James Green, former Minister Counselor for Trade Affairs at the U.S. Embassy in Beijing, gave a talk titled “U.S.-China Diplomacy: 40 Years of What’s Worked and What has Not” before a Stanford China Program audience on May 6. Green is currently Senior Research Fellow at Georgetown University and is the creator of the new U.S.-China Dialogue Podcast, which features in-depth interviews with approximately two dozen former U.S. ambassadors, cabinet-level secretaries and other senior officials who were at the forefront of U.S.-China negotiations.

He recounts salient takeaways from these conversations regarding pivotal moments in U.S.-China relations, including normalization of relations, anti-Soviet cooperation in the 1980s, Tiananmen Square crackdown in 1989, Taiwan Strait crisis of 1995-1996, WTO accession in 2001, Belgrade bombing and EP-3 incident in 1999 and 2001, respectively; global financial crisis of 2008, the Beijing Olympics and the current U.S.-China trade tensions.  Among his many motivations for beginning this podcast series include his desire to question the notion circulating among U.S. foreign policy experts today that U.S. policy of engagement towards China had somehow failed. To Green, who has been active in U.S.-China relations since the mid-1990’s, U.S. policy had never been about transforming China from a one-Party, authoritarian system into a liberal democracy. In order to more accurately pinpoint what U.S. goals have been, Green stated, he undertook the project and interviewed those who had played key roles during pivotal moments in U.S.-China bilateral relations.

His interviewees have included, among others, such luminaries as Ambassador J. Stapleton Roy, who in 1978 participated in secret negotiations that led to the establishment of U.S.-P.R.C. diplomatic relations; John Negroponte, first director of national intelligence and deputy secretary of state in the late 2000s during China’s rise; and Ambassador Michael Froman, former U.S. Trade Representative under President Obama. His talk at the Stanford China Program includes key lessons he has derived from these interviews even as we enter into one of the most volatile times in U.S.-China bilateral relations.

The recording and transcript are available below.  

"If one foreign power continues to shred, on an ever-more daring basis, the integrity and inviolability of our electoral process, other foreign powers will draw lessons and follow. And they won’t all be pitching in on the Republican side," writes Larry Diamond in The American Interest. Read here.  

Many primary-care physicians continue to join multispecialty group practices, such as the Palo Alto Medical Foundation and Stanford Health Care, instead of working in their own solo practices or in practices with only other primary care doctors.

Physicians in practices of nine or fewer dropped from 40% in 2013 to 35% in 2015; the rate of those in practices of 100 or more increased from 30% to 35% during the same period.

But is this growing trend having a positive impact on health-care use and spending?

Stanford Health Policy’s Loren Baker and Kate Bundorf set out to find a few answers.

In their new working paper published by the National Bureau of Economic Research, they focused on Medicare beneficiaries who changed their primary care physician when they moved from one area to another. They focused on people who switched from a doctor in a primary-care-only practice to one in a multispecialty practice, and those who made the opposite switch.

They then compared changes in health-care use and spending before and after the move — and among patients who switch practice types and those who do not.

“We wanted to look at people who experienced an abrupt change in their primary care physician for reasons other than an explicit choice to change their physician,” Bundorf said.

“A weakness of this approach is that they may differ from people who don’t move,” said Bundorf, an associate professor of health research and policy at Stanford Medicine and a senior fellow at the Stanford Institute for Economic Policy Research (SIEPR). “But our descriptive statistics suggest that we capture a broad cross-section of types of people.”

They identified 119,272 patients who moved from one area to another and used data from Medicare claims from 1999 to 2010.

The results were striking

The results of the analysis show that multispecialty practice decreased annual medical spending by $1,600 per Medicare beneficiary — a 35% reduction in spending.

“The size of the result is very intriguing,” said Baker, a professor of health research and policy at Stanford Medicine and also a SIEPR senior fellow. “We are often happy when a change in health-care delivery can help achieve savings of even a few percentage points, but our results suggest the potential here is much larger than that.”

