International Society for Systems Science Madison, WI July 14, 2008 International Society for...

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.”

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.

Ingredients for Transforming Population Health

A Short Menu of Policy Proposals Ingredients for Transforming Population Health

A 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

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)

Goal 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)

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



Prevalence



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


BRFSS JAMA Austin Study

Unsafe Environment Prevalence

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



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

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

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

Health Protection as a SystemHealth Protection as a System Health

Response

Adverse LivingConditions

GeneralProtection

Demand for Response

Safer,HealthierPeople

VulnerablePeople

AfflictedPeople withoutComplications

AfflictedPeople with

Complications

Dying fromcomplications

Tertiaryprevention

Secondaryprevention

Primaryprevention

Targetedprotection

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.

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)

1999 2000 2001 2002 2003 2004 2005

System Change Initiatives Encounter Limitations of Logic Models and Conventional

Planning/Evaluation Methods

Diabetes Action Labs*

Upstream-Downstream Dynamics

Obesity Overthe Lifecourse*

Fetal & Infant Health

Milestones in the Recent Use of System Dynamics Modeling at CDC

Milestones in the Recent Use of System Dynamics Modeling at CDC

AJPH Systems

Issue

2006

CDC Evaluation Framework

Recommends Logic Models

SD Identified as a Promising Methodology

Neighborhood Grantmaking

Game

National Health Economics & Reform

Syndemics Modeling*

* Dedicated multi-year budget

CVH in Context*

2007 2008

Science Seminars and Professional Development Efforts

Health System Transformation

Game*

SDR 50th Issue

ASysT Prize

Hygeia’s Constellation

NIH/CDC Symposia Series

Poised for Significant ChangePoised for Significant Change


Adverse living conditions + Absence of protective efforts = VulnerabilityAdverse living conditions + Absence of protective efforts = Vulnerability

Re-Directing the Course of ChangeQuestions of Social Navigation

Re-Directing the Course of ChangeQuestions of Social Navigation

Prevalence of Diagnosed Diabetes, United States

0

10

20

30

40

1980 1990 2000 2010 2020 2030 2040 2050

Mill

ion

pe

op

le

HistoricalData

Markov Model Constants• Incidence rates (%/yr)• Death rates (%/yr)• Diagnosed fractions(Based on year 2000 data, per demographic segment)

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.

Markov Forecasting Model

Trend is not destiny

How?

Why?

Where?

Who?

What?

Growing Portfolio of System Modeling Studies in Public Health


Wayfinding Combines Science and Social ChangeIdeas for Extending the Work

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

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

Selected CDC Projects Featuring System Dynamics Modeling (2001-2007)

Selected CDC Projects Featuring System Dynamics Modeling (2001-2007)

• Syndemics Mutually reinforcing afflictions

• Diabetes In 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

• Syndemics Mutually reinforcing afflictions

• Diabetes In 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>.

• 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

• 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



Applied Systems Thinking (ASysT) Prize 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

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>.


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

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



Prevalence



Census


Prevalence


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

BRFSS JAMA


High blood pressure (HBP) High cholesterol (HC) Asymp = Tot Chron - Symp



NHANES JAMA





BRFSS


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

Census BRFSS


Census



AMA Austin Study




NAMCS











Prevalence



Census


Prevalence


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

BRFSS JAMA





NHANES JAMA

No Health Problems Prevalence

Self-rated health is excellent or very good

No HBP or HC

Overall = 33% Advantaged = 36% Disadvantaged = 24%

BRFSS NHANES





BRFSS


attributable to disadvantage

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

Census BRFSS


Census



AMA Austin Study




NAMCS











Prevalence



Census


Prevalence


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

BRFSS JAMA





NHANES JAMA

No Health Problems Prevalence

Self-rated health is excellent or very good

No HBP or HC

Overall = 33% Advantaged = 36% Disadvantaged = 24%

BRFSS NHANES





BRFSS


attributable to disadvantage

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

Census BRFSS


Census



AMA Austin Study




NAMCS








Selected Estimates for Model Calibration

There Have Been Remarkable Successes in Redirecting the Course of Change

There Have Been Remarkable Successes in Redirecting the Course of Change

600

500

400

200

100

501950 1960 1970 1980 1990 1995

Ag

e-a

dju

ste

d D

eath

Rat

e p

er 1

00,

000

Po

pu

lati

on

1955 1965 1975 1985

300

700

Peak Rate

Rate if trend continued

Year

Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998

Marks JS. The burden of chronic disease and the future of public health. CDC Information Sharing Meeting. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion; 2003.

