Finding the Foresight and Strength to Transform Health Systems

Grand Rounds on the Future of Public HealthColumbia University

Mailman School of Public HealthNew York, NY

October 14, 2009

Bobby MilsteinSyndemics Prevention Network

Centers for Disease Control and Preventionbmilstein@cdc.gov

http://www.cdc.gov/syndemics

The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

More Money for Shorter LivesPersistent Gaps in Health by IncomePercent of Adults with Activity Limitation

Poised for Transformation…• America has a national health

shortage: we pay the most for health care, yet suffer comparatively poor health

• The disadvantaged fare worse

• Over 75% think the current system needs fundamental change

• Analyses that focus narrowly on parts of the system, without examining connections, often miss the potential for policy resistance

Commission to Build a Healthier America. America is not getting good value for its health dollar. Robert Wood Johnson Foundation 2008. Nolte E, McKee CM. Measuring the health of nations: updating an earlier analysis. Health Affairs 2008; 27(1):58-71.Blendon RJ, Altman DE, Deane C, Benson JM, Brodie M, Buhr T. Health care in the 2008 presidential primaries. NEJM 2008;358(4):414-422. White House. Americans speak on health reform: report on health care community discussions. Washington, DC: HealthReform.gov; March, 2009. Altman DE, Levitt L. The sad history of health care cost containment as told in one chart. Health Affairs 2002;Web Exclusive:hlthaff.w2.83.

• Failure to foresee

• Inability to enact higher leverage policies

• Failure to foresee

• Inability to enact higher leverage policies

“Sad History of Health Care Cost Containment: 1961-2001”

Foresight

Public Strength

People’s power to direct the course of change toward a negotiated set of valued conditions or goals.

Ability to anticipate plausible futures under different scenarios

Sisko A, Truffer C, Smith S, Keehan S, Cylus J, Poisal JA, Clemens MK, Lizonitz J. Health spending projections through 2018: recession effects add uncertainty to the outlook. Health Affairs 2009:hlthaff.28.2.w346.

King SL. Mass. health reform is failing us. Boston Globe 2009 March 2. <http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2009/03/02/mass_healthcare_reform_is_failing_us/>

Semenza JC. The intersection of urban planning, art, and public health: the Sunnyside Piazza. American Journal of Public Health 2003;93(9):1439-41.

Projected U.S. Health ExpendituresScenarios to Bend the Curve

Portland’s Sunnyside Piazza triggered a wider sense well-being

Choosing a Path

"America was not on a road to survival

before Martin Luther King. Atlanta

would not look like the thriving

metropolis that it is now. Atlanta

would probably look more like Beirut if

history had gone its normal course,

the normal violent American way."

-- Andrew Young

From: Kearns K. In Remembrance of Martin. PBS Video, 1999.

Can We Really Foresee the Future?

United Nations Department of Economic and Social Affairs. Population Division. The world at six billion. Washington D C: Population Division Dept. of Economic and Social Affairs United Nations Secretariat, 1999.

World Population Growth

Health Threats are Changing

Murray CJL, Lopez AD. The global burden of disease: summary. Cambridge, MA: Harvard University Press, 1996.

Murray CJL, Lopez AD. The global burden of disease: summary. Cambridge, MA: Harvard University Press, 1996.

Into the Top 15

War

HIV

Violence

Self-inflicted injury

Cancer of the trachea, bronchus, and lung

Below the Top 15

Measles

Malaria

Falls

Anemia

Malnutrition

Emerging Challenges Have a Very Different Complexion

How Powerful Can We Be?

Source: USDA

0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

YEAR

End of WW II

1st Smoking-Cancer Concern

Fairness Doctrine Messages on TV and

Radio

Non-Smokers Rights Movement Begins

Federal Cigarette Tax Doubles

Surgeon General’s Report on ETS

1st Surgeon General’s Report

Broadcast Ad Ban

1st Great American Smoke-out

OTC Nicotine Medications

Master Settlement Agreement

Great Depression

1st World Conference on Smoking and Health

U.S. Cigarette Consumption

“Public health is probably the most successful system of science and

technology combined, as well as social policy, that has ever been devised…It is, I think, a paradigmatic model for how you do concerned, humane, directed science.”

