Rural areas of China have made remarkable progress in reducing adult mortality within the past 15 years yet broadened health insurance was not a casual factor in that decline, according to a new study by an international research team that includes Asia Health Policy Program Director Karen Eggleston.

The New Cooperative Medical Scheme (NCMS), a government-subsidized insurance program that began in 2002-03, expanded to cover all of rural China within a decade. Examining NCMS and cause-specific mortality data for a sample of 72 counties between 2004 and 2012, the researchers found that there were no significant effects of health insurance expansion on increased life expectancy.

The study, published in the September issue of Health Affairs, showed results consistent with previous studies that also did not find a correlation between insurance and survival, although much research confirms NCMS increased access to healthcare, including preventive services, and shielded families from high health expenditures.

Commenting on the study, Eggleston said population health policies remain central to China’s efforts to increase life expectancy and to bridge the gap between rural and urban areas.

Eggleston also noted that multiple factors beyond the availability of health care determine how long people live, and anticipates the research team will continue to explore the impacts of NCMS by extending the study to look at infants and youth.

Read the study (may require subscription) and view a related article on the Stanford Scope blog.

End-stage renal disease makes up 7.2 percent of Medicare spending, even though those patients represent less than 1 percent of the Medicare population, according to a database that tracks chronic kidney disease.

Despite the gnashing of teeth about the runaway costs of Medicare spending, the national health-care system for the elderly, younger people with certain disabilities and chronic kidney disease appears to have found one way to lower costs.

Congress established the end-stage renal disease (ESRD) Prospective Payment System in 2008, as part of the Medicare Improvement for Patients and Providers Act. It mandated that ESRD Medicare patients treat themselves at home if able.

The new payment system introduced two incentives to increase home dialysis use: bundling injectable medications into a single payment for treatment and paying for training for patients to give themselves injections and treatment at home.

A new study by Stanford researchers shows home dialysis treatment among Medicare patients increased by 5.8 percent from January 2006 through August 2013. The researchers also found that non-Medicare patients covered by other forms of health insurance also turned to home dialysis by a jump of 4.1 percent.

“These spillover effects suggest that major payment changes in Medicare can affect all patients with end-stage renal disease,” the authors wrote in the study published in the latest edition of the Journal of the American Society of Nephrology. “One of the stated goals of the PPS payment reform was to incentivize an increase in-home dialysis use, and it appears that it has succeeded in this stated goal.”

Eugene Lin, a postdoctoral fellow in nephrology at the Stanford School of Medicine and lead author of the study, told me that most nephrologists believe the trend toward home dialysis is good for the taxpayers and for the patients.

People going through this phase of chronic kidney disease — when dialysis or a kidney transplant are the only chance of survival  — cost less to take care of at home and have similar outcomes to in-center hemodialysis patients.

“It’s hard to say if one therapy is definitively better than the other,” Lin said, “though home dialysis generally offers patients more independence and potentially better quality of life.”

Lin explained the difference between in-center hemodialysis and home treatment: At a center, blood is filtered through a machine, whereas home dialysis entails either having a hemodialysis machine at home (and having a caregiver help with the treatments) or performing peritoneal dialysis.

The latter is the most commonly used at-home treatment and involves using the abdominal compartment as a filter. The toxins in the blood get filtered through the abdominal membranes into clean fluid, which is then removed and discarded.

Similar drugs are used both in centers and at home, but they’re easier to give in the hemodialysis setting, so had a higher likelihood of overuse prior to payment reform.

“Once they bundled the drug reimbursement with the treatment, we saw dramatic decreases in the use of these drugs and a concurrent increase in home dialysis use,” Lin said.

The researchers, including senior author Jay Bhattacharya of Stanford Health Policy, noted that home dialysis remained stagnant at around 11 percent from 1983 to 1992 and steadily declined until 2008.

“While the cause of this decline is unknown, several policies made home dialysis less favorable than in-center hemodialysis economically,” they wrote.

First, the federal Centers for Medicare & Medicaid Services in 1991 revised its reimbursement policy for the erythropoietin-stimulating agent needed for functioning kidneys, making it the most profitable component of in-centers hemodialysis. Then, CMS introduced a tiered fee-for-service physician payment in 2004, providing the potential for enhanced revenues with in-center dialysis.

