1 / 63

Crafting a Health System that Protects Us All

Crafting a Health System that Protects Us All. Syndemics, Simulation Scenarios, and Social Change. Bobby Milstein Syndemics Prevention Network Centers for Disease Control and Prevention BMilstein@cdc.gov http://www.cdc.gov/syndemics. International Society for Systems Science Madison, WI

maille
Download Presentation

Crafting a Health System that Protects Us All

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Crafting a Health System that Protects Us All Syndemics, Simulation Scenarios, and Social Change Bobby Milstein Syndemics Prevention Network Centers for Disease Control and Prevention BMilstein@cdc.gov http://www.cdc.gov/syndemics International Society for Systems Science Madison, WI July 14, 2008

  2. 2010 2025 2050 Public Health Systems Science Addresses Navigational Policy Questions Where? What? 17% increase How? Why? Who? 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.

  3. Americans’ Views on the Health SystemPoised for Significant 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.

  4. Lessons from Previous Health Reform Ventures 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 • 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 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.

  5. Expanding Options through Boundary Critique “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.” -- Julie Gerberding CDC 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.

  6. Health “Health Policy” Power to Act “Social Policy” Living Conditions The Promise of a Syndemic Orientation “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) “Citizen-ship” A syndemic orientation clarifies the dynamic and democratic character of public health work • Explicitly includes our power to respond, while understanding its changing pressures, constraints, and consequences 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

  7. 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 Epi·demic 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 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.

  8. 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 Events System Syn·demic Co-occurring Confounding Connecting* Synergism Syndemic * Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping

  9. Tools for Policy Planning & Evaluation Events Time Series Models Describe trends • Increasing: • Depth of causal theory • Robustness for longer-term projection • Value for developing policy insights • Degrees of uncertainty • Leverage for change Multivariate Statistical Models Identify historical trend drivers and correlates Patterns Dynamic Simulation Models Anticipate new trends, learn about policy consequences, and set justifiable goals Structure

  10. CDC’s Growing Portfolio of Health System Dynamics Projects • Selected Health Priority Areas… • Diabetes • Obesity • Infant health • Cardiovascular health • Syndemics • Overall Health Protection Enterprise… • Neighborhood transformation • National health economy • Chronic illness dynamics • Upstream-downstream investments • Health protection game • Communications, Training, Funding… • Publications, special issues, monographs • Interactive workshops, symposia • Funding announcements • Website, listserv • Professional network

  11. Where to Begin with a Problem as Vast as Health System Change?Learn to How Succeed in a Simpler, Simulated System Is it too audacious to think about representing the entire U.S. health protection enterprise? 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.

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

  13. Trajectory of Hurricane Andrew: August 23, 24 and 25, 1992 Not if we take a macroscopic view, from a very particular distance… 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.

  14. Ingredients for Transforming Population HealthA Short Menu of Policy Proposals

  15. Ingredients for Transforming Population HealthA Short Menu of Policy Proposals • 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

  16. Rules of the Health Protection Game • GoalNavigate 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)

  17. Navigating Health FuturesGetting Out of a Deadly, Unhealthy, Inequitable, and Costly Trap Four Problems in the Current System: High Morbidity, Mortality, Inequity, Cost 10 6 0.2 6,000 How far can you move the system? 0 0 0 4,000 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 Death rate per thousand Unhealthy days per capita Health inequity index Healthcare spend per capita

  18. High-Level Map of Health System Dynamics Most parts of the health system—so often discussed separately—are in fact connected Strong public leadership is needed to change the modifiable drivers (shown in italics) 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

  19. Selected Estimates for Model Calibration

  20. Selected Estimates for Model Calibration

  21. Intervention Options & Scoring Criteria

  22. 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.

  23. Exploring Intervention ScenariosCut Reimbursements to Office-Based Physicians by 20% Scoring Criteria: Deaths, Unhealthy Days, Inequity, Spending 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 Prototype Model Output 0 0 0 4,000 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 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

  24. Exploring Intervention ScenariosCut Reimbursements to Office-Based Physicians by 20% Quality of disease & injury care Quality of DI care for the managed 1 1 Prototype Model Output Prototype Model Output 0.75 0.9 Advantaged 0.8 0.5 0.7 0.25 Disadvantaged 0.6 0 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 Sufficiency of primary care providers Acute nonurgent event visits to ER or OPD 70 M 1 Prototype Model Output Advantaged 55 M Disadvantaged 0.875 Prototype Model Output 40 M 0.75 Disadvantaged 0.625 25 M Advantaged 0.5 10 M 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

  25. Additional Preliminary Findings Universal 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) 6,000 0.2 6 Prototype Model Output Prototype Model Output Quality Quality 5,500 0.15 5.5 Coverage Coverage Coverage 5,000 0.1 5 Protection 4,500 4.5 0.05 Quality Protection Prototype Model Output Protection 4,000 4 0 2000 2010 2020 2030 2040 2050 2000 2010 2020 2030 2040 2050 2000 2010 2020 2030 2040 2050

  26. Game-based “Wayfinding” Dialogues Combine Science and Social Change Potential champions need more than visionary direction. They want plausible pathways and visceral preparation.

  27. Efforts to Fight Afflictions Health Equality of Outcomes Efforts to Build Power Power to Equality of Agency Act Efforts to Improve Adverse Living Conditions Equality of Opportunities Transforming All Dimensionsof the Health System Living Conditions

  28. Syndemic Orientation Governing Dynamics CausalMapping Dynamic Modeling Problems Among People inPlaces Over Time Plausible Futures Boundary Critique DemocraticPublic Work Navigational Freedoms Expanding Public Health Science “Public health imagination involves using science to expand the boundaries of what is possible.” -- Michael Resnick EpidemicOrientation 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.

