Crafting a Health System that Protects Us All

International Society for Systems ScienceMadison, WIJuly 14, 2008Syndemics, Simulation Scenarios, and Social ChangeBobby Milstein Syndemics Prevention NetworkCenters for Disease Control and [email protected]://www.cdc.gov/syndemics

Crafting a Health System that Protects Us All

Public Health Systems Science Addresses Navigational Policy Questions17% increaseCenters 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 .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?

Widening Systems View of HealthCenters for Disease Control and Prevention. Dynamic models. Atlanta, GA: Syndemics Prevention Network; March 11, 2008. .

Americans Views on the Health SystemPoised for Significant Change?Over 75% of Americans think the current system needs fundamental changeBlendon 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 VenturesHeirich 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 .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 ofPiecemeal approachesComplicated schemes that were opposed by special interestsAssumption that healthcare dynamics are separate from other areas of public concernConventional analytic methods make it difficult to Observe the health system as a large, dynamic enterpriseCraft high-leverage strategies that can overcome policy resistancePolicy 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

Expanding Options through Boundary Critique-- Julie GerberdingCDC DirectorRubin R. CDC campaign hopes to make USA healthier nation. USA Today 2008 July 7. 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 equityand [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 OrientationA syndemic orientation clarifies the dynamic and democratic character of public health workMilstein 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.htmYou think you understand two because you understand one and one. But you must also understand and.-- Sufi SayingStudying innovations in public health work where there are multiple interacting problemsThe word syndemic signals special concern for many kinds of relationships:mutually reinforcing health problemshealth status and living conditionssynergy/fragmentation in the health protection system (e.g., by issues, sectors, organizations, professionals and other citizens)Citizen-shipExplicitly includes our power to respond, while understanding its changing pressures, constraints, and consequences

Epidemic The term epidemic is an ancient word signifying a kind of relationship wherein something is put upon the peopleEpidemiology 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 DiseasesEver since then, the conditions that cause health problems have increasingly become matters of public concern and public workElliot 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.htmNational 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: NIHThe 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

Syndemic 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 arenaIt 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 waysConfoundingConnecting*SynergismSyndemicCo-occurring* Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping

Time Series ModelsDescribe trendsMultivariate Statistical ModelsIdentify historical trend drivers and correlatesPatternsStructureEventsIncreasing:Depth of causal theoryRobustness for longer-term projectionValue for developing policy insightsDegrees of uncertaintyLeverage for changeDynamic Simulation Models Anticipate new trends, learn about policy consequences, and set justifiable goalsTools for Policy Planning & Evaluation

CDCs Growing Portfolio of Health System Dynamics ProjectsSelected Health Priority AreasDiabetesObesityInfant healthCardiovascular healthSyndemicsOverall Health Protection EnterpriseNeighborhood transformationNational health economyChronic illness dynamicsUpstream-downstream investmentsHealth protection gameCommunications, Training, FundingPublications, 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 SystemMadon 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?

Definitely, if we study every detail up close

Not if we take a macroscopic view, from a very particular distanceRichardson 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

Expand insurance coverageImprove quality of careChange reimbursement ratesImprove operational efficiencySimplify administrationEncourage provider training/practiceEnable healthier behaviorsBuild safer environmentsCreate pathways to advantageStrengthen leadershipIngredients for Transforming Population Health A Short Menu of Policy Proposals

Rules of the Health Protection GameGoal Navigate the U.S. health system toward greater health and equityTask Prioritize intervention options across 10 policy domainsDecisions Craft health protection strategies over 8 rounds (from 2010-2050), using feedback available every five yearsScoring Achieve the best results across four criteria simultaneouslySave 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 Setup A population in dynamic equilibrium, with fixed rates of birth and net immigration, experiencing high starting levels of mortality, unhealthy life, social inequity, and healthcare costsNo 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 TrapFour Problems in the Current System: High Morbidity, Mortality, Inequity, CostDeath rate per thousandUnhealthy days per capitaHealth inequity indexHealthcare spend per capita10 6 0.2 6,000 0 0 0 4,000 20002005201020152020202520302035204020452050 How far can you move the system?