But the PPS bundling shifted erythropoietin from the profit side to the cost side, so it was no longer advantageous to use high doses common with in-center hemodialysis, Lin said. This paved the way for an increase in home dialysis use, which is less costly to administer.

Non-communicable diseases such as heart and respiratory disease, cancer, obesity and diabetes are now responsible for some two-thirds of premature deaths around the world. And most of those are in low- and middle-income countries.

The United Nations has estimated that on top of the social and psychological burdens of chronic disease, the cumulative loss to the global economy could reach $47 trillion by 2030 if things remain status quo.

“That was a big whopper of a number and got a lot of attention, and that was good because it raised awareness,” said Rachel Nugent, vice president for global non-communicable diseases (NDCs) at the research institute RTI International.

“It’s an issue that is driven by a lot of different factors, “ she said. “And understanding how the larger social and economic factors affect NDCs, at a policy level, very little progress has been made — there’s been very little collaboration.”

Nugent was addressing the fourth annual Global Health Economics Colloquium at University of California San Francisco, with health experts, policymakers, students and researchers from Stanford, Berkeley and UCSF who gather every year to take a deep dive into the economics of a global health issue. More than 200 experts from 10 universities and public health departments attended the conference.

The daylong gathering focused on recent developments in the economics of NDCs, looking at case studies from around the world, and new guidelines for cost-effectiveness analysis and the role of economics in reducing health inequality.

“The donors are not convinced that there are cost-effective things that we can do in these countries; a lot of them are very skeptical that this is affecting the poor,” said Nugent, a member of the World Health Organization’s expert advisory panel on the management of NCDs.

In India, for example, much of the population still defecates outdoors, contaminating water sources and agricultural products, which can lead to malnutrition and physical and cognitive disorders. Many donors would rather see funds go to building latrines as they can see tangible results; NDC prevention is a long-term slog.

“But I don’t think we should necessarily think of NDCs as either-or,” said Nugent.  “I think that integration of services and programming is very much at the forefront of what is the right way to go.”

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Cost-effectiveness Analyses

Nugent’s research has shown five cost-effective interventions would avert more than 5 million premature deaths from NCDs by 2030, or a reduction of 28.5 percent in projected mortality from chronic disease around the world. And the average benefit-cost ratio is 9:1, at a global cost of $8.5 billion a year.

The interventions are raising the price of tobacco products by 125 percent through taxation; providing aspirin to 75 percent of those suffering from acute myocardial infarction; reducing salt intake by 30 percent; reducing the prevalence of high blood pressure with low-cost hypertension medication; and providing preventive drug therapy to 70 percent of those at high risk of heart disease.

Gillian Sanders-Schmidler, a professor of medicine at Duke University Medical Center and former assistant professor of medicine at Stanford Health Policy’s Center for Primary Care and Outcomes Research, addressed the colloquium about recommendations of the Second Panel on Cost-Effectiveness in Health and Medicine.

“There is a continued emphasis on transparency and comparability across analyses,” said Sanders-Schmidler. “And of course the big changes are that we’re now asking for a second reference case and using an ‘impact inventory’ table to clarify the scope of the findings.”

The independent panel of non-government scientists and scholars, which also included Stanford Health Policy’s Douglas K. Owens, focused on new ways to deliver health care effectively, yet with a focus on efficiency, as health care spending in the United States has reached 18 percent of GDP, much greater than the global average of 10 percent.

The first panel that convened in 1996 recommended that all cost-effectiveness analyses of health interventions include a reference case that uses standard methodological practices to improve comparability and quality. The second panel, which published its findings in September, now recommends that in addition to the societal perspective recommended by the original panel, that CEAs include a second reference case that looks at the health-care sector impact of an intervention. Additional guidance was given on what to include in the societal perspective reference case.

The panel wrote in its JAMA “special communication” that these societal reference cases should include medical costs “borne by third-party payers and paid out-of-pocket by patients, time costs of patients in seeking and receiving care, time costs of informal (unpaid) caregivers, transportation costs, effects on future productivity and consumption, and other costs and effects outside the health-care sector.”

They found most countries, including the United States, give greater weight to clinical evidence in their cost-effectiveness analyses. The panel now recommends an “impact inventory” that helps analysts and end-users of cost effectiveness analyses look at the impact of interventions beyond the formal health-care sector.

“We’re trying to ask people to be explicit,” said Owens, director of the Center of Primary Care and Outcomes Research and Center for Health Policy at Stanford.