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

  30. Health Response Secondary Targeted Primary Tertiary General prevention protection prevention prevention Protection Demand for Response Safer, Afflicted Afflicted Vulnerable Healthier People without People with People People Complications Complications Adverse Living Conditions Dying from complications Health Protection as a System Gerberding JL. CDC's futures initiative. Atlanta, GA: Public Health Training Network; April 12, 2004. Jackson DJ, Valdesseri R, CDC Futures Health Systems Work Group. Health systems work group report. Atlanta, GA: Centers for Disease Control and Prevention, Office of Strategy and Innovation; January 6, 2004. Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003.

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

  32. Main Health System Dynamics Effective Health Care is Powerful—and Expensive

  33. Main Health System Dynamics Insurance Coverage Enables Access

  34. Main Health System Dynamics Disadvantage Creates a Double Vulnerability

  35. Main Health System Dynamics Demand Affects the Sufficiency of Providers

  36. Main Health System Dynamics Cutting Reimbursements May Control Cost

  37. Main Health System Dynamics Reimbursement Also Affects Quality

  38. Main Health System Dynamics Reimbursement Further Affects Profit and Attractiveness

  39. Main Health System Dynamics Health Equity Captures the Consequences of Differences in Vulnerability, Health Status, and Access to Care Strong public leadership is needed to change the modifiable drivers (shown in italics)

  40. NIH/CDC Symposia Series Science Seminars and Professional Development Efforts SD Identified as a Promising Methodology Hygeia’s Constellation CDC Evaluation Framework Recommends Logic Models AJPH Systems Issue ASysT Prize System Change Initiatives Encounter Limitations of Logic Models and Conventional Planning/Evaluation Methods SDR 50thIssue Syndemics Modeling* Neighborhood Grantmaking Game Diabetes Action Labs* Fetal & Infant Health Obesity Overthe Lifecourse* CVH in Context* Upstream-Downstream Dynamics National Health Economics & Reform Health System Transformation Game* Milestones in the Recent Use of System Dynamics Modeling at CDC 2006 2007 2008 1999 2000 2001 2002 2003 2004 2005 * Dedicated multi-year budget

  41. Poised for Significant Change

  42. Poised for Significant Change

  43. Adverse living conditions + Absence of protective efforts = Vulnerability

  44. Historical Markov Forecasting Model Data Re-Directing the Course of ChangeQuestions of Social Navigation Prevalence of Diagnosed Diabetes, United States 40 Where? 30 Million people 20 What? How? • Markov Model Constants • Incidence rates (%/yr) • Death rates (%/yr) • Diagnosed fractions • (Based on year 2000 data, per demographic segment) 10 Trend is not destiny Who? Why? 0 1980 1990 2000 2010 2020 2030 2040 2050 Honeycutt A, Boyle J, Broglio K, Thompson T, Hoerger T, Geiss L, Narayan K. A dynamic markov model for forecasting diabetes prevalence in the United States through 2050. Health Care Management Science 2003;6:155-164. Jones AP, Homer JB, Murphy DL, Essien JDK, Milstein B, Seville DA. Understanding diabetes population dynamics through simulation modeling and experimentation. American Journal of Public Health 2006;96(3):488-494.

  45. Growing Portfolio of System Modeling Studies in Public Health

  46. Wayfinding Combines Science and Social ChangeIdeas for Extending the Work Getting Beyond the Prototype • Review and Refine the Simulation Modele.g., SD methodology, health system content, parameter estimates, user interface • Develop an Effective Instructional Design e.g. stakeholder roles, facilitated debriefing, policy insights, implications for leadership • Discussing Tradeoffs (Competing Values)e.g. cost vs. health vs. equity; short-term vs. long-term Stakeholder Engagement & Action • Certify Wayfinding Consultantse.g., cadre of public health innovators trained to support stakeholders in playing the game • Convene Wayfinding Dialoguese.g., a series of nationwide events, convened by CDC and conducted by the National Network of Public Health Institutes

  47. Selected CDC Projects Featuring System Dynamics Modeling (2001-2007) • Grantmaking ScenariosTiming and sequence of outside assistance • Upstream-Downstream EffortBalancing disease treatment with prevention/protection • Healthcare ReformRelationships among cost, quality, equity, and health status • Chronic Illness DynamicsHealth and economic scenarios for downstream and upstream reforms • Health Protection GameLearning to transform our troubled health system • SyndemicsMutually reinforcing afflictions • DiabetesIn an era of rising obesity • ObesityLifecourse consequences of changes in caloric balance • Infant HealthFetal and infant morbidity/mortality • Cardiovascular HealthPreventing and managing multiple risks, in context Milstein B, Homer J. Background on system dynamics simulation modeling, with a summary of major public health studies. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; February 1, 2005. <http://www2.cdc.gov/syndemics/pdfs/SD_for_PH.pdf>.

  48. Growing Portfolio of System Modeling Studies in Public Health

  49. Applied Systems Thinking (ASysT) Prize The size of the problems addressed, combined with the diversity of the SD-CDC team and their long track record of practical engagements were decisive factors in the selection. -- ASysT Institute Applied Systems Thinking Institute. CDC-NIH System Dynamics Collaborative Wins 2008 ASysT Prize. Arlington, VA; July 9, 2008. <http://www.anser.org/Content.aspx?mid=302>.

  50. Poised for Significant Change

More Related