High-Level Map of Health System DynamicsMost parts of the health systemso often discussed separatelyare in fact connectedAdapted 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, 2008Strong public leadership is needed to change the modifiable drivers (shown in italics)

Selected Estimates for Model Calibration

ParameterProxyInitial Values (~2000)SourcesAdvantaged & Disadvantaged Prevalence Household Income (< or $25,000) Advantaged = 79% Disadvantaged = 21% Census


ParameterProxyInitial Values (~2000)SourcesAdvantaged & Disadvantaged Prevalence Household Income (< or $25,000) Advantaged = 79% Disadvantaged = 21% CensusSymptomatic Disease/InjuryPrevalence Self-rated health is good, fair, or poor Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%) BRFSS JAMAAsymptomatic 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 JAMAMortality Deaths per 1,000 Overall = 8.4 D/A Ratio = 1.80 Vital Statistics AJPHMorbidity Unhealthy days per month per capita Overall = 5.25 D/A Ratio = 1.78 BRFSSHealth Equity Unhealthy days (or deaths) attributable to disadvantage Attrib. fraction (unhealthy days) = 14.1% Attrib. fraction (deaths) = 14.4% Census BRFSSHealth Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82 CensusSufficiency of Primary Care Providers Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.71 AMA Austin StudyEmergency Care for Nonurgent Problems Acute non-urgent visits in ER or outpatient department Overall = 19% D/A Ratio = 5.5 NAMCSUnhealthy Behavior Prevalence Smoking Physical inactivity Overall = 34% D/A Ratio = 1.67 BRFSS JAMA Austin StudyUnsafe Environment Prevalence Neighborhood not safe Overall = 26% D/A Ratio = 2.5 BRFSS JAMA Austin Study

Intervention Options & Scoring Criteria

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.

Scenario NamePolicy OptionsInsurance CoverageQualityCareReimb.RatesEfficiencySimpler AdminProvider IncentivesHealthier BehaviorSafer EnvironAdvantageStronger LeadershipCut Reimbursement*Universal CoverageHigher QualityUpstream ProtectionOthers/Combos

Exploring Intervention ScenariosCut Reimbursements to Office-Based Physicians by 20%Scoring Criteria: Deaths, Unhealthy Days, Inequity, SpendingDeath rate per 1,000 Unhealthy days Health inequity index Healthcare spending per capita >>>> These results are from a prototype model.

Exploring Intervention ScenariosCut Reimbursements to Office-Based Physicians by 20%Quality of disease & injury careQuality of DI care for the managedSufficiency of primary care providersAdvantagedDisadvantagedPrototype Model OutputPrototype Model OutputPrototype Model Output10.90.80.70.62000200520102015202020252030203520402045205010.750.50.25020002005201020152020202520302035204020452050AdvantagedDisadvantaged10.8750.750.6250.520002005201020152020202520302035204020452050Acute nonurgent event visits to ER or OPD70 M55 M40 M25 M10 M20002005201020152020202520302035204020452050AdvantagedDisadvantagedPrototype Model Output

Additional Preliminary FindingsUniversal Coverage (with Leadership)Lowers morbidity and mortality quicklyIncreases 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 equityTakes 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 accessAverage unhealthy days per capitaHealth care spending per capitaHealth inequity index (morbidity)65.554.542000201020202050ProtectionCoverageQuality20302040Prototype Model Output6,0005,5005,0004,5004,00020002050ProtectionCoverageQualityPrototype Model Output20102020203020400.20.150.10.05020002050ProtectionCoverageQualityPrototype Model Output2010202020302040

Game-based Wayfinding Dialogues Combine Science and Social ChangePotential champions need more than visionary direction. They want plausible pathways and visceral preparation.