-- Richard Rhodes

Rhodes R. Limiting human violence: an emerging scientific challenge. Sarewitz D, editor. Living With the Genie: Governing Science and Technology in the 21st Century; New York, NY: Center for Science, Policy, and Outcomes; 2002.

How is it directed?

Can it be strong enough to meetcurrent challenges and opportunities?

“Public health is what we, as a society, do collectively

to assure the conditions in which people can be healthy.”

-- Institute of Medicine

Institute of Medicine. The future of public health. Washington, D.C.: National Academy Press, 1988.

Institute of Medicine. The future of the public's health in the 21th century. Washington D.C.: National Academy Press, 2002.

“Public health is what we, as a society, do collectively through organized actions to

assure the conditions in which all people can be healthy.”

What will it take to organize science and society around the goal of assuring more healthful and equitable conditions, which are…

• Massively entangled

• Constantly in flux

• Politically contested

Defining Healthier Conditions and Who Must Do the WorkGoing Beyond Government to Governance

World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986.

Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization 2008.

This requires more than strengthened government–it requires strengthened

governance: legitimacy, space, and support for civil society, for an accountable private

sector, and for people across society to agree on public interests and reinvest in the

value of collective action.

WHO Commission on Social Determinants:

• Improve daily living conditions

• Tackle the inequitable distribution of power, money, and resources

• Measure and understand the problem and assess the impact of action

Prerequisite Conditions for Health

• Peace

• Food

• Shelter

• Education

• Income

• Stable eco-system

• Sustainable resources

• Social justice and equity

Prerequisite Conditions for Health

• Peace

• Food

• Shelter

• Education

• Income

• Stable eco-system

• Sustainable resources

• Social justice and equity

Endorsed at multiple world conferences on health promotion (1986-2000)

Universities Have a Special Role in Democratic Governance Wingspread Declaration on the

Civic Mission of the American Research University

Boyte HC, Hollander E. Wingspread declaration on renewing the civic mission of the American research university. Ann Arbor, MI: University of Michigan Center for Community Service and Learning 1999. <http://www.compact.org/civic/Wingspread/Wingspread.html>.

“The challenges facing higher education go beyond the need to add more service

learning experiences or to reward faculty for community-oriented research.

As important as these objectives are, the more fundamental task is to renew our

great mission as the agents of democracy.”

According to Seth Low in the 1900s:

Columbia University…breathed the air of the city of New York, its working class population,

its problems, and its opportunities.

According to Seth Low in the 1900s:

Columbia University…breathed the air of the city of New York, its working class population,

its problems, and its opportunities.

Agents and Architects of Democracy:The Struggle for the

Future of Higher Education

November 3, 2009Webcast

http://scup.org/page/profdev/notravel/2009/democracy

Continuing the Dialogue on Civic Agency in Higher Education

How do people develop the skills, confidence, and outlook

to become shapers of their lives and agents of change?

How do people develop the skills, confidence, and outlook

to become shapers of their lives and agents of change?

Public Health as a Profession Began as 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

Confounding

Connecting*

Synergism

Syndemic

Events

System

Co-occurring

Syn·demic • The term syndemic, first used in 1992,

strips away the idea that illnesses originate from extraordinary or supernatural forces

• Recognizes connections among entities that are often understood separately

• Places responsibility for affliction squarely within the public arena

• Views 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

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.

Innovators interested in shaping health policy are exploring new concepts, methods, and moral

principles to better capture the features of dynamic, democratic systems.

Innovators interested in shaping health policy are exploring new concepts, methods, and moral

principles to better capture the features of dynamic, democratic systems.

