10/20/99

Kathleen O'Toole, News Service (650) 725-1939; e-mail: kathleen.otoole@stanford.edu

Unusual health policy and practice research centers launched

Stanford's Institute for International Studies is blazing a new trail this fall by adding health care to its research interests. The Stanford School of Medicine is taking a path less traveled by committing to support research into the routine delivery of health care.

In the words of one Stanford faculty member, the university has, after two decades of trying, finally arranged the marriage of scientists who study health at the micro-level of genes and proteins with their counterparts in the social sciences who look at the health of communities, nations and the planet.

Stanford has been known for some time as a place where an engineer and a medical doctor will team up to explore how to make a better medical record database or an improved hip or knee replacement. It's also a place where a fair number of students have earned both an M.D. and a Ph.D. in a field other than medicine.

However, it took people committed to a broader vision of what might be done about the nation's health crisis to finally bring together the resources for two permanent research centers: the Center for Health Policy (CHP) within the Institute for International Studies; and the Center for Primary Care and Outcomes Research (PCOR), affiliated with the School of Medicine. One will focus on policy questions, the other on clinical care questions.

Housed together in Encina Commons, the centers opened this fall with nine core faculty members, eight postdoctoral students and more than 50 other affiliated scholars. Seven research projects funded by foundations, the federal government and university units are under way, and faculty are team teaching courses this year with such titles as "The Political Economy of Health Care in the United States" and "Analysis of Costs, Risks and Benefits of Health Care." Doctors who have completed their residency programs can apply for fellowships that will train them in non-medical aspects of health care, and other advanced students also can pursue master's degrees in health services research.

Most universities could not pull off such a mixed marriage of disciplines because they don't have the foundations to build upon, Alan Garber, the Henry J. Kaiser, Jr. Professor in the school of medicine and director of the two centers, told a campus gathering at the center's formal opening celebration on Sept. 30.

Garber, who is trained both as an economist and medical doctor, was referring to emeriti faculty such as Nobel laureate Kenneth Arrow, who produced seminal work on health care economics in the early 1960s, and Victor Fuchs, who shocked many in the 1970s with his book, Who Shall Live. Fuchs was one of the first to show that lifestyle played a greater role than medical treatment in health outcomes. Garber also was referring to Professor Alain Enthoven of the Graduate School of Business, whom many credit with laying the intellectual framework for the managed care revolution, and Richard Scott, a sociologist of organizations who has extensively studied health care institutions. Enthoven will publish a book on the British national health care system this fall, and Scott has one due out early next year on postwar San Francisco Bay Area health care institutions.

The centers' "assets" also include more recent additions to the faculty, including Mark McClellan, a physician-economist who recently returned from a stint as deputy assistant secretary of the treasury, and Daniel Kessler, trained in economics and law. They have used large Medicare and state databases to conclude that differing liability laws in states affect the cost of care for heart attacks without affecting the health outcomes for patients. In the School of Medicine, there is Doug Owens, president of the Society for Medical Decision Making, who has teamed up with faculty in the School of Engineering in the past to search for the most efficient prevention programs for AIDS and other epidemics.

The centers would not have been founded, Garber said, without administrative support from medical researchers such as Judith Swain, chair of the Department of Medicine, one of the sponsors of PCOR, or from Walter Falcon, a Third World development economist who directed the Institute for International Studies until last year and cleared the way for CHP.

The centers' goal ­ to improve the education and research that guides health policy and clinical practices ­ is sorely needed, according to Stanford alumnus David Eddy, who spoke at the centers' opening. A former Stanford faculty member, he came to campus for a surgical residency and wound up also getting a degree in engineering-economic systems. He was one of the first mathematicians to do cost-benefit studies of pap smears and other screenings for cancer. Eddy is a senior adviser for health policy and management to Southern California Kaiser Permanente, and an essayist for the Journal of the American Medical Association. He is an internationally recognized authority on such topics as practice guidelines, outcomes research, technology assessment, mathematical modeling, cost containment, rationing and priority-setting.

"The quality problem is huge," Eddy said of today's medical care. Most studies show large variation in how doctors treat the same conditions, in what they tell their patients, and in how they and their patients perceive the outcomes. As an example, he cited one study that found 25 percent of the elderly patients were given medications that were counterproductive to their conditions or to other drugs they were taking. "We have to be extremely humble about what we think we know," Eddy said.

Policymakers also aren't getting adequate information to make health care regulatory decisions, Eddy added. Proposals in Congress and state legislatures are aimed at stopping either government or managed care providers from intervening in the doctor-patient relationship, he said. "But if we are going to fix the quality problems, we are going to have to have managed care that helps physicians do a better job of treating patients." Policymakers and the public also need to be better informed on trade-offs between the costs and benefits of treatment options, Eddy said.

Among the research projects under way are one by McClellan and collaborators in a global research network to analyze differences and changes in heart attack care. Comparing technologies and health system regulations across countries, the researchers hope to determine ways to reduce cost and increase quality in an area of treatment that is very important to industrialized countries with aging populations. Another study headed by Garber will look at the effects of new medical technology on the costs, health and well-being of the elderly. A recent study by Enthoven and Sara Singer, a senior research scholar and executive director of CHP, looked at how institutions define medical necessity in order to aid in setting standards for care. The final report on the latter project can be downloaded at the California HealthCare Foundation's website, in the California Health Policy section, http://www.chcf.org/healthpolicy/medicalnec.cfm.

"There is no shortage of voices advocating fixes for every problem facing the health care system," Garber said. "But there is a great need for informing policy through the rigorous, creative, interdisciplinary research that Stanford does so well."

In addition to Garber and Singer, key staff at the centers include Kathryn McDonald, executive director of PCOR, and Pamela Renna, CHP/PCOR administrator. An endowment from the Homer Laughlin Fund provides core support for PCOR.

More information about the centers is available from the CHP/PCOR website: http://healthpolicy.stanford.edu.

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By Kathleen O'Toole