Crafting a Health System that Protects Us All

International Society for Systems ScienceMadison, WI

July 14, 2008

International Society for Systems ScienceMadison, WI

July 14, 2008

Syndemics, Simulation Scenarios, and Social Change

Syndemics, Simulation Scenarios, and Social Change

Bobby Milstein Syndemics Prevention Network

Centers for Disease Control and [email protected]

http://www.cdc.gov/syndemics

Bobby Milstein Syndemics Prevention Network

Centers for Disease Control and [email protected]

http://www.cdc.gov/syndemics

Crafting a Health System that Protects Us All

Crafting a Health System that Protects Us All

Average Number of Adult Unhealthy Days per Month

4

5

6

7

1993 1995 1997 1999 2001 2003 2005

Year

Public Health Systems Science Addresses Navigational Policy Questions

Public Health Systems Science Addresses Navigational Policy Questions

17% increase

Centers for Disease Control and Prevention. Health-related quality of life: prevalence data. National Center for Chronic Disease Prevention and Health Promotion, 2007. Accessed October 23, 2007 at <http://apps.nccd.cdc.gov/HRQOL/index.asp>.

Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; April 15, 2008.

How?

Why?

Where?

Who?

What?

2010 2025 2050

Americans’ Views on the Health SystemPoised for Significant Change?

Americans’ Views on the Health SystemPoised for Significant Change?

Over 75% of Americans think the current system

needs fundamental change

Over 75% of Americans think the current system

needs fundamental change

Blendon RJ, Altman DE, Deane C, Benson JM, Brodie M, Buhr T. Health care in the 2008 presidential primaries. New England Journal of Medicine 2008;358(4):414-422.

Lessons from Previous Health Reform VenturesLessons from Previous Health Reform Ventures

Heirich 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 <http://www.cpn.org/topics/health/healthquestion.html>.

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 of…

• Piecemeal approaches

• Complicated schemes that were opposed by special interests

• Assumption that healthcare dynamics are separate from other areas of public concern

Conventional analytic methods make it difficult to…

• Observe the health system as a large, dynamic enterprise

• Craft high-leverage strategies that can overcome policy resistance

Prior efforts were largely disappointing because of…

• Piecemeal approaches

• Complicated schemes that were opposed by special interests

• Assumption that healthcare dynamics are separate from other areas of public concern

Conventional analytic methods make it difficult to…

• Observe the health system as a large, dynamic enterprise

• Craft high-leverage strategies that can overcome policy resistance

Policy resistance is the tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.

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-- Meadows, Richardson, Bruckman

Expanding Options through Boundary Critique

Expanding Options through Boundary Critique

-- Julie GerberdingCDC Director

-- Julie GerberdingCDC Director

Rubin R. CDC campaign hopes to make USA healthier nation. USA Today 2008 July 7. <http://www.usatoday.com/news/health/2008-07-07-cdc-gerberding_N.htm>

Park 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 equity…and [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.”

“The debate about healthcare reform needs to be enriched by including the

concepts of health protection and health equity…and [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.”

Appreciating the Wider Scope of the “Health Challenge”Health > Healthcare

Appreciating the Wider Scope of the “Health Challenge”Health > Healthcare

The Promise of a Syndemic OrientationThe Promise of a Syndemic Orientation

A syndemic orientation clarifies the dynamic and democratic character

of public health work

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; April 15, 2008. http://www.cdc.gov/syndemics/monograph/index.htm

“You think you understand two because you understand one and one. But you must also understand ‘and’.”

-- Sufi Saying

“You think you understand two because you understand one and one. But you must also understand ‘and’.”

-- Sufi Saying

Studying innovations in public health work where there are multiple interacting problems

The word syndemic signals special concern for many kinds of relationships:

mutually reinforcing health problems

health status and living conditions

synergy/fragmentation in the health protection system (e.g., by issues, sectors, organizations, professionals and other citizens)

Studying innovations in public health work where there are multiple interacting problems

The word syndemic signals special concern for many kinds of relationships:

mutually reinforcing health problems

health status and living conditions

synergy/fragmentation in the health protection system (e.g., by issues, sectors, organizations, professionals and other citizens)

Health

LivingConditions

Power toAct

“Health Policy”

“Social Policy”

“Citizen-ship”

Explicitly includes our power to respond, while understanding its changing pressures, constraints, and consequences

