On May 30, Congressional Representative Steve Russell spoke to Stanford students enrolled in Technology and Security (MS&E 193/293) about the role of Congress in national security. 

The rising level of carbon dioxide in the atmosphere means that crops are becoming less nutritious, and that change could lead to higher rates of malnutrition that predispose people to various diseases.

That conclusion comes from an analysis published Tuesday in the journal PLOS Medicine, which also examined how the risk could be alleviated. In the end, cutting emissions, and not public health initiatives, may be the best response, according to the paper's authors.

Research has already shown that crops like wheat and rice produce lower levels of essential nutrients when exposed to higher levels of carbon dioxide, thanks to experiments that artificially increased CO2 concentrations in agricultural fields. While plants grew bigger, they also had lower concentrations of minerals like iron and zinc.

Read the entire story at NPR. 

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.

"In what may be looked back upon as the most important election in the United States in 2018, the voters of Maine rejected political cynicism on Tuesday and preserved ranked-choice voting (RCV) for its future elections. To appreciate the historic significance of this vote for greater democratic choice, it’s important to understand what Mainers were up against—a two-party duopoly in which “all the levers of power” (in the words of one grassroots activist) were overtly or covertly working to block political reform," writes Larry Diamond in American Interest. Read here. 

The 2018 IISS Shangri-La Dialogue was held in Singapore, June 1-3. Shorenstein APARC's Donald Emmerson was in attendance; some of his observations from the the 17th Asia Security Summit are provided below.

NOTE: This post is forthcoming from YaleGlobal.

Donald K. Emmerson heads the Southeast Asia Program at Stanford University where he is also affiliated with the Center on Democracy, Development, and the Rule of Law.

The following article first appeared on The Diplomat.

With the historic U.S.-North Korea summit on the immediate horizon, we must recognize that denuclearization will not and cannot be permanent or irreversible as long as there is a desire to reverse it. U.S. President Donald Trump may strike a “grand deal” with North Korean leader Kim Jong-un to denuclearize North Korea, but Kim can — and most likely will — reverse course at his convenience to construct new nuclear weapons. By focusing solely on denuclearization, we risk losing sight of the bigger, more important picture — that is, transforming North Korea into a normal state that no longer sees the need to pursue nuclearization for deterrence, survival, or any other reason.

Much of debate has centered on why Kim suddenly emerged from long-held silence to take the world’s center stage through a series of summits. Was he pressured by toughened sanctions, as Trump credits himself for? Or was it an expression of Kim’s confidence as a leader of a now de facto nuclear power, with more leverage for negotiation? Or has he simply been trying to buy time to avoid war — to get through the unpredictable and ruthless Trump’s tenure as U.S. president? Yet, what really matters now is not so much the question of why Kim came to the table, but rather how we can make the latest détente sustainable without repeating the failures of the past. Will it be different this time?

With the Trump-Kim summit now back on the track after a 24-hour drama of cancellation then resumption, each side seems to have softened its stance by lowering the bar. Next week in Singapore, both leaders will be sorely tempted by clear political and economic interests to paint the meeting as a success. Real challenges, however, will arise as the logistical details of North Korea’s denuclearization are discussed following the summit. The Trump team is unlikely to abandon its goal of the CVID (complete, verifiable, and irreversible denuclearization) of North Korea, while Kim and his men will stand firmly against this all-out approach so as not to follow the footsteps of Libya, Iraq, or Ukraine. North Korea has reportedly demanded a CVIG (complete, verifiable, and irreversible guarantee) of the security of the current regime, but there is a great danger that these deals, if made, will be nothing more than another sheet of paper full of empty words. The deep mistrust between the two countries cannot be overcome overnight, especially considering that both leaders have pretty bad track records of reneging on previous commitments. Neither CVID nor CVIG has much chance of being realized in the current context, from either a technical or a practical perspective.

With all this skepticism, why should we still bother playing this game with North Korea again? It is because we see a window of opportunity to guide North Korea into the international community through processes of diplomatic communication, exchange, and engagement. North Korea’s summit diplomacy has revealed its desire to appear a normal state. Kim vigorously showcased four summit meetings  — twice each with China’s Xi Jinping and South Korea’s Moon Jae-in — and numerous high-level meetings, within two months, all within the parameters of conventional “state-to-state” relationships, departing from past practices. Standing side-by-side with the South Korean president to read out a joint declaration, immediately releasing news of Kim’s summit meetings through its media, presenting Kim’s wife, Ri Sol-ju, as the state’s first lady — all of this would have been unthinkable in his father or grandfather’s generation.

North Korea’s latest efforts at international recognition as a normal state may be insincere and ill-intentioned, but even so, we should continue to allow North Korea and Kim to experience firsthand what it feels like and means to be treated as a normal state and a normal leader according to the ordinary conventions of international diplomacy. Although the goal seems so far away and unreachable, we should strive to normalize North Korea in all respects — its economy, its domestic and international politics, its integration into international institutions, and its adherence to international laws, norms, rights, duties, orders, etc.

