Crafting a Health System that Protects Us AllUniversity of MinnesotaMinneapolis, MNMay 13, 2008Dynamic Principles and Democratic PowersBobby Milstein Centers for Disease Control and PreventionBMilstein@cdc.gov

Poised for Significant Change

Lessons from Previous Health Reform VenturesHeirich M. Rethinking health care: innovation and change in America. Boulder CO: Westview Press, 1999.Kari NN, Boyte HC, Jennings B. Health as a civic question. American Civic Forum, 1994. Available at .Meadows DH, Richardson J, Bruckmann G. Groping in the dark: the first decade of global modelling. New York, NY: Wiley, 1982.

Prior efforts were largely disappointing because ofPiecemeal approachesComplicated schemes that were opposed by special interestsAssumption that healthcare dynamics are separate from other areas of public concernConventional analytic methods make it difficult to Observe the health system as a large, dynamic enterpriseCraft high-leverage strategies that can overcome policy resistanceBeen thinking of health and healthcare as nouns (i.e., commodities to be distributed), not as verbs (i.e., public work to be produced)Policy resistance is the tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.-- Meadows, Richardson, Bruckman

-- Julie GerberdingPark A. Time 100: the people who shape our world. Time Magazine 2004 April 26.The debate about healthcare reform needs to be enriched by including the concepts of health protection and health equityand [we] have never had a better opportunity to truly influence how we get from where we are to wherever the new health system will be.

Adverse living conditions + Absence of protective efforts = Vulnerability

Appreciating the Wider Scope of the Health ChallengeHealth > HealthcareAdler N, Stewart J. Reaching for a healthier life: facts on socioeconomic status and health in the USA. San Francisco, CA: John D. and Catherine T. MacArthur Research Network on Socioeconomic Status and Health 2007. http://www.macses.ucsf.edu/News/NEWS.htmlBraveman P, Egerter S. Overcoming obstacles to health. Princeton, NJ: Robert Wood Johnson Foundation, Commission to Build a Healthier America; February, 2008. http://www.rwjf.org/pr/product.jsp?id=26673California Newsreel. Unnatural causes: is inequality making us sick? San Francisco, CA: PBS; 2008.Hofrichter R, editor. Tackling health inequalities through public health practice. Washington, DC and Lansing, MI: The National Association of County and City Health Officials and the Ingham County Health Department; 2006.Institute of Medicine. The future of the public's health in the 21th century. Washington, DC: National Academy Press, 2002.Wilkinson RG, Marmot MG, editors. The solid facts: social determinants of health. 2nd ed. Copenhagen: Centre for Urban Health, World Health Organization; 2003.World Health Organization. Commission on social determinants of health. WHO, 2008. http://www.who.int/social_determinants/en/

The Promise of a Syndemic OrientationA syndemic orientation clarifies the dynamic and democratic character of public health workMilstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008. http://www.cdc.gov/syndemics/monograph/index.htmYou think you understand two because you understand one and one. But you must also understand and.-- Sufi SayingStudying innovations in public health work, with emphasis on transformations in concepts, methods, and moral orientations The word syndemic signals special concern for many kinds of relationships:mutually reinforcing health problemshealth status and living conditionssynergy/fragmentation in the health protection system (e.g., by issues, sectors, organizations, professionals and other citizens)

Citizen-shipIt is one of a few approaches that explicitly includes within it our power to respond, along with an understanding of its changing pressures, constraints, and consequences

Epidemic The term epidemic is an ancient word signifying a kind of relationship wherein something is put upon the peopleEpidemiology first appeared just over a century ago (in 1873), in the title of J.P. Parkin's book "Epidemiology, or the Remote Cause of Epidemic DiseasesEver since then, the conditions that cause health problems have increasingly become matters of public concern and public workElliot G. Twentieth century book of the dead. New York,: C. Scribner, 1972.Martin PM, Martin-Granel E. 2,500-year evolution of the term epidemic. Emerging Infectious Diseases 2006. Available from http://www.cdc.gov/ncidod/EID/vol12no06/05-1263.htmNational Institutes of Health. A Short History of the National Institutes of Health. Bethesda, MD: 2006. Available from http://history.nih.gov/exhibits/history/Parkin J. Epidemiology; or the remote cause of epidemic diseases in the animal and the vegetable creation. London: J and A Churchill, 1873.A representation of the cholera epidemic of the nineteenth century. Source: NIHThe pioneers of public health did not change nature, or men, but adjusted the active relationship of men to certain aspects of nature so that the relationship became one of watchful and healthy respect.-- Gil Elliot