Explicitly includes our power to respond, while understanding its changing pressures, constraints, and consequences

Epi·demic Epi·demic The term epidemic is an ancient word signifying a kind of relationship wherein something is put upon the people

Epidemiology 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 Diseases“

Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work

The term epidemic is an ancient word signifying a kind of relationship wherein something is put upon the people

Epidemiology 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 Diseases“

Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work

Elliot 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.htm

National 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: NIH

“The 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

“The 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

Syn·demic Syn·demic

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 arena

It 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 ways

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 arena

It 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 ways

Confounding

Connecting*

Synergism

Syndemic

Events

System

Co-occurring

* Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping

Time Series Models

Describe trends

Multivariate Statistical Models

Identify historical trend drivers and correlates

Patterns

Structure

Events

Increasing:

• Depth of causal theory

• Robustness for longer-term projection

• Value for developing policy insights

• Degrees of uncertainty

• Leverage for change

Increasing:

• Depth of causal theory

• Robustness for longer-term projection

• Value for developing policy insights

• Degrees of uncertainty

• Leverage for changeDynamic Simulation Models

Anticipate new trends, learn about policy consequences,

and set justifiable goals

Tools for Policy Planning & EvaluationTools for Policy Planning & Evaluation

CDC’s Growing Portfolio of Health System Dynamics Projects

CDC’s Growing Portfolio of Health System Dynamics Projects

Selected Health Priority Areas…DiabetesObesityInfant healthCardiovascular healthSyndemics

Overall Health Protection Enterprise…Neighborhood transformationNational health economyChronic illness dynamicsUpstream-downstream investmentsHealth protection game

Communications, Training, Funding…Publications, special issues, monographsInteractive workshops, symposiaFunding announcementsWebsite, listservProfessional network

Selected Health Priority Areas…DiabetesObesityInfant healthCardiovascular healthSyndemics

Overall Health Protection Enterprise…Neighborhood transformationNational health economyChronic illness dynamicsUpstream-downstream investmentsHealth protection game

Communications, Training, Funding…Publications, special issues, monographsInteractive workshops, symposiaFunding announcementsWebsite, listservProfessional network

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

Learn to How Succeed in a Simpler, Simulated System

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

Learn to How Succeed in a Simpler, Simulated System

Madon 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?

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

Definitely, if we study every detail up close…Definitely, if we study every detail up close…

Not if we take a macroscopic view, from a very particular distance…

Not if we take a macroscopic view, from a very particular distance…

Trajectory of Hurricane Andrew: August 23, 24 and 25, 1992

Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: Univ. 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; April 15, 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.

Expand insurance coverage

Improve quality of care

Change reimbursement rates

Improve operational efficiency

Simplify administration

Encourage provider training/practice

Enable healthier behaviors

Build safer environments

Create pathways to advantage

Strengthen leadership

Expand insurance coverage

Improve quality of care

Change reimbursement rates

Improve operational efficiency

Simplify administration

Encourage provider training/practice

Enable healthier behaviors

Build safer environments

Create pathways to advantage

Strengthen leadership

Ingredients for Transforming Population HealthA Short Menu of Policy Proposals

Ingredients for Transforming Population HealthA Short Menu of Policy Proposals

Rules of the Health Protection GameRules of the Health Protection GameGoal Navigate the U.S. health system toward greater health and equity

TaskPrioritize intervention options across 10 policy domains

DecisionsCraft health protection strategies over 8 rounds (from 2010-2050), using feedback available every five years

ScoringAchieve the best results across four criteria simultaneously

Save 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 spending (i.e., reduce expenses per capita)

Appropriate implementation expenses (i.e., subsidy, program cost)

Game SetupA population in dynamic equilibrium, with fixed rates of birth and net immigration, experiencing high starting levels of mortality, unhealthy life, social inequity, and healthcare costs

No changes due to trends originating outside the health sector (e.g., aging, migration, economic cycles, technology, climate change)

Navigating Health FuturesGetting Out of a Deadly, Unhealthy, Inequitable, and Costly Trap

Navigating Health FuturesGetting Out of a Deadly, Unhealthy, Inequitable, and Costly Trap

Four Problems in the Current System: High Morbidity, Mortality, Inequity, Cost

Death rate per thousandUnhealthy days per capita

Health inequity indexHealthcare spend per capita

10

6

0.2

6,000

0

0

0

4,000

2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

How far can you move

the system?