With their co-author Anne B. Royalty of Indiana University-Purdue University Indianapolis, they found the results were driven primarily by changes in hospital expenditures and are concentrated among patients with two or more chronic condition. This suggests multispecialty practices improve care delivery by reducing hospitalizations among relatively sick patients.

“The results imply that, while research has shown the potential for physician consolidation to increase prices in some settings, large multispecialty groups also have the potential to lower costs,” the authors wrote.

Baker said when they set out to do this research, they were not sure what they would find. 

“The results suggest that the way care is organized can be important for health-care delivery and that there may be organizational changes that could help us better manage spending.”

Larger practices don’t always lead to better health outcomes

While the pervasive view underlying the move toward consolidated practices is that larger, more integrated organizations provide care more efficiently through greater coordination of care, the literature on physician integration largely does not support this view. 

The authors point to a study that looked at data from the 1970s to 2013, which found little evidence that these larger practices improve the quality and lower the cost of health care. 

“The hope of many policymakers was that the larger, multispecialty organizations could organize care more efficiently,” Bundorf said. “Yet there is little evidence to date that larger practices have generated these types of benefits for patients. Since the literature has not taken a hard look at the single or multispecialty side of things, we wanted to investigate that here.”

While the trend is toward these big multispecialty practices, many physicians choose to remain in smaller or solo ones.

The Kaiser Family Foundation estimates that there are some 139,000 primary care physicians in the United States. Despite the transition to multispecialty practices, some 40% of physicians continue to work in solo practice or a small group of two-to-nine physicians.

It’s important, they said, to continue examining the health-care spending of all practice sizes.

“We are very curious to continue work on ways to learn more about how organizations achieve savings,” Baker said. “We are also excited to continue thinking about opportunities for policies that would encourage the formation of effective practices, for example through payment policy reforms.

Primary care physicians in the United States are increasingly joining multispecialty group practices, such as the Palo Alto Medical Foundation and Stanford Health Care.

Stanford Health Policy’s Loren Baker and Kate Bundorf analyzed how a physician’s single practice vs. a multispecialty practice (MSP) affects health-care spending and use.

Focusing on Medicare beneficiaries who changed their primary care physician due to a geographic move, they compared changes in practice patterns before and after the move between patients who switch practice types and those who do not.  

With their co-author Anne B. Royalty of Indiana University-Purdue University Indianapolis, they found that changing from a single to a multispecialty primary care group practice decreases annual Medicare-financed, per-capita expenditures by about $1,600, or a 28% reduction.

“The effect is driven primarily by changes in hospital expenditures and is concentrated among patient with two or more chronic conditions, suggesting that MSP improves care delivery by reducing hospitalizations among relatively sick patients,” they wrote in their working paper published by the National Bureau of Economic Research.

“The results imply that, while research has shown the potential for physician consolidation to increase prices in some settings, large multispecialty groups also have the potential to lower costs.” 

Read More

Physician training has long been notorious for marathon shifts, sleepless nights on call, and holidays worked. But that began to change in 2003, when the medical profession placed restrictions on work hours during residency. However, experts wondered, can we train residents in fewer hours and still make good doctors?

A new study in the BMJ says yes. The researchers, led by Dr. Anupam Jena, a professor of health care policy and medicine at Harvard Medical School, and Stanford Health Policy's Jay Bhattacharya, looked at the performance of internal medicine doctors in their first year of unsupervised medical practice after completing their training. 

They compared the outcomes for patients of two groups of physicians: those trained before 2003, when the typical work week was 100 hours; and those trained later under the new rules, which capped weekly hours at a mere 80, with no individual shift exceeding 30 hours. For the three quality measures examined — mortality within 30 days of being hospitalized, readmissions, and hospital services used (a measure of efficiency) — they found no differences between the groups.

Read More from this article published in STAT News.

Formed in 1979, the National Intelligence Council (NIC) works to provide policymakers with the U.S. intelligence community’s best judgments on crucial international issues. As a locus for coordinated intelligence analysis, the NIC’s work reflects the coordinated judgments of multiple agencies and departments in the broader intelligence community. But while it may be less shrouded in secrecy than many other intelligence offices, in some respects it is less well known.

