As health-care costs climb ever upward, controlling expenses without sacrificing high-quality care becomes increasingly important. Payment systems based on the value of care are emerging as a way to combat rising costs.

Many researchers like Jason Wang, an associate professor of pediatrics and a Stanford Health Policy core faculty member, have found that bundled payment systems may help health-care institutions achieve better value of care.

In a new study in the Journal of the American Medical Association Oncology, Wang and his co-authors show that a value-based bundled payment system is associated with cost containment and improvement in care, even improving chances for survival.

The study examined Taiwan’s bundled pay-for-performance (PFP) system for breast cancer. Instead of the traditional fee-for-service (FFS) system that is typical in the United States — in which every test, surgery and exam is billed individually — this system includes all aspects of treatment in a single established cost, or bundled payment.

Based on guidelines set by Taiwan’s National Health Insurance Administration (NHIA), the pilot program reimbursed health-care institutions’ costs for breast cancer treatment based on the patient’s cancer stage, 0 to IV. Institutions that exceeded the NHIA’s standards received a financial bonus as an incentive for better performance.

The study followed 4,215 patients in the bundled-care system over a five-year period, comparing the quality of their care, the cost of their treatment and the outcomes of their treatment to 12,506 similar patients in the traditional FFS system.

The authors found that patients in the bundled-payment system received better care throughout treatment, were more likely to survive, and contained medical costs over time, compared to their peers in the FFS system.

Costs for patients in the bundled payment system remained about the same throughout the study. However, the cost of treatment for those in the FFS system steadily increased throughout the study period. By the end, even health-care institutions receiving the maximum bonus incentive would incur lower costs than those in the FFS system.

Yet even though their treatment was cheaper, patients in the bundled system experienced better results. Patients using the bundled system had significantly higher survival rates for cancer stages 0 to III, and they were more likely to receive higher quality care based on quality indicators.

This is largely due to the better coordination of care made necessary by the bundled system, according to Wang.

“When you play in an orchestra, the whole group needs to play together, so it plays the right tune,” said Wang. “Focusing on value for the patient and the health-care system forces people to play the same tune.”

Wang believes the lessons learned from Taiwan’s program could be applied in other parts of the world, including the United States, which is currently moving toward bundled cancer care.

Though the U.S. already bundles care for conditions like appendicitis and chemotherapy — in which costs are fairly predictable — many hospital administrators fear that broadening the use of bundled payments for more complex conditions is too risky, financially.

Wang does not share their misgivings.

“People say, ‘We can’t do this for a very complex disease.’ It’s not true,” he said. “When we went outside of the U.S., we started to find systems that work.”

Wang found that when institutions can coordinate care for patients — that is, when a single institution manages all aspects of a patient’s care — the patient is more likely to have better outcomes.

“If institutions take the leadership of providing the infrastructure to coordinate care, they can really deliver better care with the same or lower costs.”

There are benefits for the institutions, too. Right now, because health insurance providers may accept or reject particular costs in an unpredictable way, care institutions never know how much they’re going to get paid for a service. But in a bundled payment system, costs are much more stable and revenue easier to predict.

Considering the benefits, Wang hopes the Taiwan breast cancer study will show institutions in the United States and around the world that bundled payments for cancer can be done on a broad scale.

The value, he said, is worth the risk.

Jeff Decker knows what war can do to a person. He lived it for four deployments, as an Army special operations squad leader in Iraq and Afghanistan who twice earned the Army Commendation Medal for valorous conduct in combat.

Decker, who now serves as a research assistant in Stanford’s Center for International Security and Cooperation under Joe Felter, is the founder of March on Veteran, an organization that supports veterans suffering from mental health issues, such as post-traumatic stress disorder, or PTSD. March on Veteran is a free, online program available to any former member of the military.

Decker joined CISAC in September, about a year after he launched March on Veteran. Felter, a special forces veteran, is a senior research scholar who studies counterinsurgencies, terrorism and political violence for CISAC.

Decker, after his military service, struggled with the transition to civilian life due to the anger, anxiety, chronic pain, and sleeplessness that PTSD caused. On top of this, he did not have access to a Veteran Affairs treatment facility. That’s when the native of Buffalo, N.Y. turned to self-educating himself on mental health treatments available to veterans.

“When I studied for my doctorate in Australia, I cobbled together a mental health program to help myself. Now I’m sharing that and making those resources available to other veterans with the same needs,” said Decker, who earned his doctorate in international relations from Bond University, where he wrote his dissertation “Enhancing the Effectiveness of Private Military Contractors.”

So far, about 83 veterans have begun March on Veteran’s pilot program, which is a web-based and self-directed study. Decker handles almost all of the human contact. He is currently expanding the program to incorporate the veteran-to-veteran peer element with the help of other veteran volunteers.

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March on Veteran is, as Decker calls it, “support for veterans by veterans.” It is a recovery program personalized to one’s particular needs and is provided by people who have lived experience. It is not affiliated with any government organization like the VA or Department of Defense to maintain the veteran’s confidentiality. Veterans can access the program or sign-up to meet other veterans online.

“This program focuses on trying to help veterans reach their personal goals instead of focusing on ‘fixing’ them,” Decker said. “We are all about improving veteran quality of life, and a big part of that is connecting with other veterans.”