High-Level Map of Health System DynamicsHigh-Level Map of Health System Dynamics

Health carecosts

Sufficiency ofproviders

Provider netincome

Reimbursementrates

Diseaseprevalence

Morbidity &mortality

Effective healthcare provision

--

Health careaccess

Operational &administrative

overhead-

Insurancecoverage

-

Healthequity

Behavioralrisks Quality

of care

--

Number ofproviders

-

Socioeconomicdisadvantage

-

- Attractiveness ofhealth careprofessions

-

Environmentalhazards

Incentives forprovider training

and practice

Most parts of the health system—so often discussed separately—are in fact connectedMost parts of the health system—so often discussed separately—are in fact connected

Adapted 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

Strong public leadership is needed to change the modifiable drivers

(shown in italics)


(shown in italics)

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

Health carecosts

Diseaseprevalence


Behavioralrisks


Main Health System Dynamics Main Health System Dynamics Effective Health Care is Powerful—and ExpensiveEffective Health Care is Powerful—and Expensive

Health carecosts

Diseaseprevalence



--

Health careaccess

Behavioralrisks


Main Health System Dynamics Main Health System Dynamics Insurance Coverage Enables AccessInsurance Coverage Enables Access

Health carecosts

Diseaseprevalence



--

Health careaccess

Insurancecoverage

-

Behavioralrisks


Main Health System Dynamics Main Health System Dynamics Disadvantage Creates a Double Vulnerability Disadvantage Creates a Double Vulnerability

Health carecosts

Diseaseprevalence



--

Health careaccess

Insurancecoverage

-

Behavioralrisks


-


Main Health System Dynamics Main Health System Dynamics Demand Affects the Sufficiency of ProvidersDemand Affects the Sufficiency of Providers

Health carecosts


Diseaseprevalence



--

Health careaccess

Insurancecoverage

-

Behavioralrisks

--


-


Main Health System Dynamics Main Health System Dynamics Cutting Reimbursements May Control CostCutting Reimbursements May Control Cost

Health carecosts


Reimbursementrates

Diseaseprevalence



--

Health careaccess

Insurancecoverage

-

Behavioralrisks

--


-


Main Health System Dynamics Main Health System Dynamics Reimbursement Also Affects Quality Reimbursement Also Affects Quality

Health carecosts


Reimbursementrates

Diseaseprevalence



--

Health careaccess

Insurancecoverage

-


of care

---


-


Main Health System Dynamics Main Health System Dynamics Reimbursement Further Affects Profit and AttractivenessReimbursement Further Affects Profit and Attractiveness

Health carecosts


Provider netincome

Reimbursementrates

Diseaseprevalence



--

Health careaccess


overhead-

Insurancecoverage

-


of care

--

Number ofproviders

-





and practice

Main Health System Dynamics Main Health System Dynamics Health Equity Captures the Consequences of Differences in

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

Vulnerability, Health Status, and Access to Care

Health carecosts


Provider netincome

Reimbursementrates

Diseaseprevalence



--

Health careaccess


overhead-

Insurancecoverage

-

Healthequity


of care

--

Number ofproviders

-


-


-



and practice


(shown in italics)


(shown in italics)

Parameter Proxy Initial Values (~2000) Sources

Advantaged & Disadvantaged

Prevalence

Household Income (< or ≥ $25,000)

Advantaged = 79% Disadvantaged = 21%

Census

Selected Estimates for Model CalibrationSelected Estimates for Model Calibration

Parameter Proxy Initial Values (~2000) Sources

Advantaged & Disadvantaged

Prevalence

Household Income (< or ≥ $25,000)

Advantaged = 79% Disadvantaged = 21%

Census

Symptomatic Disease/Injury

Prevalence

Self-rated health is good, fair, or poor

Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%)

BRFSS JAMA

Asymptomatic 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 JAMA

Mortality Deaths per 1,000 Overall = 8.4 D/A Ratio = 1.80

Vital Statistics AJPH

Morbidity Unhealthy days

per month per capita Overall = 5.25 D/A Ratio = 1.78

BRFSS

Health Equity Unhealthy days (or deaths)

attributable to disadvantage Attrib. fraction (unhealthy days) = 14.1% Attrib. fraction (deaths) = 14.4%

