Health Care
Shorenstein APARC Encina Hall E301 Stanford University
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Visiting Scholar at APARC, 2021-2022
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Ph.D

Dr. Cynthia Chen joined the Walter H. Shorenstein Asia-Pacific Research Center (APARC) as visiting scholar with the Asia Health Policy Program during the 2022 winter and spring quarters. She is an Assistant Professor at the National University of Singapore (NUS). Her current research focuses on the well-being and older adults, healthcare financing, and the economics of ageing. She is interested in how demographic, economic and social changes can affect the burden of care, financing needs and optimal resource allocation in the future. Her research has been supported by the Singapore’s Ministry of Health, Ministry of Education, the US National Institutes of Aging, and the Thai Health Promotion Foundation among others. To date, she has published more than 45 internationally peer-reviewed journals on societal ageing, the burden of chronic diseases, and cost-effectiveness research. Dr. Chen obtained her Ph.D. in Public Health, Masters and BSc in Statistics from NUS.

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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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Publication Type
Journal Articles
Publication Date
Subtitle
Impact on Health Care Utilization, Financial Risk Protection, and Health Status
Journal Publisher
Applied Economics
Authors
Qin Zhou
Qing He
Karen Eggleston
Gordon G. Liu
Authors
Noa Ronkin
News Type
News
Date
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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

Read More

A parent holds a child waiting to be given an infusion at an area hospital in China.
News

In China, Better Financial Coverage Increases Health Care Access and Utilization

Research evidence from China’s Tongxiang county by Karen Eggleston and colleagues indicates that enhanced financial coverage for catastrophic medical expenditures increased health care access and expenditures among resident insurance beneficiaries while decreasing out-of-pocket spending as a portion of total spending.
In China, Better Financial Coverage Increases Health Care Access and Utilization
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News

A New Validated Tool Helps Predict Lifetime Health Outcomes for Prediabetes and Type 2 Diabetes in Chinese Populations

A research team including APARC's Karen Eggleston developed a new simulation model that supports the economic evaluation of policy guidelines and clinical treatment pathways to tackle diabetes and prediabetes among Chinese and East Asian populations, for whom existing models may not be applicable.
A New Validated Tool Helps Predict Lifetime Health Outcomes for Prediabetes and Type 2 Diabetes in Chinese Populations
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News

Robotics and the Future of Work: Lessons from Nursing Homes in Japan

On the Future Health podcast, Karen Eggleston discusses the findings and implications of her collaborative research into the effects of robot adoption on staffing in Japanese nursing homes.
Robotics and the Future of Work: Lessons from Nursing Homes in Japan
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Subtitle

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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Health systems globally face increasing morbidity and mortality from chronic diseases, yet many — especially in low- and middle-income countries — lack strong chronic disease management in primary health care (PHC). We provide evidence on China’s efforts to promote PHC management using unique five-year panel data in a rural county, including health care utilization from medical claims and health outcomes from biomarkers. Utilizing plausibly exogenous variation in management intensity generated by administrative and geographic boundaries, we compare hypertension/diabetes patients in villages within two kilometers distance but managed by different townships. Results show that, compared to patients in townships with median management intensity, patients in high-intensity townships have 4.8% more PHC visits, 5.2% fewer specialist visits, 11.7% fewer inpatient admissions, and 3.6% lower medical spending. They also tend to have better medication adherence and better control of blood pressure. The resource savings from avoided inpatient admissions substantially outweigh the costs of the program. 

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Publication Type
Journal Articles
Publication Date
Journal Publisher
Journal of Health Economics
Authors
Hui Ding
Yiwei Chen
Min Yu
Jieming Zhong
Ruying Hu
Xiangyu Chen
Chunmei Wang
Kaixu Xie
Karen Eggleston
Paragraphs

This paper is positioned at the intersection of two literatures: partisan polarization and deliberative democracy. It analyzes results from a national field experiment in which more than 500 registered voters were brought together from around the country to deliberate in depth over a long weekend on five major issues facing the country. A pre–post control group was also asked the same questions. The deliberators showed large, depolarizing changes in their policy attitudes and large decreases in affective polarization. The paper develops the rationale for hypotheses explaining these decreases and contrasts them with a literature that would have expected the opposite. The paper briefly concludes with a discussion of how elements of this “antidote” can be scaled.