“We want them to look at how to value outcomes in a societal perspective, not just the health-care sector, to look at all these other sectors such as productivity consumption, criminal justice, education, housing and the environment,” he said.

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Case Studies

Several case studies presented at the colloquium indicated that policy changes, government intervention and social factors are key to preventing obesity and diabetes and other NCDs.

Kristine Madsen, an associate professor of public health at UC Berkeley who focuses on childhood obesity, spoke about the nation’s first “soda tax” on sugar-sweetened beverages, which was implemented in Berkeley in March 2015.

The city has seen a 21 percent decline in the drinking of soda and other sugary drinks in low-income neighborhoods after the city levied a penny-per-ounce tax on sodas and sugary drinks. At the same time, according to a study in the American Journal of Public Health, neighboring San Francisco — where a similar soda-tax measure was defeated — and Oakland saw a 4 percent increase in the purchase of sweetened beverages.

“This decline of 21 percent in Berkeley represents the largest public health impact in an intervention that I have ever seen,” said Madsen.

Sergio Bautista of the Mexico National Institute of Public Health and UC Berkeley, said that Mexico’s sugary drinks tax implemented in January 2014 is expected to lead to a 10 percent reduction in sugary drinks consumption and prevent an estimated 189,300 cases of diabetes in a country famed for its sugary bottled cola.

William Dow, a professor of health policy management at UC Berkeley, shared his research on Costa Rica, where on average people live longer than Americans, despite the several times higher income and 10 times higher health expenditures in the United States.

Costa Rican men have a life expectancy of 77 and the women typically live until age 82; in Americans the numbers are 76 and 81, respectively. Obesity is low among Costa Rican men and few of their women smoke. Lung cancer mortality in the United States is four times higher among men and six times higher among women.

“It’s remarkable in so many ways,” Dow said, noting that deaths in the Central American country are due predominantly to infectious disease. “Does Costa Rica have any unique effective programs to emulate, or is there something going on upstream driving those health outcomes?”

He believes Costa Rica’s national health insurance and excellent access to primary care for nearly all its people are key. Having this guaranteed lifetime access to health care also reduces the stress and depression that can so badly harm physical health.

“And I would argue that probably diet is one of the most important things going on here,” said Dow, noting their diets are healthy.

Costa Ricans eat mostly unprocessed foods such as rice and black beans, corn tortilla, yam and squash, with little meat and plenty of fresh fruit.

“They also have the highest remaining life expectancy at age 80 of any country in the world, he said. “What we have learned in Costa Rica would be helpful in many other countries.”

The health gap between rich and poor children in developing countires is staggeringly high, but Assistant Professor of Medicine Eran Bendavid found that it is shrinking. In his pilot project, "Empirical Evidence on Wealth Inequality and Health in Developing Countries," Bendavid discovered that since the mid-2000s, life expectancies for children under five are starting to converge. How can we continue to close the gap? Watch to find out.

Consider the lowly worm. For some, it’s just a garden pest. But for more than a billion people in the developing world, parasitic worms can be a pernicious threat, causing disease, disability and sometimes death.

In a newly published perspective in the medical journal The Lancet, Stanford researchers, including Stanford Health Policy's Eran Bendavid and a host of distinguished colleagues, urge the World Health Organization to develop sweeping new guidelines to help end parasitic worm diseases, one of the world’s most prevalent health problems. They call for greatly expanded treatment of these diseases, which could save years of human suffering and an estimated $3 billion in lost productivity — similar to the impact of the Ebola and Zika epidemics of recent years, they say.

“Now everyone is coming together to say, ‘Now is the time, after more than a decade of new experience and data, to update the way we do things,’ said Nathan Lo, a Stanford MD/PhD candidate who is the first author of the commentary. “There is so much opportunity, whether it’s expanding treatment from children to the entire community or bringing in other strategies, such as sanitation, to strengthen the way we approach these diseases.”

The perspective is published today in Lancet Infectious Diseases and coincides with a WHO meeting in Geneva where officials, including many of the authors, are gathering to consider new treatment guidelines.

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The U.S. Preventive Services Task Force now recommends adults ages 40 to 75 with no history of heart disease — but who nevertheless have at least one risk factor and an elevated risk of cardiovascular disease — take a low- to moderate-dose statin.