Census BRFSS

Health Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82

Census

Sufficiency of Primary Care Providers

Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.71

AMA Austin Study

Emergency Care for Nonurgent Problems

Acute non-urgent visits in ER or outpatient department

Overall = 19% D/A Ratio = 5.5

NAMCS

Unhealthy Behavior Prevalence

Smoking Physical inactivity

Overall = 34% D/A Ratio = 1.67

BRFSS JAMA Austin Study

Unsafe Environment Prevalence

“Neighborhood not safe” Overall = 26% D/A Ratio = 2.5

BRFSS JAMA Austin Study

Selected Estimates for Model CalibrationSelected Estimates for Model Calibration

Intervention Options & Scoring Criteria Intervention Options & Scoring Criteria

Illustrative Intervention Scenarios Illustrative Intervention Scenarios

Scenario Name

Policy Options

Insurance Coverage

QualityCare

Reimb.Rates

EfficiencySimpler Admin

ProviderIncentives

Healthier Behavior

Safer Environ

AdvantageStronger

Leadership

Cut Reimbursement*

Universal Coverage

Higher Quality

Upstream Protection

Others/Combos…

* 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, Spending

Death rate per 1,000

Unhealthy days Health inequity index Healthcare spending per capita

>>>> These results are from a prototype model.<<<< Please do not cite or quote without permission.c

>>>> These results are from a prototype model.<<<< Please do not cite or quote without permission.c

10 6

0.2 6,000

7.5 4.5

0.15 5,500

5 3

0.1 5,000

2.5 1.5

0.05 4,500

0 0

0 4,000

2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

Prototype Model Output



Quality of disease & injury care Quality of DI care for the managed

Sufficiency of primary care providers

Advantaged

Disadvantaged




1

0.9

0.8

0.7

0.62000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

1

0.75

0.5

0.25

02000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

Advantaged

Disadvantaged

1

0.875

0.75

0.625

0.5

2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

Acute nonurgent event visits to ER or OPD70 M

55 M

40 M

25 M

10 M

2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

Advantaged

Disadvantaged


Additional Preliminary FindingsAdditional Preliminary FindingsUniversal Coverage (with Leadership)

Lowers morbidity and mortality quickly

Increases 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 Care (with Leadership)

Lowers morbidity and mortality quickly, more so than “Universal Coverage” (more people benefit)

Costs rise initially, then fall (the benefits of disease prevention accrue gradually)

Worsens inequity (better quality exacerbates pre-existing provider shortage for disadvantaged)

Upstream Health Protection (with Leadership)

Consistent pattern of strong, sustained improvements in morbidity, mortality, cost, and equity

Takes 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 access

Average unhealthy days per capita Health care spending per capita Health inequity index (morbidity)6

5.5

5

4.5

42000 2010 2020 2050

Protection

Coverage

Quality

2030 2040


6,000

5,500

5,000

4,500

4,0002000 2050

Protection

Coverage

Quality


2010 2020 2030 2040

0.2

0.15

0.1

0.05

02000 2050

Protection

Coverage

Quality


2010 2020 2030 2040

Game-based “Wayfinding” Dialogues Combine Science and Social ChangeGame-based “Wayfinding” Dialogues Combine Science and Social Change

Potential champions need more than visionary direction. They want plausible pathways and visceral preparation.Potential champions need more than visionary direction. They want plausible pathways and visceral preparation.

Transforming All Dimensionsof the Health System

Transforming All Dimensionsof the Health System

Health

LivingConditions

Power toAct

Efforts to Fight Afflictions

Efforts to Fight Afflictions

Efforts to Improve Adverse Living Conditions

Efforts to Improve Adverse Living Conditions

Efforts to Build PowerEfforts to

Build Power

Equality of Agency

Equality ofOutcomes

Equality of Opportunities

Syndemic Orientation

Expanding Public Health ScienceExpanding Public Health Science“Public health imagination involves using science to expand the

boundaries of what is possible.”

-- Michael Resnick

“Public health imagination involves using science to expand the boundaries of what is possible.”

-- Michael Resnick

EpidemicOrientation

Problems Among

People inPlaces

Over Time

BoundaryCritique

Governing Dynamics

Ca

us

al

Ma

pp

ing

Plausible Futures

DynamicModeling

Navigational Freedoms

De

mo

cra

tic

Pu

bli

c W

ork

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; April 15, 2008.

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

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

Crafting a Health System that Protects Us All

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