Syndemic The term syndemic, first used in 1992, strips away the idea that illnesses originate from extraordinary or supernatural forces and places the responsibility for affliction squarely within the public arenaIt acknowledges relationships and signals a commitment to understanding population health as a fragile, dynamic state requiring continual effort to maintain and one that is imperiled when social and physical forces operate in harmful waysConfoundingConnecting*SynergismSyndemicCo-occurring* Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping

Tools for Policy Planning & EvaluationTime Series ModelsDescribe trendsMultivariate Stat ModelsIdentify historical trend drivers and correlatesPatternsStructureEventsIncreasing:Depth of causal theoryRobustness for longer-term projectionValue for developing policy insightsDegrees of uncertaintyLeverage for changeDynamic Simulation Models Anticipate new trends, learn about policy consequences, and set justifiable goals

Growth of Citizen ActorsAlmost everyone knows about the explosion of the dot-comsbut millions have still not heard the big story: the worldwide explosion of dot-orgs.More people today have the freedom, time, wealth, health, exposure, social mobility, and confidence to address social problems in bold new ways.-- David BornsteinBornstein D. How to change the world: social entrepreneurs and the power of new ideas. New York: Oxford University Press, 2004.60%

Power Has to be Organized Loose groupings of interested individuals dont have a prayer of addressing major criseshousing, crime, schools, jobs, and others. Each crisis is, at bottom, a power crisis. The power of the mob, the power of drug lords, the power of corrupt borough machines, and the inertia of the police bureaucracy could only be challenged by another, deeper institutional power. -- Michael GecanGecan M. Going public. Boston: Beacon Press, 2002.

Even Broad-Based Organizing May Not Be Enough Insights from the North Karelia ProjectPuska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995.National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Available at .Mortality Changes in North Karelia in 1970-1995 (men, 35-64) Coronary heart disease -73% All cardiovascular disease-68% Lung cancer-71% All cancers-44% All causes-49%Mortality Changes in North Karelia in 1970-1995 (men, 35-64) Coronary heart disease -73% All cardiovascular disease-68% Lung cancer-71% All cancers-44% All causes-49%

North Karelia ProjectBuilding Power, Turning Jobs into Public WorkHealth ProfessionalsPhysiciansHealth EducatorsPsychologistsEpidemiologistsSociologistsHospital administratorsPharmaceutical manufacturersNursesRehabilitation therapists

Other Citizens BakersFarmers Grocers Food scientistsManufacturersRestaurant owners HousewivesEntertainersEntrepreneursJournalistsMedia professionalsTeachersSchool administratorsElected representativesPuska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995.National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Available at .Boyte HC, Kari NN. Building America: the democratic promise of public work. Philadelphia: Temple University Press, 1996.

Transforming All Dimensionsof the System

Expand insurance coverageImprove quality of careChange reimbursement ratesImprove operational efficiencySimplify administrationOffer provider incentivesEnable healthier behaviorsBuild safer environmentsCreate pathways to advantageIngredients for Transforming Population HealthA Short Menu of Policy Proposals

Are these ingredients connected?

How?

Does that matter?

Where to Begin with a Problem as Vast as Health System Change?

Learn to How Succeed in a Simpler, Simulated SystemMadon T, Hofman KJ, Kupfer L, Glass RI. Implementation science. Science 2007;318(5857):1728-1729. Milstein B, Homer J, Hirsch G. The health protection game: prototype design, preliminary insights, and future directions. Atlanta, GA: Centers for Disease Control and Prevention; May 8, 2008.

Is it too audacious to think about representing the entire U.S. health protection enterprise?

Definitely, if we study every detail up close

Not if we take a macroscopic view, from a very particular distanceRichardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; January 28, 2008. Rosnay J. The macroscope: a new world scientific system. New York, NY: Harper & Row, 1979.White F. The overview effect: space exploration and human evolution. 2nd ed. Reston VA: American Institute of Aeronautics and Astronautics, 1998.