Centers for Disease Control and Prevention. Achievements in public health, 1900-1999: decline in deaths from heart disease and stroke -- United States, 1900-1999. MMWR 1999;48(30):649-656. Available at <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4830a1.htm>

Actual Rate

Overall Decline is Linked to…

• Reduced smoking

• Changes in diet

• Better diagnosis and treatment

• More heath services utilization

Overall Decline is Linked to…

• Reduced smoking

• Changes in diet

• Better diagnosis and treatment

• More heath services utilization

684,000 fewer deaths in 1998 alone

684,000 fewer deaths in 1998 alone

Fewer Deaths Mean More People Living with Illness and its Associated Burden and Costs

Fewer Deaths Mean More People Living with Illness and its Associated Burden and Costs

0

4

8

12

16

200420001996199219881984198019761972196819641960

Consumer price index (CPI-U) relative to 1960

Healthcare

Total economy

Consumer Price Indices for Healthcare and the General Economy United States, 1960-2004 (1960=1)

500,000

750,000

1,000,000

1,250,000

1,500,000

1,750,000

2,000,000

2,250,000

2,500,000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

American Bankruptcy Institute. Bankruptcy filing statistics: non-business filings. Alexandria, VA: American Bankruptcy Institute; October, 2007. <http://www.abiworld.org/AM/TemplateRedirect.cfm?template=/CM/ContentDisplay.cfm&ContentID=48428>.

Himmelstein DU, Warren E, Thorne D, Woolhandler S. Illness and injury as contributors to bankruptcy. Health Affairs 2005:hlthaff.w5.63. Available at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.63v1

Fox M. Half of Bankruptcy Due to Medical Bills -- U.S. Study: Reuters; February 2, 2005.

Total Personal Bankruptcy Filings, United States, 1994-2005

Total Personal Bankruptcy Filings, United States, 1994-2005

Healthcare Cost is Also the Leading Driver of Personal Bankruptcy

Healthcare Cost is Also the Leading Driver of Personal Bankruptcy

61% of the filers surveyed failed to seek needed medical treatments

61% of the filers surveyed failed to seek needed medical treatments

Entrenched InequitiesEntrenched Inequities

Murray CJ, Kulkarni SC, Michaud C, Tomijima N, Bulzacchelli MT, Iandiorio TJ, Ezzati M. Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States. PLoS Med 2006;3(9). Available at <http://medicine.plosjournals.org/archive/1549-1676/3/9/pdf/10.1371_journal.pmed.0030260-L.pdf>

Entrenched InequitiesEntrenched Inequities

Life Expectancy at Birth in the Eight Americas (1982-2001)

Life Expectancy at Birth in the Eight Americas (1982-2001)

A Dynamic Model Simulates Policy ScenariosA Dynamic Model Simulates Policy Scenarios

Are these ingredients connected?

How?

Does that matter?

Are these ingredients connected?

How?

Does that matter?

Trends in Self-reported Health & Health Care Spending United States, 1982-2004

National Health Interview Survey, National Health Expenditure Accounts

Trends in Self-reported Health & Health Care Spending United States, 1982-2004

National Health Interview Survey, National Health Expenditure Accounts

Data Sources: National Health Expenditure Accounts (NHEA), US Census; National Health Interview Survey (NHIS), CDC

Homer J, Hirsch G, Milstein B. Chronic illness in a complex health economy: the perils and promises of downstream and upstream reforms. System Dynamics Review 2007;23(2/3):313–343.

Hea

lth

car

e sp

end

ing

per

cap

ita

(yea

r 20

00 d

olla

rs)

40%

50%

60%

70%

80%

90%

100%

200420022000199819961994199219901988198619841982

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

Percen

tage R

epo

rting

E

xcellent o

r Very G

oo

d

Self-reported health (i.e., excellent or very good)

oscillated within a narrow range of 65% to 69%

Health care spendingper capita in year 2000 dollars more than doubled in 20 years

POLICY CHOICES

SCORING CRITERIA (Averaged from 2000—2050)*

Save Lives

Improve Well-being

Achieve Health Equity

Lower Healthcare

Costs

Appropriate Intervention Expenses

Mortality rate

(or YLL)

Unhealthy days

(or QALY)

Unhealthy days attributable to disadvantage

(or attrib deaths)

Healthcare spendingper capita

(or % of GDP)

Total outlay for subsidies and program costs

1 Expand insurance coverage

2 Improve quality of care

3 Change reimbursement rates

4 Improve operational efficiency

5 Simplify administration

6 Offer provider incentives

7 Enable healthier behaviors

8 Build safer environments

9 Create pathways to advantage

10 Strengthen leadership

Intervention Options & Scoring Criteria Intervention Options & Scoring Criteria

* Other metrics could be developed to explore policy consequences beyond the health sphere, such as economic prosperity, environmental quality, civic engagement, etc…* Other metrics could be developed to explore policy consequences beyond the health sphere, such as economic prosperity, environmental quality, civic engagement, etc…

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