CVID can still serve as a short- to mid-term goal, but not as a definitive solution to the long-standing North Korean threat. Whatever is decided at the upcoming summit, a more comprehensive roadmap should be set for enacting desirable transformations in security and economic relations with North Korea, putting the country on a path to become a stable and normal state increasingly integrated into the international community, where it would feel secure without a need for nuclear armament. As Trump says, he is starting a “process” of dealing with North Korea; the upcoming summit should be the beginning of an opportunity to advance this goal. After all, a normal North Korea can achieve CVID, but CVID cannot achieve a normal state.

Gi-Wook Shin is director of the Shorenstein Asia-Pacific Research Center at Stanford University, and Joyce Lee is a research professional in the Korea Program at the Shorenstein Asia-Pacific Research Center at Stanford University.

The health insurance marketplaces created by the Affordable Care Act (ACA) could unravel because its enrollees strategically drop in and out of coverage, Stanford scholars write in a new working paper released June 4 by the National Bureau of Economic Research.

The end result could be a complete unraveling of the market, said Petra Persson, an assistant professor of economics in the Stanford School of Humanities and Sciences.

“If you have too many people who drop out after a few months of coverage, you might end up in a situation where insurers don’t want to offer any insurance at all in the market,” said Persson, who co-authored the paper with Stanford Graduate School of Business assistant professors Rebecca Diamond and Timothy McQuade and NYU Stern’s Michael J. Dickstein. Persson and Diamond are also fellows at the Stanford Institute for Economic Policy Research.

The ACA, also known as Obamacare, passed in March 2010 with the goal of making health insurance more accessible. It established a competitive marketplace where individuals could shop for federal and state-level health care plans. Over 2014 and 2015 – the first two years of the program – the share of Americans covered by individually purchased health insurance rose by 50 and 75 percent, respectively.

Health care consumption surged, especially in low-income households and families with young children. But, as the researchers discovered, so did attrition: Dropout was sharpest after just one month of coverage. And only half of all new enrollees committed a full year to an insurance program.

Health care consumption and attrition

To analyze enrollment and attrition, the researchers studied 104,233 households that purchased health insurance in California either before or after the ACA came into effect.

The researchers examined spending habits and income sources for possible explanations of why people might have discontinued health care coverage. For example, did they drop out because they could no longer afford it, because of a job loss or other large expense?

The researchers found that this was the case before the ACA came into effect. Pre-ACA, people often dropped out early because they experienced a loss of income, like unemployment. But post-ACA, the loss of income was much less important in explaining early dropout.

“These findings indicate that the ACA limited the risk of being forced to drop insurance coverage due to unexpected liquidity shocks,” said Persson.

If income shocks can’t account for dropout, then what can?

The researchers found that some people strategically drop coverage after they have used the health care services they need.

“Our analysis shows that many consumers are strategically signing up for insurance to help defray the costs of non-chronic, potentially discretionary, health care needs and then dropping coverage once they have satisfied these needs,” said Diamond.

“The regulatory structure of the ACA law potentially incentivizes exactly this behavior,” the researchers wrote, noting that because the ACA prevents insurers from discriminating against applicants, they cannot legally reject applicants who strategically dropped coverage the previous year.

The fallout of dropouts

This behavior makes it difficult for insurers to set prices, said Persson.

When people consume a year’s worth of health care in only a three-month period – and only pay a portion of the annual premium – it can be incredibly expensive for insurers. They can only guess what fraction of policyholders will end up dropping out mid-year.

The researchers discovered a counterintuitive response from insurers: Health care plans that experienced more dropouts reduced their premium prices the following year.

“Insurers are trying to increase the demand from the pool of consumers who don’t drop out,” said Diamond, observing that these are the people who are more price sensitive to the cost of an annual plan. “People who drop out are going to be less sensitive to the price set by the plan. They are always going to be willing to pay a higher monthly premium because they know they are not going to pay the full annual amount.”

While lowered annual premiums may seem like a beneficial result for committed health care consumers, the presence of dropouts undermines the stability of the market, the researchers said. As a result, insurers may be unwilling to offer plans in the individual market, they said.

Next steps

The ACA has been especially effective in providing lower-income households with health care coverage through a market that previously had largely served more affluent households, said Persson.

But for ACA to continue being effective, enrollees must stay enrolled, Persson added.

While the ACA originally came with penalties for ceasing coverage early, the researchers said it was not enough. It was still cheaper for new enrollees to pay the fine for dropping out mid-year than paying a full year of annual premiums, the researchers found in their cost analysis.

The recent removal of the individual mandate will likely increase the midyear dropout rate, said Diamond. “More dropout will raise financial pressure on insurers, increasing the possibility that the market unravels completely.”