Transforming All Dimensionsof the Health SystemLivingConditions

Expanding Public Health SciencePublic health imagination involves using science to expand the boundaries of what is possible.-- Michael ResnickEpidemic OrientationMilstein 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

Health Protection as a SystemGerberding 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 Risk, Disease, Health Status, and Costs

Main Health System Dynamics Effective Health Care is Powerfuland Expensive

Main Health System Dynamics Insurance Coverage Enables Access

Main Health System Dynamics Disadvantage Creates a Double Vulnerability

Main Health System Dynamics Demand Affects the Sufficiency of Providers

Main Health System Dynamics Cutting Reimbursements May Control Cost

Main Health System Dynamics Reimbursement Also Affects Quality

Main Health System Dynamics Reimbursement Further Affects Profit and Attractiveness

Main Health System Dynamics Health Equity Captures the Consequences of Differences in Vulnerability, Health Status, and Access to Care Strong public leadership is needed to change the modifiable drivers (shown in italics)

1999200020012002200320042005Milestones in the Recent Use of System Dynamics Modeling at CDC2006* Dedicated multi-year budget20072008

Poised for Significant Change

Adverse living conditions + Absence of protective efforts = Vulnerability

Re-Directing the Course of ChangeQuestions of Social NavigationPrevalence of Diagnosed Diabetes, United States01020304019801990200020102020203020402050Million peopleMarkov 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.Trend is not destinyHow?Why?Where?Who?What?

Growing Portfolio of System Modeling Studies in Public Health

Wayfinding Combines Science and Social ChangeIdeas for Extending the WorkGetting Beyond the PrototypeReview and Refine the Simulation Model e.g., SD methodology, health system content, parameter estimates, user interfaceDevelop an Effective Instructional Design e.g. stakeholder roles, facilitated debriefing, policy insights, implications for leadershipDiscussing Tradeoffs (Competing Values) e.g. cost vs. health vs. equity; short-term vs. long-termStakeholder Engagement & ActionCertify Wayfinding Consultants e.g., cadre of public health innovators trained to support stakeholders in playing the gameConvene Wayfinding Dialogues e.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)Syndemics Mutually reinforcing afflictionsDiabetes In an era of rising obesityObesity Lifecourse consequences of changes in caloric balanceInfant Health Fetal and infant morbidity/mortalityCardiovascular Health Preventing and managing multiple risks, in contextMilstein 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. .Grantmaking Scenarios Timing and sequence of outside assistanceUpstream-Downstream Effort Balancing disease treatment with prevention/protectionHealthcare Reform Relationships among cost, quality, equity, and health statusChronic Illness Dynamics Health and economic scenarios for downstream and upstream reformsHealth Protection Game Learning to transform our troubled health system

Growing Portfolio of System Modeling Studies in Public Health

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 InstituteApplied Systems Thinking Institute. CDC-NIH System Dynamics Collaborative Wins 2008 ASysT Prize. Arlington, VA; July 9, 2008. .

Poised for Significant Change

Appreciating the Wider Scope of the Health ChallengeHealth > Healthcare


ParameterProxyInitial Values (~2000)SourcesAdvantaged & Disadvantaged Prevalence Household Income (< or $25,000) Advantaged = 79% Disadvantaged = 21% CensusSymptomatic Disease/InjuryPrevalence Self-rated health is good, fair, or poor Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%) BRFSS JAMAAsymptomatic 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 JAMAMortality Deaths per 1,000 Overall = 8.4 D/A Ratio = 1.80 Vital Statistics AJPHMorbidity Unhealthy days per month per capita Overall = 5.25 D/A Ratio = 1.78 BRFSSHealth Equity Unhealthy days (or deaths) attributable to disadvantage Attrib. fraction (unhealthy days) = 14.1% Attrib. fraction (deaths) = 14.4% Census BRFSSHealth Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82 CensusSufficiency of Primary Care Providers Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.71 AMA Austin StudyEmergency Care for Nonurgent Problems Acute non-urgent visits in ER or outpatient department Overall = 19% D/A Ratio = 5.5 NAMCSUnhealthy Behavior Prevalence Smoking Physical inactivity Overall = 34% D/A Ratio = 1.67 BRFSS JAMA Austin StudyUnsafe Environment Prevalence Neighborhood not safe Overall = 26% D/A Ratio = 2.5 BRFSS JAMA Austin Study