Rules of the Health Protection GameGoal Navigate the U.S. health system toward greater health and equityTask Prioritize intervention options across nine policy domainsDecisions Craft health protection strategies over 8 rounds (from 2010-2050), using feedback available every five yearsScoring Achieve the best results across four criteria simultaneouslySave lives (i.e., reduce the mortality rate)Improve well-being (i.e., reduce unhealthy days)Achieve equity (i.e., reduce unhealthy days due to Disadvantage)Lower healthcare costs (i.e., reduce expenses per capita)Appropriate implementation expenses (i.e., subsidy, program cost)Game Setup A population in dynamic equilibrium, with fixed rates of birth and net immigration, experiencing high starting levels of mortality, unhealthy life, social inequity, and healthcare costsNo changes are due to trends originating outside the health sector such as aging, migration, economic cycles, technology, climate change, etc.

Navigating Health FuturesGetting Out of a Deadly, Unhealthy, Inequitable, and Costly TrapFour Problems in the Current System: High Morbidity, Mortality, Inequity, CostDeath rate per thousandUnhealthy days per capitaHealth inequity indexHealthcare spend per capita10 6 0.2 6,000 0 0 0 4,000 20002005201020152020202520302035204020452050 How far can you move the system?

High-Level Map of Health System DynamicsMost parts of the health systemso often discussed separatelyare in fact connectedAdapted from: Milstein B, Homer J, Hirsch G. Leading health system change using The Health Protection Game. Syndemics Prevention Network, Centers for Disease Control and Prevention; Work in Progress, May 2008. DRAFT: May 8, 2008

Main Health System Dynamics Risk, Disease, Health Status, and Costs

Main Health System Dynamics Effective Health Care is Powerfuland Expensive

Main Health System Dynamics Insurance Coverage Enables Access

Main Health System Dynamics Disadvantage Creates a Double Vulnerability

Main Health System Dynamics Demand Affects the Sufficiency of Providers

Main Health System Dynamics Cutting Reimbursements May Control Cost

Main Health System Dynamics Reimbursement Also Affects Quality

Main Health System Dynamics Reimbursement Further Affects Profit and Attractiveness

Main Health System Dynamics Health Equity Captures the Consequences of Differences in Vulnerability, Health Status, and Access to Care

Selected Estimates for Model Calibration

ParameterProxyInitial Values (~2000)SourcesAdvantaged & Disadvantaged Prevalence Household Income (< or $25,000) Advantaged = 79% Disadvantaged = 21% CensusSymptomatic Disease/InjuryPrevalence Self-rated health is good, fair, or poor Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%) BRFSS JAMAAsymptomatic Chronic Disease Prevalence High blood pressure (HBP) High cholesterol (HC) Asymp = Tot Chron - Symp Overall = 40% (54.5% tot chron - 14.5% Symp) D/A Ratio (tot chronic) = 1.15 (= 61%/53%) NHANES JAMANo Health Problems Prevalence Self-rated health is excellent or very good No HBP or HC Overall = 33% Advantaged = 36% Disadvantaged = 24% BRFSS NHANES Mortality Deaths per 1,000 Overall = 8.4 D/A Ratio = 1.80 Vital Statistics AJPHMorbidity Unhealthy days per month per capita Overall = 5.25 D/A Ratio = 1.78 BRFSSHealth Equity Unhealthy days (or deaths) attributable to disadvantage Attrib. fraction (unhealthy days) = 14.1% Attrib. fraction (deaths) = 14.4% Census BRFSSHealth Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82 CensusUnhealthy Behavior Prevalence Smoking Physical inactivity Overall = 34% D/A Ratio = 1.67 BRFSS JAMA Austin StudyUnsafe Environment Prevalence Neighborhood not safe Overall = 26% D/A Ratio = 2.5 BRFSS JAMA Austin Study

Illustrative Intervention Scenarios * The reimbursement cut is relative to health care input factor costs (labor, services, overhead). In model, this is done as an absolute cut. In real life, it could represent a freeze in reimbursements relative to ongoing inflation in factor costs.

Exploring Intervention ScenariosCut Reimbursements to Office-Based Physicians by 20%Scoring Criteria: Deaths, Unhealthy Days, Inequity, Cost10 6 0.2 6,000 0 0 0 4,000 20002005201020152020202520302035204020452050Death rate per 1,000 Unhealthy days Health inequity index Healthcare spending per capita >>>> These results are from a prototype model.

