journal Biostatistics from 2019-2023.

She received her PhD in Biostatistics from the University of California, Berkeley and a BS in Statistics from The George Washington University before completing an NSF Mathematical Sciences Postdoctoral Research Fellowship at Johns Hopkins University. 

Director, Health Policy Data Science Lab
Date Label
Associate Professor of Health Policy Stanford University
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Title: Customer Discrimination and Quality Signals: A Field Experiment with Healthcare Shoppers

Abstract: This paper provides evidence that customer discrimination in the market for doctors can be largely accounted for by statistical discrimination. I evaluate customer preferences in the field with an online platform where cash-paying consumers can shop and book a provider for medical procedures based on an experimental paradigm called validated incentivized conjoint analysis (VIC). Customers evaluate doctor options they know to be hypothetical to be matched with a customized menu of real doctors, preserving incentives. Racial discrimination reduces patient willingness-to-pay for black and Asian providers by 12.7% and 8.7% of the average colonoscopy price respectively; customers are willing to travel 100–250 miles to see a white doctor instead of a black doctor, and somewhere between 50–100 to 100–250 miles to see a white doctor instead of an Asian doctor. Further, providing signals of provider quality reduces this willingness-to-pay racial gap by about 90%, which suggests that statistical discrimination is an important cause of the gap. Actual booking behavior allows cross-validation of incentive compatibility of stated preference elicitation via VIC. 

Alex Chan, MPH

Alex Chan is a PhD candidate in Health Economics, and a Gerhard Casper Stanford Graduate Fellow. He has research interests in health economics, experimental economics, market design, and labor economics. His projects look at the causes and consequences of discrimination and diversity in medicine, U.S. Health Policy (especially organ transplantation), and market design in health policy and medicine. He holds an MPH from Harvard University. Before Stanford, he developed extensive experience in the healthcare industry starting as a McKinsey consultant, and most recently as Senior Vice President of Market Strategy with Optum/UnitedHealth before joining academia.

Personal Website: https://www.alexchan.net 

Register in advance for this meeting:


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PhD Candidate in Health Economics Department of Health Policy, Stanford University
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Timothy J. Layton, PhD

Associate Professor of Health Care Policy, Department of Health Care Policy, Harvard Medical School

His research focuses on the economics of health insurance markets with particular emphasis on understanding insurer behavior in those markets and designing optimal health plan payment systems. 

Dr. Layton and his collaborators are using economic models of health insurer behavior to design payment systems that combat inefficiencies caused by adverse selection. In one project, he and his coauthors are deriving new methods for designing health plan payment systems that set payments to insurers in a way that discourages insurers from inefficiently rationing care used by sick individuals with multiple chronic conditions. This work focuses on designing payment systems for the state and federal Health Insurance Marketplaces, as well as the Dutch health insurance market and the Medicare Advantage program.

Stay Tuned for Details

Timothy J. Layton Associate Professor Department of Health Care Policy, Harvard Medical School
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Amanda Starc, Ph.D.

Associate Professor of Strategy at the Kellogg School of Management
Faculty Research Fellow at the National Bureau of Economic Research (NBER)

Professor Amanda Starc received her BA in Economics from Case Western Reserve University, and her PhD in Business Economics from Harvard University. Dr. Starc's research interests include industrial organization and health economics. Her research examines the Medicare Advantage, Medicare Part D, and Medicare Supplement ("Medigap") markets, as well as consumer behavior in insurance exchanges. Recent work measures the effectiveness of direct-to-consumer advertising of pharmaceuticals. Her work links models of consumer choice and supply side incentives, and uses a range of econometric techniques to analyze data.

This will be an in-person event: Encina Commons, Conference Rom 119, with a boxed lunch served.

Amanda Starc Associate Professor Northwestern University, Kellogg School of Management
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Stacie B. Dusetzina, Ph.D

Associate Professor, Health Policy
Ingram Associate Professor of Cancer Research, Vanderbilt University Medical Center

Dr. Dusetzina is an associate professor in the Department of Health Policy and an Ingram associate professor of cancer research at Vanderbilt. She is a health services researcher whose work focuses on measuring and evaluating population-level use and costs of medications in the United States. Dr. Dusetzina’s work has contributed to the evidence base for the role of drug costs on patient access to care and policy changes that might improve patient access to high-priced drugs.

She has been recognized for her work at a national level, including being an invited participant for two working group meetings on “Patient Access to Affordable Cancer Drugs,” hosted by the President’s Cancer Panel, and being selected to co-author a National Academies of Sciences, Engineering and Medicine report on the same topic. Dr. Dusetzina’s research has also been broadly covered by The New York Times, NPR, Reuters, The Washington Post, STAT News, ABC News and The Wall Street Journal

In addition to her work on drug pricing, Dr. Dusetzina is a population health scientist and pharmacoepidemologist specializing in large data informatics. She has authored or co-authored more than 163 peer reviewed applied studies using Medicaid, Medicare, and commercial insurance claims data, and contributed several methods papers to the field. 

Seminar Title: Improving Access to Prescription Drugs through Policy Change

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Stacie B. Dusetzina Associate Professor, Health Policy Vanderbilt University
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