Re-Directing the Course of ChangeQuestions for Navigating Health System Dynamics

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?

Simulation Experiments

in Action Labs

Supporting Multi-Stakeholder Planning and Action

What changes to consider? Likely consequences?

Costs? Time-frame?

How to catalyze action?

Dynamic Hypothesis (Causal Structure)

Cardiovascularevents

Air pollutionexposure(PM 2.5)

Quality of acute andrehab care for

cardiovascular events

Use of qualitypreventive care

Use of weightloss services

by obese

Use of help servicesfor distress

Bans on smokingin public places

SmokingObesity

-Hypertension-High cholesterol

-Diabetes

Uncontrolledchronic disorders

Secondhandsmoke

Junk foodinterventions

(N=4)

Physical activityinterventions

(N=6)

Heart-unhealthy diet

Physicalinactivity Distress

Efforts to promoteprovision and use of

quality preventive care

Sodiumreduction

Trans fatreduction

Excesscalorie diet

Fruit &vegetable

interventions(N=3)

CVD deaths,disability,and costs

Excesssodium diet

Air pollutionreduction

Tobaccointerventions

(N=4)

Chronic Disorders

Other deaths and costsattributable to risk factors,

and costs of risk factormanagement

Total consequencecosts

System

Plausible Futures (Policy Experiments)

Dynamics

Years of Life Lost40 M

30 M

20 M

10 M

01990 2000 2010 2020 2030 2040

Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

Sterman JD. Learning from evidence in a complex world. American Journal of Public Health 2006;96(3):505-514.

Homer JB. Why we iterate: scientific modeling in theory and practice. System Dynamics Review 1996;12(1):1-19.

Models are…Inexact representations of the real thing They help 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

Sterman JD. All models are wrong: reflections on becoming a systems scientist. System Dynamics Review 2002;18(4):501-531. Available at <http://web.mit.edu/jsterman/www/All_Models.html>

Sterman J. A sketpic's guide to computer models. In: Barney GO, editor. Managing a Nation: the Microcomputer Software Catalog. Boulder, CO: Westview Press; 1991. p. 209-229. <http://web.mit.edu/jsterman/www/Skeptic%27s_Guide.html>

Over-relianceOver-reliance Under-relianceUnder-reliance

Exploratory Insight Goal SettingLeadership Development

Selected CDC Models of Health System DynamicsAcross a Continuum of Purposes (2001-2009)

Centers for Disease Control and Prevention. Dynamic models. Syndemics Prevention Network, 2009. http://www2.cdc.gov/syndemics/models.htm

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.

Milstein B, Homer J, Hirsch G. Are coverage and quality enough? A dynamic systems approach to health policy. AJPH (under review).

Milstein B, Homer J, Hirsch G. The "HealthBound" policy simulation game: an adventure in US health reform. International System Dynamics Conference; Albuquerque, NM; July 26-30, 2009.

Diabetes Action Labs

Upstream-Downstream

Dynamics

Obesity Overthe Lifecourse

Fetal & Infant Health

Neighborhood Transformation

Game

National Health Economics & Reform

Syndemics

Local Context of Chronic Disease Prevention and

Control

HealthBoundPolicy Simulation Game

Important Structures

EmpiricalData

The name “HealthBound” is used courtesy of Associates & Wilson, Inc.

• Cognitive and experiential learning for health leaders• Four simultaneous goals: save lives, improve health,

achieve health equity, and lower health care cost• Intervene without expense, risk, or delay• Not a prediction, but a way for diverse stakeholders

to explore how the health system can change

HealthBound is a Simplified Health SystemDesigned to bring more structure, evidence, and creativity

to the challenge of health system change

HealthBound

Lead DevelopersBobby MilsteinJack HomerGary Hirsch

HealthBound Presents a Navigational ChallengeGet Out of a Deadly, Unhealthy, Inequitable, and Costly Predicament

Starting Values for Mortality, Morbidity, Inequity, Cost (~2003)

Death rate per thousand

Unhealthy days per capitaHealth inequity indexHealthcare spend per capita

8 6

0.2 7,000

4 3

0.1 5,000

0 0 0

3,000

-5 0 5 10 15 20 25

How far can you move

the system?