ParameterProxyInitial Values (~2000)SourcesAdvantaged & Disadvantaged Prevalence Household Income (< or $25,000) Advantaged = 79% Disadvantaged = 21% CensusSymptomatic Disease/InjuryPrevalence Self-rated health is good, fair, or poor Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%) BRFSS JAMAAsymptomatic 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 JAMANo 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 AJPHMorbidity Unhealthy days per month per capita Overall = 5.25 D/A Ratio = 1.78 BRFSSHealth Equity Unhealthy days (or deaths) attributable to disadvantage Attrib. fraction (unhealthy days) = 14.1% Attrib. fraction (deaths) = 14.4% Census BRFSSHealth Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82 CensusSufficiency of Primary Care Providers Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.71 AMA Austin StudyEmergency Care for Nonurgent Problems Acute non-urgent visits in ER or outpatient department Overall = 19% D/A Ratio = 5.5 NAMCSUnhealthy Behavior Prevalence Smoking Physical inactivity Overall = 34% D/A Ratio = 1.67 BRFSS JAMA Austin StudyUnsafe Environment Prevalence Neighborhood not safe Overall = 26% D/A Ratio = 2.5 BRFSS JAMA Austin Study

There Have Been Remarkable Successes in Redirecting the Course of Change60050040020010050195019601970198019901995Age-adjusted Death Rate per 100,000 Population1955196519751985300700Peak RateRate if trend continuedYearActual and Expected Death Rates for Coronary Heart Disease, 19501998Marks 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 Actual RateOverall Decline is Linked to Reduced smoking Changes in diet Better diagnosis and treatment More heath services utilization

Fewer Deaths Mean More People Living with Illness and its Associated Burden and Costs0481216200420001996199219881984198019761972196819641960Consumer price index (CPI-U) relative to 1960HealthcareTotal economyConsumer Price Indices for Healthcare and the General Economy United States, 1960-2004 (1960=1)

American Bankruptcy Institute. Bankruptcy filing statistics: non-business filings. Alexandria, VA: American Bankruptcy Institute; October, 2007. .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.w5.63v1Fox M. Half of Bankruptcy Due to Medical Bills -- U.S. Study: Reuters; February 2, 2005. Total Personal Bankruptcy Filings, United States, 1994-2005Healthcare Cost is Also the Leading Driver of Personal Bankruptcy61% of the filers surveyed failed to seek needed medical treatments

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

A Dynamic Model Simulates Policy Scenarios

Are these ingredients connected?

How?

Does that matter?

Trends in Self-reported Health & Health Care Spending United States, 1982-2004National Health Interview Survey, National Health Expenditure AccountsData Sources: National Health Expenditure Accounts (NHEA), US Census; National Health Interview Survey (NHIS), CDCHomer 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):313343. Health care spending per capita (year 2000 dollars)40%50%60%70%80%90%100%200420022000199819961994199219901988198619841982$0$1,000$2,000$3,000$4,000$5,000$6,000Percentage Reporting Excellent or Very GoodSelf-reported health (i.e., excellent or very good) oscillated within a narrow range of 65% to 69%Health care spending per capita in year 2000 dollars more than doubled in 20 years

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

POLICY CHOICESSCORING CRITERIA (Averaged from 20002050)*Save LivesImprove Well-beingAchieve Health EquityLower Healthcare CostsAppropriate Intervention ExpensesMortality rate (or YLL)Unhealthy days(or QALY)Unhealthy days attributable to disadvantage(or attrib deaths)Healthcare spending per capita(or % of GDP)Total outlay for subsidies and program costs1Expand insurance coverage2Improve quality of care3Change reimbursement rates4Improve operational efficiency5Simplify administration6Offer provider incentives7Enable healthier behaviors8Build safer environments9Create pathways to advantage10Strengthen leadership

*Greatest accomplishmentsLead in gasolineCVD Mortality North Karelia trends Action PlanTobacco Consumption CA & MA Best practices commitment to comprehensivness

Beyond programs to focus on policies

Retrospective policy eval is essential, but today we will concentrate on prospective policy eval the evaluative aspect of planning, organizing, and literally directing the course of social change

Introduce basic principles

Expand conventional approach to a more explicit dynamic and democratic foundation (Venn Diagram)