Exploring Intervention ScenariosCut Reimbursements to Office-Based Physicians by 20%Quality of disease & injury care0.60.40.2020002005201020152020202520302035204020452050Prevalence of disease & injury0.60.40.2020002005201020152020202520302035204020452050 Quality of DI care for the managed10.750.50.25020002005201020152020202520302035204020452050Primary care providers per 10 thousand popn2015105020002005201020152020202520302035204020452050AdvantagedDisadvantagedAdvantagedDisadvantagedAdvantagedDisadvantaged>>>> These results are from a prototype model.

Additional Preliminary FindingsUniversal CoverageLowers morbidity and mortality quicklyIncreases cost significantly (greater volume of mediocre services, which do little to prevent disease)Worsens inequity (greater demand exacerbates pre-existing provider shortage for disadvantaged)Quality of CareLowers morbidity and mortality quickly, even more so than Universal Coverage (more people benefit)Costs rise initially, then fall (the benefits of disease prevention accrue gradually)Worsens inequity (better quality services exacerbate pre-existing provider shortage for disadvantaged)Upstream Health ProtectionConsistent pattern of strong, sustained improvements in morbidity, mortality, cost, and equityTakes time to generate significant effects (~10 years)Works in three ways, all favoring the disadvantaged: (1) fewer upstream risks lower disease prevalence, which in turn (2) eases demand on scarce provider resources; and (3) reduces costs and improves health care accessAverage unhealthy days per capita65.554.54200020102020203020402050ProtectionCoverageQualityPrototype Model OutputHealth care spending per capita6,0005,5005,0004,5004,000200020102020203020402050ProtectionCoverageQualityPrototype Model OutputHealth inequity index (morbidity)0.20.150.10.050200020102020203020402050 ProtectionCoverageQualityPrototype Model Output

Additional Preliminary FindingsPathways to AdvantageConsistent pattern of sustained improvements in morbidity, mortality, cost, and equityProfound effect on equity, with lesser impacts on health status and costSpending actually rises slightly at first, then falls as lower vulnerability prevents disease and reduces healthcare costs (a mix of downstream and upstream dynamics) Average unhealthy days per capita65.554.54200020102020203020402050ProtectionCoveragePathwaysQualityPrototype Model OutputHealth care spending per capita6,0005,5005,0004,5004,000200020102020203020402050 ProtectionCoveragePathwaysQualityPrototype Model OutputHealth Inequity Index (Morbidity)0.20.150.10.050200020102020203020402050 ProtectionCoveragePathwaysQualityPrototype Model Output

A Model IsAn inexact representation of the real thing

Gaming Supports Learning and WayfindingMorecroft JDW, Sterman J. Modeling for learning organizations. Portland, OR: Productivity Press, 2000.Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.Multi-stakeholder Dialogue

For Further Informationhttp://www.cdc.gov/syndemics

EXTRAS

Syndemics Prevention NetworkGreatest accomplishmentsLead in gasolineCVD Mortality North Karelia trends Action PlanTobacco Consumption CA & MA Best practices commitment to comprehensivness

Beyond programs to focus on policies

Retrospective policy eval is essential, but today we will concentrate on prospective policy eval the evaluative aspect of planning, organizing, and literally directing the course of social change

Introduce basic principles

Expand conventional approach to a more explicit dynamic and democratic foundation (Venn Diagram)

Highlight role of one particular methodology: simulation modelingBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkThe health sector now is one of the most consequential parts of the American economy, employing more people than any other area and quadrupling its share of the gross national product in the past 40 years. Innovations both large and small have sought to limit this harmful instability, but those reforms have been uniformly unsuccessful. Six times since the Depression, the United States has tried and failed to establish universal financial access to healing services, and the balance between prevention and treatment remains almost no balance at all, with 97% of all resources spent on health devoted to healing those living with an affliction. The character and composition of the system has evolved markedly, but the system-wide problems of poor performance, spiraling cost, and stark inequity not only persist but show signs of intensifying. The central challenge does not stem from the absence of sound policy options, but in our failure to perceive the larger dynamics that ultimately scuttle or subvert even the most logical innovations. The end result is counterintuitive: America has evolved the most rapidly advancing health care industry in the world, but it neither adequately nor equitably secures the health of the public; and worse, the unrestrained cost of healing preventable afflictions now exerts a destabilizing force in the larger political economy of the nation and the world.