Deaths

Unhealthy Days

Health Inequity

Healthcare costs

The U.S. health system is dense

with diverse issues and opportunities

Healthier behaviorsHealthier behaviors

Adherence to care guidelines Adherence to

care guidelines

Insurance coverageInsurance coverage

Insurance overheadInsurance overhead

Socioeconomic disadvantage

Socioeconomic disadvantage

Provider capacityProvider capacity

Reimbursement rates

Reimbursement rates

Extent of care

Extent of care

Provider income

Provider income

Provider efficiencyProvider efficiency

Access to careAccess to care

ER useER use

Safer environments

Safer environments

CitizenInvolvement

CitizenInvolvement

Major Causal Pathways

Science Behind the Game

Integrating prior findings and estimates• On costs, prevalence, risk factors, inequity,

utilization, insurance, quality of care, etc. (8 databases and large professional literatures)

Using sound methodology• Reflecting real-world accumulations, resource

constraints, delays, behavioral feedback

Simplifying as appropriate• Three states of health:

Healthy, Asymptomatic disorder, Disease/injury

• Two SES categories: Advantaged, Disadvantaged

• Twelve policy domains

• Some complicating trends not included in simplified game (e.g., aging, technology, economy); an extended model incorporates such factors

Combining Information into a Single Testable Framework

HealthBound Intervention OptionsA Short Menu of Major Policy Proposals

Improve quality of care

Expand primary care supply

Simplify insurance

Change self pay fraction

Change reimbursement ratesExpand insurance coverage

Enable healthier behaviors

Build safer environments

Create pathways to advantage

Strengthen civic muscle

Improve primary care efficiency

Coordinate care

Three Intervention ScenariosExpand Insurance CoverageReduces the uninsured fraction by 90%

Improve Quality of Care Raises provider adherence to guidelines for preventive, chronic and urgent care (eliminating non-adherence by 50%)Implementation Cost = $10k/MD/yr.; $500k/hospital/yr. Expand Primary Care SupplyRaises the number of primary care providers per capita to the Disadvantaged by 60% over 15 yearsImplementation Cost = $300k/additional MD Improve Primary Care EfficiencyRaises the fraction of primary care offices that run efficiently (eliminating inefficiency by 90%)Implementation Cost = $10k/MD/yr. Enable Healthier BehaviorsIncreases the fraction with healthier behavior (eliminating unhealthy behavior by 40% over 15 years)Implementation Cost = $2,000 per person helped Build Safer EnvironmentsIncreases the fraction living in safer environments(eliminating unsafe environments by 50% over 15 years)Implementation Cost = $500 per person helped

Capacity

Protection

Coverage & Quality

Simulated Results: Morbidity Average Unhealthy Days per Month

Days per month (average over entire population)6

5.25

4.5

3.75

3-5 0 5 10 15 20 25

Coverage + Quality

Coverage + Quality + Capacity

Coverage + Quality + Capacity + Protect

Year

HealthBound is designed for training purposes. Simulated scenarios cannot be interpreted as predictions for the future.

Simulated Results: Health Inequity Index Fraction of Morbidity Attributable to Disadvantage

Health Inequity Index (Fraction)

Year

Coverage + Quality

Coverage + Quality + Capacity

Coverage + Quality + Capacity + Protect

0.2

0.15

0.1

0.05

0

-5 0 5 10 15 20 25

HealthBound is designed for training purposes. Simulated scenarios cannot be interpreted as predictions for the future.

Simulated Results: Total Costs*Health Care Costs + Intervention Program Costs

Dollars per capita per year

600

300

0

-300

-600

-5 0 5 10 15 20 25

Coverage + Quality

Coverage + Quality + Capacity

Coverage + Quality + Capacity + Protect

HealthBound is designed for training purposes. Simulated scenarios cannot be interpreted as predictions for the future.