Highlight role of one particular methodology: simulation modeling****The health sector now is one of the most consequential parts of the American economy, employing more people than any other area and quadrupling its share of the gross national product in the past 40 years. Innovations both large and small have sought to limit this harmful instability, but those reforms have been uniformly unsuccessful. Six times since the Depression, the United States has tried and failed to establish universal financial access to healing services, and the balance between prevention and treatment remains almost no balance at all, with 97% of all resources spent on health devoted to healing those living with an affliction. The character and composition of the system has evolved markedly, but the system-wide problems of poor performance, spiraling cost, and stark inequity not only persist but show signs of intensifying. The central challenge does not stem from the absence of sound policy options, but in our failure to perceive the larger dynamics that ultimately scuttle or subvert even the most logical innovations. The end result is counterintuitive: America has evolved the most rapidly advancing health care industry in the world, but it neither adequately nor equitably secures the health of the public; and worse, the unrestrained cost of healing preventable afflictions now exerts a destabilizing force in the larger political economy of the nation and the world.

Sociologist Max Heirich points to three reasons for our disappointing track record in reforming health policy. First, problems were often tackled piecemeal, as though a single intervention in one area (even a major one) would correct the larger dynamic at workSecond, the more comprehensive reform plans roused the opposition of interest groups and the larger publicBut even if they had succeeded politically, those proposals probably would not have succeeded practically, because they did not address more fundamental dynamics that were creating problems in health careAnd third, health-care dynamics were treated as if they existed independently of everything else that was happening in the political and economic system-a serious miscalculation (Heirich 1999).*

Probing deeper, he goes on to suggest that a different mix of strategies might have emerged had the health sectors organizational problems been viewed in terms of their connections to changes occurring in wider national and international contexts. Potentially effective reforms were overlooked, in Heirichs view, because most of the analytic strategies popular among academics, politicians, and policy makers fail to observe the system as a whole in ways that let policy makers shape individual choicesand even fewer analytic strategies have made it possible to discuss processes of mutual change that are occurring, or to analyze how innovations fit into larger nonequilibrium dynamics that are developing.

Such methodological shortcomings call for novel ways of thinking about the essence of public health work. Through serious reflection and committed action we may yet repair the disconnection between our experience of the health system and the tools that we use to study and govern its behavior. That disconnection sits at the core of our failed reform attempts, and it is the genesis of the disarray and disorientation against which we struggle today. Many of the problems undermining the public's health (e.g., chronic illnesses, environmental decay, depression, violent conflict, HIV/AIDS, emerging infectious disease, terrorism) will remain entrenched and insolvable using conventional policies and practices. Moreover, the sheer number of health threats will increase and become inexorably intertwined unless we adjust the fundamental mismatch between the expanding scope of public health work and the comparative narrowness of our models for understanding and directing change. That mismatch must be solved the way all problems are solved: by rethinking the situation, clarifying values, and reorienting our frame of reference for action. Officials at the CDC, along with leaders of the System Dynamics Society and a worldwide network of other interested citizens, are now exploring a pioneering approach that promises to reorient public health work and transform health futures for generations to come. It begins with the following commitments....**Public health work is becoming moreInter-connected (ecological, multi-causal, dynamic, systems-oriented) Concerned more with leverage than control Public (broad-based, partner-oriented, citizen-led, inter-sector, democratic) Concerned with many interests and mutual-accountabilityQuestioning (evaluative, reflexive, critical, practical) Concerned with creating and protecting values like health, dignity, security, satisfaction, justice, wealth, and freedom in both means and ends

Taken together, these changes present serious challenges for planners and evaluators, some of which includeLocating categorical disease programs within a broader system of health protectionConstructing credible knowledge without comparison/control groupsDifferentiating questions that focus on attribution versus contributionBalancing trade-offs between short- and long-term effectsAvoiding the pitfalls of professonalismHarnessing the power of citizen-led public workDefining standards and values for judgmentOthers

*****Time series of trends*******This figure focuses on the population and its movement among states of health, risk behavior, environmental exposures, and socioeconomic advantage or disadvantage. Disadvantage makes it harder for people to choose healthier behaviors and exposes them to more hazardous environments, leaving them more vulnerable to an array of afflictions that increase aggregate disease prevalence. The disadvantaged also have worse access to health care than do the advantaged, due to less insurance coverage and less sufficiency of providers to meet patient demand. Greater disease prevalence combined with worse access to care means that the disadvantaged experience greater morbidity and mortality per capita than the advantaged do. Another factor affecting health outcomes is the quality of care delivered, reflecting the extent to which providers take the time to listen carefully to their patients and do a better job of diagnosis, counseling, and care. Quality of care may be improved by encouraging adoption of guidelines for best practice, but the incentive for such adoption is hindered if insurance reimbursement rates are not adequate. These relationships stand as a broad summary of the a much larger causal structure that governs health system change over time.