In Truth to Power, published by Oxford University Press, editors Robert Hitchings and Gregory Treverton shed light on this little-understood intelligence agency. The volume provides the first-ever history of the NIC as recounted through the reflections of its eight chairs in the period from the end of the Cold War until 2017. APARC Fellow Thomas Fingar, who chaired the NIC from 2005 to 2008, is one of the contributors to the book.

In his chapter “New Mission, New Challenges”, Fingar discusses some of the challenges during his service with the agency. In particular, he reflects on two specific obstacles he faced during his tenure: executing the intelligence reforms drafted in the wake of 9/11, and repairing damage done to the NIC’s credibility by the failures of the National Intelligence Estimate (NIE) on Iraqi weapons of mass destruction (WMD).

During his tenure, Fingar wore not one but two hats; along with the NIC chairmanship, he concurrently served as deputy director of national intelligence for analysis (DDNI/A). He describes actions taken not only to restore confidence in the intelligence community, but also to effectively execute its expanded brief. For instance, having national intelligence officers take the DDNI’s seat at meetings afforded senior officials the opportunity to perceive their value and thereby rebuild confidence in the broader intelligence community.

The Council’s reforms would soon be put to the test by way of the production of an NIE on Iranian WMD. Fingar recognized that the estimate would be a strong indicator of whether the NIC had learned its lessons following the flawed 2002 Iraq WMD estimate, and that policymakers were certain to finely examine the end product for flaws (whether made unintentionally or with political purposes in mind). As such, Fingar needed to produce an NIE that was accurate, timely, and non-political, all while handling and incorporating newly received intelligence. Through the Iran NIE, Fingar found an opportunity to redress the often-fraught relationship between Congress and the intelligence community.

Fingar closes with a review of the NIC’s pathbreaking work in the area of climate change. At the behest of a U.S. senator, the NIC took on the task of producing an NIE on the strategic implications of climate change. The resulting study categorized countries according to both their vulnerabilities and ability to manage impacts, as well as the broader implications it had for U.S. national security over the next twenty years. And while policymakers ultimately did not use the report as Fingar had hoped, he takes justified comfort in pointing out how it laid the groundwork for additional reports that followed, such as the National Research Council’s 2013 report Climate Change and Social Stress: Implications for Security Analysis.

Read Fingar's Chapter

Nearly one year ago on August 10, 2018, SPICE honored the top three students in the 2018 Reischauer Scholars Program (RSP). The students gave presentations based on their final research papers and were honored by their instructor, Naomi Funahashi. One of the RSP honorees was Stacy Shimanuki, then a senior at Amador Valley High School in Pleasanton, California. While listening to her impressive presentation on the Pacific War, I recall continually having to remind myself that she was a high school student. After spending a gap year participating in a Mandarin language immersion program in Beijing through the Department of State’s National Security Language Initiative for Youth, Shimanuki is now working at SPICE as a summer intern.

For her internship at Stanford, Shimanuki is undertaking a list of tasks, which is growing steadily given her immense talents. As an RSP alumna and soon-to-be undergraduate student, she brings a unique perspective to SPICE’s work—especially in the area of curriculum development for high school students. Funahashi commented, “It is enormously rewarding to have one of my former students here at SPICE this summer, and I’m thrilled to have her as a colleague. SPICE is fortunate to have not only a brilliant student but also a person with exemplary interpersonal skills and tremendous focus. Stacy’s future is so bright. All of us at SPICE are excited to see the growth in her capacity for leadership in U.S.–Asia relations as she begins her undergraduate career this fall.”

Following her summer internship at SPICE, Shimanuki will be attending the University of Pennsylvania as a Huntsman Scholar. She will be enrolled in the Huntsman Dual-Degree Program for International Studies and Economics through the Wharton School of the University of Pennsylvania. Students like her make our work at SPICE incredibly rewarding.