* Undiscounted, constant 2003 dollars

Simulated Results: Net Social BenefitNet Benefit = (QALYs*$75k – Total Costs)*

Dollars per capita per year8,000

6,000

4,000

2,000

0-5 0 5 10 15 20 25

Year

Coverage + Quality

Coverage + Quality + Capacity

Coverage + Quality + Capacity + Protect

* Undiscounted, constant 2003 dollars

HealthBound is designed for training purposes. Simulated scenarios cannot be interpreted as predictions for the future.

Some Policy InsightsValue Tradeoffs Come to the Foreground

• Expanded coverage and higher quality of care may improve health but, if done alone, would likely raise costs and worsen equity

• Additional primary care supply and greater efficiency could eliminate current shortages (esp. for the poor), reducing costs and improving equity

• Upstream health protection (behavioral + environmental remedies) could reduce costs, elevate health, and improve equity, with an initial investment and a time delay, but the benefits would grow over time

Why a Game?To Build Foresight, Experience, and Motivation to Act

Experiential Learning“Wayfinding”

Expert Recommendations

Who Has Been Playing? (N~500)

• Federal, state, local health officials

• Public health leadership institutes

• Citizen organizations

• Labor unions

• University faculty and students

• Think tanks

• Philanthropists

Who Has Been Playing? (N~500)

• Federal, state, local health officials

• Public health leadership institutes

• Citizen organizations

• Labor unions

• University faculty and students

• Think tanks

• Philanthropists

How Strong is Civic Muscle in the Real World?

• Only 8% tried to change policies in their local communities

• 12% contacted public officials about issues

• 33% tried to persuade friends

In the aftermath of the intense 2008 presidential campaign…

National Conference on Citizenship. Civic health index: civic health in hard times. Washington, DC: National Conference on Citizenship; August 27, 2009. <http://www.ncoc.net/index.php?tray=series&tid=top5&cid=2gp54>.

Continuing the Tradition of Concerned, Humane, Directed Science

Shook J. The pragmatism cybrary. 2006. Available at <http://www.pragmatism.org/>.

Addams J. Democracy and social ethics. Urbana, IL: University of Illinois Press, 2002.

West C. The American evasion of philosophy: a genealogy of pragmatism. Madison, WI: University of Wisconsin Press, 1989.

Pragmatism• Presumes engagement (insider consciousness)• Begins with a response to a perplexity or injustice in the world• Learning through action and reflection (even simulated action)• Asks, “Under what conditions can we make a difference?”• Produces working relationships that shape public life

Positivism • Presumes objectivity (onlooker consciousness)• Begins with a theory about the world• Learning through observation and falsification• Asks, “Is this theory true?”• Produces knowledge to serve those in need

These are not theories. They are different orientations, which shape how we think, how we act, and what we value.

These are not theories. They are different orientations, which shape how we think, how we act, and what we value.

Assuring Healthier

Conditions

Mutually Reinforcing Priorities

Foresight Public Strength

• The wider our view of system dynamics (both past and future), the more we appreciate the influence of diverse actors—and especially organized groups—in our plural world.

• The more we respect and build public strength—with its many constraints and contingencies—the greater foresight we'll acquire.

• We are each system citizens in the literal sense of being (potential) agents of change in the systems of which we are a part.

• Universities have a unique role in fostering citizen scholars who are better equipped to help navigate the systems in which we live.

Either without the other squanders time and resources

Either without the other squanders time and resources

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

Catalyzing Change: Systems Thinking to Transform

Health Care and the Public's HealthJohn Sterman, MIT

October 21

Agents and Architects of Democracy:The Struggle for the

Future of Higher EducationNovember 3

Webcasthttp://scup.org/page/profdev/notravel/2009/democracy