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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)
Strong public leadership is needed to change the modifiable drivers
(shown in italics)
Parameter Proxy Initial Values (~2000) Sources
Advantaged & Disadvantaged
Prevalence
Household Income (< or ≥ $25,000)
Advantaged = 79% Disadvantaged = 21%
Census
Selected Estimates for Model CalibrationSelected Estimates for Model Calibration
Parameter Proxy Initial Values (~2000) Sources
Advantaged & Disadvantaged
Prevalence
Household Income (< or ≥ $25,000)
Advantaged = 79% Disadvantaged = 21%
Census
Symptomatic Disease/Injury
Prevalence
Self-rated health is good, fair, or poor
Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%)
BRFSS JAMA
Asymptomatic Chronic Disease Prevalence
High blood pressure (HBP) High cholesterol (HC) Asymp = Tot Chron – Symp
Overall = 40% (54.5% tot chron - 14.5% Symp)
D/A Ratio (tot chronic) = 1.15 (= 61%/53%)
NHANES JAMA
Mortality Deaths per 1,000 Overall = 8.4 D/A Ratio = 1.80
Vital Statistics AJPH
Morbidity Unhealthy days
per month per capita Overall = 5.25 D/A Ratio = 1.78
BRFSS
Health Equity Unhealthy days (or deaths)
attributable to disadvantage Attrib. fraction (unhealthy days) = 14.1% Attrib. fraction (deaths) = 14.4%
Census BRFSS
Health Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82
Census
Sufficiency of Primary Care Providers
Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.71
AMA Austin Study
Emergency Care for Nonurgent Problems
Acute non-urgent visits in ER or outpatient department
Overall = 19% D/A Ratio = 5.5
NAMCS
Unhealthy Behavior Prevalence
Smoking Physical inactivity
Overall = 34% D/A Ratio = 1.67
BRFSS JAMA Austin Study
Unsafe Environment Prevalence
“Neighborhood not safe” Overall = 26% D/A Ratio = 2.5
BRFSS JAMA Austin Study
Selected Estimates for Model CalibrationSelected Estimates for Model Calibration
Intervention Options & Scoring Criteria Intervention Options & Scoring Criteria
Illustrative Intervention Scenarios Illustrative Intervention Scenarios
Scenario Name
Policy Options
Insurance Coverage
QualityCare
Reimb.Rates
EfficiencySimpler Admin
ProviderIncentives
Healthier Behavior
Safer Environ
AdvantageStronger
Leadership
Cut Reimbursement*
Universal Coverage
Higher Quality
Upstream Protection
Others/Combos…
* The reimbursement cut is relative to health care input factor costs (labor, services, overhead). In model, this is done as an absolute cut. In real life, it could represent a freeze in reimbursements relative to ongoing inflation in factor costs.
Exploring Intervention ScenariosCut Reimbursements to Office-Based Physicians by 20%
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
Exploring Intervention ScenariosCut Reimbursements to Office-Based Physicians by 20%
Exploring Intervention ScenariosCut Reimbursements to Office-Based Physicians by 20%
Quality of disease & injury care Quality of DI care for the managed
Sufficiency of primary care providers
Advantaged
Disadvantaged
Prototype Model Output
Prototype Model Output
Prototype Model Output
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
Prototype Model Output
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
Prototype Model Output
6,000
5,500
5,000
4,500
4,0002000 2050
Protection
Coverage
Quality
Prototype Model Output
2010 2020 2030 2040
0.2
0.15
0.1
0.05
02000 2050
Protection
Coverage
Quality
Prototype Model Output
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
Morbidity &mortality
Behavioralrisks
Environmentalhazards
Main Health System Dynamics Main Health System Dynamics Effective Health Care is Powerful—and ExpensiveEffective Health Care is Powerful—and Expensive
Health carecosts
Diseaseprevalence
Morbidity &mortality
Effective healthcare provision
--
Health careaccess
Behavioralrisks
Environmentalhazards