Sociologist Max Heirich points to three reasons for our disappointing track record in reforming health policy. First, problems were often tackled piecemeal, as though a single intervention in one area (even a major one) would correct the larger dynamic at workSecond, the more comprehensive reform plans roused the opposition of interest groups and the larger publicBut even if they had succeeded politically, those proposals probably would not have succeeded practically, because they did not address more fundamental dynamics that were creating problems in health careAnd third, health-care dynamics were treated as if they existed independently of everything else that was happening in the political and economic system-a serious miscalculation (Heirich 1999).*

Probing deeper, he goes on to suggest that a different mix of strategies might have emerged had the health sectors organizational problems been viewed in terms of their connections to changes occurring in wider national and international contexts. Potentially effective reforms were overlooked, in Heirichs view, because most of the analytic strategies popular among academics, politicians, and policy makers fail to observe the system as a whole in ways that let policy makers shape individual choicesand even fewer analytic strategies have made it possible to discuss processes of mutual change that are occurring, or to analyze how innovations fit into larger nonequilibrium dynamics that are developing.

Such methodological shortcomings call for novel ways of thinking about the essence of public health work. Through serious reflection and committed action we may yet repair the disconnection between our experience of the health system and the tools that we use to study and govern its behavior. That disconnection sits at the core of our failed reform attempts, and it is the genesis of the disarray and disorientation against which we struggle today. Many of the problems undermining the public's health (e.g., chronic illnesses, environmental decay, depression, violent conflict, HIV/AIDS, emerging infectious disease, terrorism) will remain entrenched and insolvable using conventional policies and practices. Moreover, the sheer number of health threats will increase and become inexorably intertwined unless we adjust the fundamental mismatch between the expanding scope of public health work and the comparative narrowness of our models for understanding and directing change. That mismatch must be solved the way all problems are solved: by rethinking the situation, clarifying values, and reorienting our frame of reference for action. Officials at the CDC, along with leaders of the System Dynamics Society and a worldwide network of other interested citizens, are now exploring a pioneering approach that promises to reorient public health work and transform health futures for generations to come. It begins with the following commitments....Bobby Milstein (August 26, 2004)Syndemics Prevention NetworkBut I believe the time has come where we have even more to contribute to this debate. We are about prevention, but were also about something thats even more expansive, and that really is the notion of health protection. Yes, prevention is a very important part of health protection, prevention of disease, injury and disability. But increasingly, were in the business of health promotion as well as preparedness, preparedness for infectious and occupational, environmental, and terrorist threats. Certainly thats been a conspicuous part of our portfolio since 2001, although its always been part of CDCs core mission. Health protection expands the debate about healthcare and healthcare reform, but its not the whole picture, because we know that the other part of the debate is about fairness in our healthcare system. And the concept of health equity is one that we at CDC use as an implicit part of our value system when were thinking about our work. Its what drives our passion. Its what motivates us to go anywhere, anytime, to do anything that needs to be done to help protect peoples health. And it really is the principle that, I think, is hidden behind some of the statements that weve traditionally made about our mission. So when you think about CDCs mission, its important to include the concept of health equity in it. And we havent clearly defined this for our agency, but I think we are recognizing that at least this is the absence of health disparity. It may require a measurement so that we can define equality among groups with more or less social advantage, and there is the element of social justice that in the health equity environment there is fairness in peoples opportunity to achieve optimal health status. So if we think about these two principles, health protection and health equity, its very clear that the healthcare system that we have today is lacking these two principles in too many families and in too many locations. Bobby Milstein (August 26, 2004)Syndemics Prevention NetworkBut I believe the time has come where we have even more to contribute to this debate. We are about prevention, but were also about something thats even more expansive, and that really is the notion of health protection. Yes, prevention is a very important part of health protection, prevention of disease, injury and disability. But increasingly, were in the business of health promotion as well as preparedness, preparedness for infectious and occupational, environmental, and terrorist threats. Certainly thats been a conspicuous part of our portfolio since 2001, although its always been part of CDCs core mission. Health protection expands the debate about healthcare and healthcare reform, but its not the whole picture, because we know that the other part of the debate is about fairness in our healthcare system. And the concept of health equity is one that we at CDC use as an implicit part of our value system when were thinking about our work. Its what drives our passion. Its what motivates us to go anywhere, anytime, to do anything that needs to be done to help protect peoples health. And it really is the principle that, I think, is hidden behind some of the statements that weve traditionally made about our mission. So when you think about CDCs mission, its important to include the concept of health equity in it. And we havent clearly defined this for our agency, but I think we are recognizing that at least this is the absence of health disparity. It may require a measurement so that we can define equality among groups with more or less social advantage, and there is the element of social justice that in the health equity environment there is fairness in peoples opportunity to achieve optimal health status. So if we think about these two principles, health protection and health equity, its very clear that the healthcare system that we have today is lacking these two principles in too many families and in too many locations. Bobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkPublic health work is becoming moreInter-connected (ecological, multi-causal, dynamic, systems-oriented) Concerned more with leverage than control Public (broad-based, partner-oriented, citizen-led, inter-sector, democratic) Concerned with many interests and mutual-accountabilityQuestioning (evaluative, reflexive, critical, practical) Concerned with creating and protecting values like health, dignity, security, satisfaction, justice, wealth, and freedom in both means and ends