The various parts of the health system, often discussed separately in popular discourse and in analytic studies, are in fact connected. In some cases, these connections may create unanticipated side effects, where short-term improvements turn into longer-term losses (or vice versa). For example, cutting reimbursement rates may initially lower costs, but it also has the tendency to diminish quality of care, as providers gradually adjust their practice to maintain their incomes. Lower quality implies less effective care, leading quickly to greater morbidity and mortality particularly among those with chronic diseases; less effective preventive care also leads more gradually to increased prevalence of disease. These contrary effects can overwhelm the initial cost saving from reimbursement reduction and produce a net increase in health care costs.

The main values (or outcomes) at stake in any scenario for health system change are shown in bold Italics indicate broad classes of potential policy intervention Blue arrows indicate same-direction effects (e.g., lower reimbursement means lower provider income), Orange arrows indicate opposite-direction effects (e.g., more operational and administrative overhead means lower provider income.)

*NAMCS (33% to 6%)*NAMCS (33% to 6%)***Cutting reimbursements does 3 things: (1) immediately cuts HC costs, (2) immediately leads to lower quality of care (less time spent with pts, more emphasis on trying to maintain income), (3) gradually leads to decline of providers. #2 and #3 explain increasing death and UD. But why does HC spending rise after initial bump down? And why does inequity get better, but then rebound? *The reason HC spending rebounds is that reduced quality means (1) more urgent events and (2) gradually rising in DI prevalence (more onset, slower recovery). The higher cost of urgent care, especially, quickly overcomes the initial decline in HC spending. Why inequity down-up? Because the decline in quality most affects those who go to the doctor, i.e. the advantaged (in the first instance). However, over time quality for disadvantaged erodes faster than it does for adv, because loss of providers impacts them more; the Adv have some buffer, and spending less time per patient actually frees up providers somewhat, so Adv quality doesnt erode further until after 2025.*******************But I believe the time has come where we have even more to contribute to this debate. We are about prevention, but were also about something thats even more expansive, and that really is the notion of health protection. Yes, prevention is a very important part of health protection, prevention of disease, injury and disability. But increasingly, were in the business of health promotion as well as preparedness, preparedness for infectious and occupational, environmental, and terrorist threats. Certainly thats been a conspicuous part of our portfolio since 2001, although its always been part of CDCs core mission. Health protection expands the debate about healthcare and healthcare reform, but its not the whole picture, because we know that the other part of the debate is about fairness in our healthcare system. And the concept of health equity is one that we at CDC use as an implicit part of our value system when were thinking about our work. Its what drives our passion. Its what motivates us to go anywhere, anytime, to do anything that needs to be done to help protect peoples health. And it really is the principle that, I think, is hidden behind some of the statements that weve traditionally made about our mission. So when you think about CDCs mission, its important to include the concept of health equity in it. And we havent clearly defined this for our agency, but I think we are recognizing that at least this is the absence of health disparity. It may require a measurement so that we can define equality among groups with more or less social advantage, and there is the element of social justice that in the health equity environment there is fairness in peoples opportunity to achieve optimal health status. So if we think about these two principles, health protection and health equity, its very clear that the healthcare system that we have today is lacking these two principles in too many families and in too many locations. ********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.htmlBraveman 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=26673California 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/

HousingEducation, Environment, EquityAccessLaborTransportationH*NAMCS (33% to 6%)*NAMCS (33% to 6%)*NAMCS (33% to 6%)*CHD accounted for 460,000 deaths in 1998. It would have accounted for 1,144,000 if the rate had remained at its 1963 peak.

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Crafting a Health System that Protects Us All

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