Crafting a Health System that Protects Us All

1. Crafting a Health System that Protects Us All Dynamic Principles and Democratic Powers Bobby Milstein Centers for Disease Control and Prevention BMilstein@cdc.gov University of Minnesota Minneapolis, MN May 13, 2008

2. Poised for Significant Change

3. 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 • Been thinking of health and healthcare as nouns (i.e., commodities to be distributed), not as verbs (i.e., public work to be produced) 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.

4. “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 Park A. Time 100: the people who shape our world. Time Magazine 2004 April 26.

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

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

7. The Promise of a Syndemic Orientation Health “Health Policy” Power to Act “Social Policy” Living Conditions “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, with emphasis on transformations in concepts, methods, and moral orientations • 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 • It is one of a few approaches that explicitly includes within it our power to respond, along with an understanding of its changing pressures, constraints, and consequences 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 Syn·demic Events System 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 Stat Models Identify historical trend drivers and correlates Patterns Dynamic Simulation Models Anticipate new trends, learn about policy consequences, and set justifiable goals Structure

11. Growth of Citizen Actors “Almost everyone knows about the explosion of the dot-coms…but millions have still not heard the big story: the worldwide explosion of dot-orgs. More people today have the freedom, time, wealth, health, exposure, social mobility, and confidence to address social problems in bold new ways.” 60% -- David Bornstein Bornstein D. How to change the world: social entrepreneurs and the power of new ideas. New York: Oxford University Press, 2004.

12. Power Has to be Organized Loose groupings of interested individuals don’t have a prayer of addressing major crises–housing, crime, schools, jobs, and others. Each crisis is, at bottom, a power crisis. The power of the mob, the power of drug lords, the power of corrupt borough machines, and the inertia of the police bureaucracy could only be challenged by another, deeper institutional power. -- Michael Gecan Gecan M. Going public. Boston: Beacon Press, 2002.

13. Even Broad-Based Organizing May Not Be EnoughInsights from the North Karelia Project • Mortality Changes in North Karelia in 1970-1995 (men, 35-64) • Coronary heart disease -73% • All cardiovascular disease -68% • Lung cancer -71% • All cancers -44% • All causes -49% • Mortality Changes in North Karelia in 1970-1995 (men, 35-64) • Coronary heart disease -73% • All cardiovascular disease -68% • Lung cancer -71% • All cancers -44% • All causes -49% Puska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995. National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Available at <http://www.ktl.fi/eteo/cindi/northkarelia.html>.

14. Health Professionals Physicians Health Educators Psychologists Epidemiologists Sociologists Hospital administrators Pharmaceutical manufacturers Nurses Rehabilitation therapists Other Citizens Bakers Farmers Grocers Food scientists Manufacturers Restaurant owners Housewives Entertainers Entrepreneurs Journalists Media professionals Teachers School administrators Elected representatives North Karelia ProjectBuilding Power, Turning Jobs into Public Work Puska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995. National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Available at <http://www.ktl.fi/eteo/cindi/northkarelia.html>. Boyte HC, Kari NN. Building America: the democratic promise of public work. Philadelphia: Temple University Press, 1996.

15. Transforming All Dimensionsof the System Efforts to Fight Afflictions Health Efforts to Build Power Power to Act Living Conditions Efforts to Improve Adverse Living Conditions

16. 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 • Offer provider incentives • Enable healthier behaviors • Build safer environments • Create pathways to advantage

17. Are these ingredients connected?How?Does that matter?

18. 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.

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

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

21. 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: University of Pennsylvania Press, 1991. Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; January 28, 2008. Rosnay J. The macroscope: a new world scientific system. New York, NY: Harper & Row, 1979. White F. The overview effect: space exploration and human evolution. 2nd ed. Reston VA: American Institute of Aeronautics and Astronautics, 1998.

22. Rules of the Health Protection Game • GoalNavigate the U.S. health system toward greater health and equity • TaskPrioritize intervention options across nine 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 costs (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 are due to trends originating outside the health sector such as aging, migration, economic cycles, technology, climate change, etc….

23. 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

24. High-Level Map of Health System Dynamics Most 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

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

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

27. Main Health System Dynamics Insurance Coverage Enables Access

28. Main Health System Dynamics Disadvantage Creates a Double Vulnerability

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

30. Main Health System Dynamics Cutting Reimbursements May Control Cost

31. Main Health System Dynamics Reimbursement Also Affects Quality

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

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

34. Selected Estimates for Model Calibration

35. 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.

36. Exploring Intervention ScenariosCut Reimbursements to Office-Based Physicians by 20% Scoring Criteria: Deaths, Unhealthy Days, Inequity, Cost 10 6 0.2 6,000 0 0 Prototype Model Output 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.

37. Exploring Intervention ScenariosCut Reimbursements to Office-Based Physicians by 20% Quality of disease & injury care Quality of DI care for the managed 0.6 1 0.75 0.4 Advantaged 0.5 Disadvantaged 0.2 0.25 Prototype Model Output Prototype Model Output 0 0 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 Prevalence of disease & injury Primary care providers per 10 thousand popn 0.6 20 15 0.4 Disadvantaged 10 Advantaged Advantaged 0.2 5 Disadvantaged Prototype Model Output Prototype Model Output 0 0 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 >>>> These results are from a prototype model.<<<< Please do not cite or quote without permission.

38. Additional Preliminary Findings Universal Coverage • 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 • Lowers morbidity and mortality quickly, even more so than “Universal Coverage” (more people benefit) • Costs rise initially, then fall (the benefits of disease prevention accrue gradually) • Worsens inequity (better quality services exacerbate pre-existing provider shortage for disadvantaged) Upstream Health Protection • 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 Quality 6,000 0.2 Prototype Model Output Prototype Model Output Coverage 5.5 5,500 0.15 Coverage Coverage 5 5,000 Protection 0.1 Quality 4.5 Quality 4,500 0.05 Prototype Model Output Protection Protection 4 0 4,000 2000 2010 2020 2030 2040 2050 2000 2010 2020 2030 2040 2050 2050 2000 2010 2020 2030 2040

39. Additional Preliminary Findings Pathways to Advantage • Consistent pattern of sustained improvements in morbidity, mortality, cost, and equity • Profound effect on equity, with lesser impacts on health status and cost • Spending actually rises slightly at first, then falls as lower vulnerability prevents disease and reduces healthcare costs (a mix of downstream and upstream dynamics) Average unhealthy days per capita Health care spending per capita Health Inequity Index (Morbidity) 6 6,000 Quality 0.2 Prototype Model Output Prototype Model Output Coverage 5.5 5,500 0.15 Coverage Coverage 5 5,000 Protection 0.1 Quality Pathways Pathways 4.5 4,500 Quality 0.05 Protection Protection Prototype Model Output Pathways 4 4,000 0 2000 2010 2020 2030 2040 2050 2000 2010 2020 2030 2040 2050 2000 2010 2020 2030 2040 2050

40. A Model Is… It helps us understand, explain, anticipate, and make decisions “All models are wrong, some are useful.” -- George Box An inexact representation of the real thing

41. Gaming Supports Learning and Wayfinding Dynamic Hypothesis (Causal Structure) Plausible Futures (Policy Experiments) Health Inequity Index (Morbidity) Quality 0.2 Coverage 0.15 Protection 0.1 0.05 Prototype Model Output Pathways 0 2000 2010 2020 2030 2040 2050 Multi-stakeholder Dialogue Morecroft JDW, Sterman J. Modeling for learning organizations. Portland, OR: Productivity Press, 2000. Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

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

43. EXTRAS