Taken together, these changes present serious challenges for planners and evaluators, some of which includeLocating categorical disease programs within a broader system of health protectionConstructing credible knowledge without comparison/control groupsDifferentiating questions that focus on attribution versus contributionBalancing trade-offs between short- and long-term effectsAvoiding the pitfalls of professonalismHarnessing the power of citizen-led public workDefining standards and values for judgmentOthers

Bobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkTime series of trendsBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkThis figure focuses on the population and its movement among states of health, risk behavior, environmental exposures, and socioeconomic advantage or disadvantage. Disadvantage makes it harder for people to choose healthier behaviors and exposes them to more hazardous environments, leaving them more vulnerable to an array of afflictions that increase aggregate disease prevalence. The disadvantaged also have worse access to health care than do the advantaged, due to less insurance coverage and less sufficiency of providers to meet patient demand. Greater disease prevalence combined with worse access to care means that the disadvantaged experience greater morbidity and mortality per capita than the advantaged do. Another factor affecting health outcomes is the quality of care delivered, reflecting the extent to which providers take the time to listen carefully to their patients and do a better job of diagnosis, counseling, and care. Quality of care may be improved by encouraging adoption of guidelines for best practice, but the incentive for such adoption is hindered if insurance reimbursement rates are not adequate. These relationships stand as a broad summary of the a much larger causal structure that governs health system change over time.

The various parts of the health system, often discussed separately in popular discourse and in analytic studies, are in fact connected. In some cases, these connections may create unanticipated side effects, where short-term improvements turn into longer-term losses (or vice versa). For example, cutting reimbursement rates may initially lower costs, but it also has the tendency to diminish quality of care, as providers gradually adjust their practice to maintain their incomes. Lower quality implies less effective care, leading quickly to greater morbidity and mortality particularly among those with chronic diseases; less effective preventive care also leads more gradually to increased prevalence of disease. These contrary effects can overwhelm the initial cost saving from reimbursement reduction and produce a net increase in health care costs.

The main values (or outcomes) at stake in any scenario for health system change are shown in bold Italics indicate broad classes of potential policy intervention Blue arrows indicate same-direction effects (e.g., lower reimbursement means lower provider income), Orange arrows indicate opposite-direction effects (e.g., more operational and administrative overhead means lower provider income.)

Bobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkCutting reimbursements does 3 things: (1) immediately cuts HC costs, (2) immediately leads to lower quality of care (less time spent with pts, more emphasis on trying to maintain income), (3) gradually leads to decline of providers. #2 and #3 explain increasing death and UD. But why does HC spending rise after initial bump down? And why does inequity get better, but then rebound? Bobby Milstein (August 26, 2004)Syndemics Prevention NetworkThe reason HC spending rebounds is that reduced quality means (1) more urgent events and (2) gradually rising in DI prevalence (more onset, slower recovery). The higher cost of urgent care, especially, quickly overcomes the initial decline in HC spending. Why inequity down-up? Because the decline in quality most affects those who go to the doctor, i.e. the advantaged (in the first instance). However, over time quality for disadvantaged erodes faster than it does for adv, because loss of providers impacts them more; the Adv have some buffer, and spending less time per patient actually frees up providers somewhat, so Adv quality doesnt erode further until after 2025.Bobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkIn its current form, the diabetes system model can test over 10 classes of intervention policies. Here is a simplified picture of what those are and where they fit in the overall system. Our analyses are attempting to learn what combination of strategies has the greatest leverage for delivering both short- and long-term health effects. Bobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)Syndemics Prevention NetworkBobby Milstein (August 26, 2004)