With Felter, Decker will be mostly working on his Hacking for Defense class project, which uses startup methodology to innovate and find solutions for critical challenges facing America’s defense and intelligence agencies.

Before arriving on campus, Decker conducted national security and international affairs research as a RAND Corporation summer associate for two summers in Washington, D.C.

CDDRL Mosbacher Director Francis Fukuyama participated the screening of the Children of Men, the 2006 film adaptation of PD James’ dystopian novel, at the event organized by the Future Tense - “My Favorite Movie” series, in which thought leaders host screenings and discussions on their favorite movies with science and technology themes. Children of Men is set in the year 2027, 18 years after the last child was born, due to worldwide infertility. In the video at the top of this post, filmed Sept. 21, Fukuyama expanded on the thoughts he shared at the screening. Watch here. 

The consequences of state collapse anywhere in the world can be devastating and destabilizing for neighboring and even distant countries.

The complexity of each situation demands a tailored response, according to Stanford scholars embarking on a new American Academy Arts & Sciences project to identify the best policy responses to failing states embroiled in civil wars.

A failed state is that whose political or economic system has become so weak that the government is no longer in control. Such instability has already threatened or affected Syria, Libya, Yemen and other polities.

The project, Civil Wars, Violence and International Responses, is led by Stanford’s Karl Eikenberry and Stephen Krasner. Eikenberry is a faculty affiliate at Stanford’s Center for International Security and Cooperation (CISAC) and the former U.S. ambassador to Afghanistan. Krasner is a faculty member in the political science department and a senior fellow at the Freeman Spogli Institute for International Relations and Hoover Institution.

Other Stanford scholars involved include Francis Fukuyama and Steve Stedman of the Center on Democracy, Development, and the Rule of Law; CISAC's Martha Crenshaw, political scientist James Fearon; Paul Wise of the Center for Health Policy and the Center for Health Policy and the Center for Primary Care and Outcomes Research; and Michele Barry, the senior associate dean for global health at the medical school.

The effort will culminate in a two-volume issue in AAAS’s journal Dædalus. On Nov. 2-4, the academy will hold an authors’ workshop in Cambridge, Mass., to discuss journal content.

Different approaches

In an interview, Eikenberry said the problematic U.S. interventions in Iraq and Afghanistan make it clear that different approaches must be used for different countries.

“The robust counterinsurgency campaign that the U.S. employed for periods of time in both Afghanistan and Iraq was premised on the viability of the standard development model that aims to put countries on the path to economic well-being and consolidated democracy,” he said.

However, such an approach assumes that decision makers in those states have the same objectives as the intervening states, which typically seek to improve the lives of people in those countries, said Eikenbery. Prior to serving as the U.S. ambassador to Afghanistan from 2009 until 2011, Eikenberry had a 35-year career in the U.S. Army, retiring in 2009 with the rank of lieutenant general.

As Krasner points out, when intervention occurs, the hope is that improvements in one area – such as the quality of elections, rule of law, economic growth, or military recognition of civilian authority – would lead to improvements in other areas, according to Eikenberry.

But opposition and a constrained sense of “limited opportunities” can arise to thwart a well-meaning intervention, Eikenberry said.

He added, “Information asymmetries and the absence of mutually compatible interests between national and external elites, make it impossible to put target countries on a rapid path to prosperity and consolidated democracy. External actors must have much more modest goals.”

Syrian consequences

As for the case of Syria, Eikenberry noted that such civil wars can actually become more lethal and dangerous to global order than inter-state conflicts.

These types of conflicts like that in Syria tend to escalate into high levels of violence because of the costs that the losing parties believe they will incur, he said.

“This in turn leads to state fragmentation and the possibility of transnational groups with international ambitions getting involved,” he said. “Civil wars can result in an enormous number of civilian casualties, which generates large scale refugee flows” and puts huge pressure on neighboring states.

Eikenberry said Syria is being “internationalized by entangling regional and great powers in proxy wars,” which is exacerbating that conflict beyond Syria and throughout the greater Middle East. As for the immediate, direct threat to the U.S., that debate still continues, he added. 

On that note, one project goal is to assess risks to other countries that may emanate from civil wars and protracted intrastate violence like that in Syria, Eikenberry said. He and his colleagues will examine the effects of  international terrorism, massive displacements of people, proxy wars that escalate to interstate warfare, criminal organizations that displace governments, and pandemics. 

Policy implications

Eikenberry is hopeful the project influences policy and practice toward countries experiencing civil war and violence.

“Facilitating dialogue among a variety of constituencies with knowledge on the dynamics and impact of civil wars that might not normally or directly interact, including government and military officials, human rights organizations, academic and scholarly experts, and the media, will be one outcome of the project,” he said.

The idea is to allow “new ideas to emerge” regarding how to handle such states, as well as methods of applying such findings, he said.

“Exploring ways to create stability and more lasting peace, taking into consideration voices from academic and practical fields, should prove valuable to the policy community,” Eikenberry said.

Following publication of the volumes, the project will convene international workshops aimed at developing better regional perspectives. Such outreach activities will provide the feedback for the publication of another AAAS paper aimed at informing U.S. and international policy and research on the subject. A series of roundtable discussions in Washington is also planned.