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Publication Type
Journal Articles
Publication Date
Journal Publisher
American Political Science Review
Authors
James S. Fishkin
Alice Siu
Larry Diamond
Norman Bradburn
Number
pp. 1 - 18
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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,
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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
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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 

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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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Faculty Lead, Center for Human and Planetary Health
Professor of Medicine (Infectious Diseases)
Professor of Epidemiology & Population Health (by courtesy)
Senior Fellow at the Freeman Spogli Institute for International Studies
Senior Fellow at the Woods Institute for the Environment
Faculty Affiliate at the Stanford Center on China's Economy and Institutions
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MD

Prof. Stephen Luby studied philosophy and earned a Bachelor of Arts summa cum laude from Creighton University. He then earned his medical degree from the University of Texas Southwestern Medical School at Dallas and completed his residency in internal medicine at the University of Rochester-Strong Memorial Hospital. He studied epidemiology and preventive medicine at the Centers for Disease Control and Prevention.

Prof. Luby's former positions include leading the Epidemiology Unit of the Community Health Sciences Department at the Aga Khan University in Karachi, Pakistan, for five years and working as a Medical Epidemiologist in the Foodborne and Diarrheal Diseases Branch of the U.S. Centers for Disease Control and Prevention (CDC) exploring causes and prevention of diarrheal disease in settings where diarrhea is a leading cause of childhood death.  Immediately prior to joining the Stanford faculty, Prof. Luby served for eight years at the International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b), where he directed the Centre for Communicable Diseases. He was also the Country Director for CDC in Bangladesh.

During his over 25 years of public health work in low-income countries, Prof. Luby frequently encountered political and governance difficulties undermining efforts to improve public health. His work within the Center on Democracy, Development, and the Rule of Law (CDDRL) connects him with a community of scholars who provide ideas and approaches to understand and address these critical barriers.

 

Director of Research, Stanford Center for Innovation in Global Health
Affiliated faculty at the Center on Democracy, Development and the Rule of Law
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Encina Commons,
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Stanford, California 94305-6006

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Associate Professor, Health Policy
MS in Health Policy Program Director
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PhD

Maria Polyakova, PhD, is an Associate Professor of Health Policy at the Stanford University School of Medicine. Her research investigates the equity and efficiency of government interventions in healthcare markets. She is especially interested in questions surrounding the design, financing, and broad economic impacts of public health insurance systems. Her work also investigates the drivers of individual decision-making in health care and the roots of socio-economic differences in health outcomes. Dr. Polyakova received a BA degree in Economics and Mathematics from Yale University, and a PhD in Economics from MIT.

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Professor, Health Policy
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PhD

Jeremy Goldhaber-Fiebert, PhD, is a Professor of Health Policy, a Core Faculty Member at the Center for Health Policy and the Department of Health Policy, and a Faculty Affiliate of the Stanford Center on Longevity and Stanford Center for International Development. His research focuses on complex policy decisions surrounding the prevention and management of increasingly common, chronic diseases and the life course impact of exposure to their risk factors. In the context of both developing and developed countries including the US, India, China, and South Africa, he has examined chronic conditions including type 2 diabetes and cardiovascular diseases, human papillomavirus and cervical cancer, tuberculosis, and hepatitis C and on risk factors including smoking, physical activity, obesity, malnutrition, and other diseases themselves. He combines simulation modeling methods and cost-effectiveness analyses with econometric approaches and behavioral economic studies to address these issues. Dr. Goldhaber-Fiebert graduated magna cum laude from Harvard College in 1997, with an A.B. in the History and Literature of America. After working as a software engineer and consultant, he conducted a year-long public health research program in Costa Rica with his wife in 2001. Winner of the Lee B. Lusted Prize for Outstanding Student Research from the Society for Medical Decision Making in 2006 and in 2008, he completed his PhD in Health Policy concentrating in Decision Science at Harvard University in 2008. He was elected as a Trustee of the Society for Medical Decision Making in 2011.