Main Health System Dynamics Main Health System Dynamics Insurance Coverage Enables AccessInsurance Coverage Enables Access
Health carecosts
Diseaseprevalence
Morbidity &mortality
Effective healthcare provision
--
Health careaccess
Insurancecoverage
-
Behavioralrisks
Environmentalhazards
Main Health System Dynamics Main Health System Dynamics Disadvantage Creates a Double Vulnerability Disadvantage Creates a Double Vulnerability
Health carecosts
Diseaseprevalence
Morbidity &mortality
Effective healthcare provision
--
Health careaccess
Insurancecoverage
-
Behavioralrisks
Socioeconomicdisadvantage
-
Environmentalhazards
Main Health System Dynamics Main Health System Dynamics Demand Affects the Sufficiency of ProvidersDemand Affects the Sufficiency of Providers
Health carecosts
Sufficiency ofproviders
Diseaseprevalence
Morbidity &mortality
Effective healthcare provision
--
Health careaccess
Insurancecoverage
-
Behavioralrisks
--
Socioeconomicdisadvantage
-
Environmentalhazards
Main Health System Dynamics Main Health System Dynamics Cutting Reimbursements May Control CostCutting Reimbursements May Control Cost
Health carecosts
Sufficiency ofproviders
Reimbursementrates
Diseaseprevalence
Morbidity &mortality
Effective healthcare provision
--
Health careaccess
Insurancecoverage
-
Behavioralrisks
--
Socioeconomicdisadvantage
-
Environmentalhazards
Main Health System Dynamics Main Health System Dynamics Reimbursement Also Affects Quality Reimbursement Also Affects Quality
Health carecosts
Sufficiency ofproviders
Reimbursementrates
Diseaseprevalence
Morbidity &mortality
Effective healthcare provision
--
Health careaccess
Insurancecoverage
-
Behavioralrisks Quality
of care
---
Socioeconomicdisadvantage
-
Environmentalhazards
Main Health System Dynamics Main Health System Dynamics Reimbursement Further Affects Profit and AttractivenessReimbursement Further Affects Profit and Attractiveness
Health carecosts
Sufficiency ofproviders
Provider netincome
Reimbursementrates
Diseaseprevalence
Morbidity &mortality
Effective healthcare provision
--
Health careaccess
Operational &administrative
overhead-
Insurancecoverage
-
Behavioralrisks Quality
of care
--
Number ofproviders
-
Socioeconomicdisadvantage
- Attractiveness ofhealth careprofessions
Environmentalhazards
Incentives forprovider training
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
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
Strong public leadership is needed to change the modifiable drivers
(shown in italics)
Strong public leadership is needed to change the modifiable drivers
(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
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
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
Growing Portfolio of System Modeling Studies in Public Health
Growing Portfolio of System Modeling Studies in Public Health
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>.
Poised for Significant ChangePoised for Significant Change
Appreciating the Wider Scope of the “Health Challenge”Health > Healthcare
Appreciating the Wider Scope of the “Health Challenge”Health > Healthcare
Parameter Proxy Initial Values (~2000) Sources
Advantaged & Disadvantaged
Prevalence
Household Income (< or ≥ $25,000)
Advantaged = 79% Disadvantaged = 21%
Census
Symptomatic Disease/Injury
Prevalence
Self-rated health is good, fair, or poor
Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%)
BRFSS JAMA
Asymptomatic Chronic Disease Prevalence
High blood pressure (HBP) High cholesterol (HC) Asymp = Tot Chron - Symp
Overall = 40% (54.5% tot chron - 14.5% Symp)
D/A Ratio (tot chronic) = 1.15 (= 61%/53%)
NHANES JAMA
Mortality Deaths per 1,000 Overall = 8.4 D/A Ratio = 1.80
Vital Statistics AJPH
Morbidity Unhealthy days
per month per capita Overall = 5.25 D/A Ratio = 1.78
BRFSS
Health Equity Unhealthy days (or deaths)
attributable to disadvantage Attrib. fraction (unhealthy days) = 14.1% Attrib. fraction (deaths) = 14.4%
