Crafting a Health System that Protects Us All

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

7. 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

8. 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.

9. 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

10. 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

11. 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

12. 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.

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

14. 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.

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

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

21. Main Health System Dynamics Insurance Coverage Enables Access

22. Main Health System Dynamics Disadvantage Creates a Double Vulnerability

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

24. Main Health System Dynamics Cutting Reimbursements May Control Cost

25. Main Health System Dynamics Reimbursement Also Affects Quality

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

27. 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)

28. Selected Estimates for Model Calibration

29. Selected Estimates for Model Calibration

30. Intervention Options & Scoring Criteria

31. 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.

32. 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

33. 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

34. 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

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

36. 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

37. 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.

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