Past and current research topics:

  1. Type 2 diabetes and cardiovascular risk factors: Randomized and observational studies in Costa Rica examining the impact of community-based lifestyle interventions and the relationship of gender, risk factors, and care utilization.
  2. Cervical cancer: Model-based cost-effectiveness analyses and costing methods studies that examine policy issues relating to cervical cancer screening and human papillomavirus vaccination in countries including the United States, Brazil, India, Kenya, Peru, South Africa, Tanzania, and Thailand.
  3. Measles, haemophilus influenzae type b, and other childhood infectious diseases: Longitudinal regression analyses of country-level data from middle and upper income countries that examine the link between vaccination, sustained reductions in mortality, and evidence of herd immunity.
  4. Patient adherence: Studies in both developing and developed countries of the costs and effectiveness of measures to increase successful adherence. Adherence to cervical cancer screening as well as to disease management programs targeting depression and obesity is examined from both a decision-analytic and a behavioral economics perspective.
  5. Simulation modeling methods: Research examining model calibration and validation, the appropriate representation of uncertainty in projected outcomes, the use of models to examine plausible counterfactuals at the biological and epidemiological level, and the reflection of population and spatial heterogeneity.
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Encina Commons Room 180,
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LCY: Tan Lan Lee Professor
Professor, Health Policy
Professor Pediatrics (General Pediatrics)
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MD, PhD

C. Jason Wang, M.D., Ph.D. is a Professor of Pediatrics and Health Policy and director of the Center for Policy, Outcomes, and Prevention at Stanford University.  He received his B.S. from MIT, M.D. from Harvard, and Ph.D. in policy analysis from RAND.  After completing his pediatric residency training at UCSF, he worked in Greater China with McKinsey and Company, during which time he performed multiple studies in the Asian healthcare market. In 2000, he was recruited to serve as the project manager for the Taskforce on Reforming Taiwan's National Health Insurance System. His fellowship training in health services research included the Robert Wood Johnson Clinical Scholars Program and the National Research Service Award Fellowship at UCLA. Prior to coming to Stanford in 2011, he was an Assistant Professor of Pediatrics and Public Health (2006-2010) and Associate Professor (2010-2011) at Boston University and Boston Medical Center. 

Among his accomplishments, he was selected as the student speaker for Harvard Medical School Commencement (1996).  He received the Overseas Chinese Outstanding Achievement Medal (1996), the Robert Wood Johnson Physician Faculty Scholars Career Development Award (2007), the CIMIT Young Clinician Research Award for Transformative Innovation in Healthcare Research (2010), and the NIH Director’s New Innovator Award (2011). He was recently named a “Viewpoints” editor and a regular contributor for the Journal of the American Medical Association (JAMA).  He served as an external reviewer for the 2011 IOM Report “Child and Adolescent Health and Health Care Quality: Measuring What Matters” and as a reviewer for AHRQ study sections.

Dr. Wang has written two bestselling Chinese books published in Taiwan and co-authored an English book “Analysis of Healthcare Interventions that Change Patient Trajectories”.  His essay, "Time is Ripe for Increased U.S.-China Cooperation in Health," was selected as the first-place American essay in the 2003 A. Doak Barnett Memorial Essay Contest sponsored by the National Committee on United States-China Relations.

Currently he is the principal investigator on a number of quality improvement and quality assessment projects funded by the Robert Wood Johnson Foundation, the National Institutes of Health (USA), Health Resources and Services Administration (HRSA), and the Andrew T. Huang Medical Education Promotion Fund (Taiwan).

Dr. Wang’s research interests include: 1) developing tools for assessing and improving the quality of healthcare; 2) facilitating the use of innovative consumer technology in improving quality of care and health outcomes; 3) studying competency-based medical education curriculum, and 4) improving health systems performance.

Director, Center for Policy, Outcomes & Prevention (CPOP)
Co-Director, PCHA-UHA Research & Learning Collaborative
Co-Chair, Mobile Health & Other Technologies, Stanford Center for Population Health Sciences
Co-Director, Academic General Pediatrics Fellowship
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