Census BRFSS
Health Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82
Census
Sufficiency of Primary Care Providers
Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.71
AMA Austin Study
Emergency Care for Nonurgent Problems
Acute non-urgent visits in ER or outpatient department
Overall = 19% D/A Ratio = 5.5
NAMCS
Unhealthy Behavior Prevalence
Smoking Physical inactivity
Overall = 34% D/A Ratio = 1.67
BRFSS JAMA Austin Study
Unsafe Environment Prevalence
“Neighborhood not safe” Overall = 26% D/A Ratio = 2.5
BRFSS JAMA Austin Study
Selected Estimates for Model CalibrationSelected Estimates for Model Calibration
Parameter Proxy Initial Values (~2000) Sources
Advantaged & Disadvantaged
Prevalence
Household Income (< or ≥ $25,000)
Advantaged = 79% Disadvantaged = 21%
Census
Symptomatic Disease/Injury
Prevalence
Self-rated health is good, fair, or poor
Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%)
BRFSS JAMA
Asymptomatic Chronic Disease Prevalence
High blood pressure (HBP) High cholesterol (HC) Asymp = Tot Chron - Symp
Overall = 40% (54.5% tot chron - 14.5% Symp)
D/A Ratio (tot chronic) = 1.15 (= 61%/53%)
NHANES JAMA
No Health Problems Prevalence
Self-rated health is excellent or very good
No HBP or HC
Overall = 33% Advantaged = 36% Disadvantaged = 24%
BRFSS NHANES
Mortality Deaths per 1,000 Overall = 8.4 D/A Ratio = 1.80
Vital Statistics AJPH
Morbidity Unhealthy days
per month per capita Overall = 5.25 D/A Ratio = 1.78
BRFSS
Health Equity Unhealthy days (or deaths)
attributable to disadvantage
Attrib. fraction (unhealthy days) = 14.1% Attrib. fraction (deaths) = 14.4%
Census BRFSS
Health Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82
Census
Sufficiency of Primary Care Providers
Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.71
AMA Austin Study
Emergency Care for Nonurgent Problems
Acute non-urgent visits in ER or outpatient department
Overall = 19% D/A Ratio = 5.5
NAMCS
Unhealthy Behavior Prevalence
Smoking Physical inactivity
Overall = 34% D/A Ratio = 1.67
BRFSS JAMA Austin Study
Unsafe Environment Prevalence
“Neighborhood not safe” Overall = 26% D/A Ratio = 2.5
BRFSS JAMA Austin Study
Selected Estimates for Model CalibrationSelected Estimates for Model Calibration
Parameter Proxy Initial Values (~2000) Sources
Advantaged & Disadvantaged
Prevalence
Household Income (< or ≥ $25,000)
Advantaged = 79% Disadvantaged = 21%
Census
Symptomatic Disease/Injury
Prevalence
Self-rated health is good, fair, or poor
Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%)
BRFSS JAMA
Asymptomatic Chronic Disease Prevalence
High blood pressure (HBP) High cholesterol (HC) Asymp = Tot Chron - Symp
Overall = 40% (54.5% tot chron - 14.5% Symp)
D/A Ratio (tot chronic) = 1.15 (= 61%/53%)
NHANES JAMA
No Health Problems Prevalence
Self-rated health is excellent or very good
No HBP or HC
Overall = 33% Advantaged = 36% Disadvantaged = 24%
BRFSS NHANES
Mortality Deaths per 1,000 Overall = 8.4 D/A Ratio = 1.80
Vital Statistics AJPH
Morbidity Unhealthy days
per month per capita Overall = 5.25 D/A Ratio = 1.78
BRFSS
Health Equity Unhealthy days (or deaths)
attributable to disadvantage
Attrib. fraction (unhealthy days) = 14.1% Attrib. fraction (deaths) = 14.4%
Census BRFSS
Health Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82
Census
Sufficiency of Primary Care Providers
Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.71
AMA Austin Study
Emergency Care for Nonurgent Problems
Acute non-urgent visits in ER or outpatient department
Overall = 19% D/A Ratio = 5.5
NAMCS
Unhealthy Behavior Prevalence
Smoking Physical inactivity
Overall = 34% D/A Ratio = 1.67
BRFSS JAMA Austin Study
Unsafe Environment Prevalence
“Neighborhood not safe” Overall = 26% D/A Ratio = 2.5
BRFSS JAMA Austin Study
Selected Estimates for Model 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…