syndemics prevention network university of minnesota minneapolis, mn may 13, 2008 dynamic principles...

Syndemics

Prevention Network

University of MinnesotaMinneapolis, MN

May 13, 2008

Dynamic Principles and Democratic Powers

Bobby Milstein Centers for Disease Control and

[email protected]

Crafting a Health System that Protects Us All

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Poised for Significant Change

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Lessons 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

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

(i.e., public work to be produced)

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

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-- Julie Gerberding

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.”

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

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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/

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The 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

• 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)

Health

LivingConditions

Power toAct

“Health Policy”

“Social Policy”

“Citizen-ship”

• 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

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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

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

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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

Confounding

Connecting*

Synergism

Syndemic

Events

System

Co-occurring

* Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping

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Time Series Models

Describe trends

Multivariate Stat 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 & Evaluation

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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.”

-- David Bornstein

Bornstein D. How to change the world: social entrepreneurs and the power of new ideas. New York: Oxford University Press, 2004.

Number of Public Service GroupsRegistered with IRS

0

500,000

1,000,000

1989 1998

Nu

mb

er

Re

gis

tere

d

60%

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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

Power Has to be Organized

Gecan M. Going public. Boston: Beacon Press, 2002.

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Even Broad-Based Organizing May Not Be Enough Insights from the North Karelia Project

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>.

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%






• All causes -49%






• All causes -49%






• All causes -49%

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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.

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Transforming All Dimensionsof the System

Health

LivingConditions

Power toAct

Efforts to Fight Afflictions

Efforts to Improve Adverse Living Conditions

Efforts to Build Power

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• 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

Ingredients for Transforming Population HealthA Short Menu of Policy Proposals

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Are these ingredients connected?

How?

Does that matter?

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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.

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

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Definitely, if we study every detail up close…

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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.

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Rules of the Health Protection Game• Goal

Navigate 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….

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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?

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High-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 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

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

Health carecosts

Diseaseprevalence


Behavioralrisks


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

Health carecosts

Diseaseprevalence



--

Health careaccess

Behavioralrisks


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Main Health System Dynamics Insurance Coverage Enables Access

Health carecosts

Diseaseprevalence



--

Health careaccess

Insurancecoverage

-

Behavioralrisks


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Main Health System Dynamics Disadvantage Creates a Double Vulnerability

Health carecosts

Diseaseprevalence



--

Health careaccess

Insurancecoverage

-

Behavioralrisks


-


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Main Health System Dynamics Demand Affects the Sufficiency of Providers

Health carecosts


Diseaseprevalence



--

Health careaccess

Insurancecoverage

-

Behavioralrisks

--


-


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Main Health System Dynamics Cutting Reimbursements May Control Cost

Health carecosts


Reimbursementrates

Diseaseprevalence



--

Health careaccess

Insurancecoverage

-

Behavioralrisks

--


-


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Main Health System Dynamics Reimbursement Also Affects Quality

Health carecosts


Reimbursementrates

Diseaseprevalence



--

Health careaccess

Insurancecoverage

-


of care

---


-


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Main Health System Dynamics Reimbursement Further Affects Profit and Attractiveness

Health carecosts


Provider netincome

Reimbursementrates

Diseaseprevalence



--

Health careaccess


overhead-

Insurancecoverage

-


of care

--

Number ofproviders

-





and practice

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Main Health System Dynamics 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

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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

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

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Illustrative Intervention Scenarios

Scenario Name

Policy Options

Coverage Quality Rates Efficiency Admin Incent Behave Environ Advantage

Cut Reimbursement*

Universal Coverage

Improve Quality Upstream Health

Protection Pathways to

Advantage

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.

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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

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.


Prototype Model Output

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Exploring Intervention ScenariosCut Reimbursements to Office-Based Physicians by 20%

Quality of disease & injury care0.6

0.4

0.2

0

2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

Prevalence of disease & injury0.6

0.4

0.2

0

2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

Quality of DI care for the managed1

0.75

0.5

0.25

0

2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

Primary care providers per 10 thousand popn20

15

10

5

0

2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

Advantaged

Disadvantaged

Advantaged

Disadvantaged

Advantaged

Disadvantaged




Prototype Model Output Prototype Model Output


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Additional Preliminary FindingsUniversal 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 capita6

5.5

5

4.5

42000 2010 2020 2030 2040 2050

Protection

Coverage

Quality


Health care spending per capita6,000

5,500

5,000

4,500

4,0002000 2010 2020 2030 2040 2050

Protection

Coverage

Quality


Health inequity index (morbidity)0.2

0.15

0.1

0.05

02000 2010 2020 2030 2040 2050

Protection

Coverage

Quality


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Additional Preliminary FindingsPathways 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 capita6

5.5

5

4.5

42000 2010 2020 2030 2040 2050

Protection

Coverage

Pathways

Quality


Health care spending per capita6,000

5,500

5,000

4,500

4,0002000 2010 2020 2030 2040 2050

Protection

Coverage

Pathways

Quality


Health Inequity Index (Morbidity)0.2

0.15

0.1

0.05

02000 2010 2020 2030 2040 2050

Protection

Coverage

Pathways

Quality


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A Model Is…

An inexact representation of the real thing

It helps us understand, explain, anticipate, and make decisions

“All models are wrong, some are useful.”

-- George Box

“All models are wrong, some are useful.”

-- George Box

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Gaming Supports Learning and Wayfinding

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.

Multi-stakeholder Dialogue

Dynamic Hypothesis (Causal Structure) Plausible Futures (Policy Experiments)

Health Inequity Index (Morbidity)0.2

0.15

0.1

0.05

02000 2010 2020 2030 2040 2050

Protection

Coverage

Pathways

Quality


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

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syndemics prevention network university of minnesota minneapolis, mn may 13, 2008 dynamic principles...

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