Bobby Milstein, PhD, MPH, director of the ReThink Health and visiting scientist at MIT Sloan School of Management, gave the October 9 Grand Rounds on the Future of Public Health at Columbia's Mailman School of Public Health. Dr. Milstein's talk, "Beyond Reform and Rebound: Frontiers for Rethinking and Redirecting Health System Performance," was part of this year's Grand Rounds series focusing on the decline in the health status of the U.S. population compared to peer nations, as well as the opportunities for public health leadership that are needed to close this gap. While at the Mailman School, Dr. Milstein also met with a group of doctoral students and Prof. Ronald Bayer to discuss approaches to effectively improve health systems in the United States. Visit the events page to find out more, http://www.mailman.columbia.edu/events/grand-rounds.

1. Beyond Reform & Rebound:
Frontiers for Rethinking and Redirecting
Health System Performance
Bobby Milstein
Director, ReThink Health
Visiting Scientist, MIT Sloan School of Management
bmilstein@rethinkhealth.org
Columbia University, Mailman School of Public Health,
Grand Rounds on the Future of Public Health
New York, NY
October 9, 2013

2. More Money for Shorter Lives
Commission to Build a Healthier America. America is not getting good value for its health dollar.
Robert Wood Johnson Foundation 2008.
Institute of Medicine. U.S. Health in International Perspective: Shorter Lives, Poorer Health.
Washington, DC: National Academies Press; 2013.
2

3. 3

4. “Sad History of Health Care Cost Containment:
1961-2001”
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.
4

5. “The tendency for interventions
to be delayed, diluted, or defeated
by the response of the system
to the intervention itself.”
-- Meadows, Richardson & Bruckmann
Caused by…
• Tunnel vision
• Narrow mental models
• Neglected data
• Defensive routines
• Failure to foresee
• Inability to enact higher
leverage policies
Meadows DH, Richardson J, Bruckmann G. Groping in the Dark: The First Decade of Global Modelling. Wiley: New York, 1985.
Sterman JD. Learning from evidence in a complex world. American Journal of Public Health 2006;96(3):505-514.
Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.
5

6. Forces Under Debate
Cutler and Sahni, Health Affairs 2013 32(5): 841-850
Chandra, Holmes, Skinner. Brookings Sept 2013.
Ryu et.al., Health Affairs 2013 32(5):835-840
Holahan and McMorrow. Urban Institute May 2013
Cuckler et.al., Health Affairs 2013 32(10)














Recession
Business cycles
Uninsurance
Payment rate cuts
Cost sharing
Efficiency and waste
Patient demand
Health sector stock prices
Legislation and regulation
Technology
Aging (only one)
Epidemiology (none)
Risk and vulnerability (none)
Power and social policy (none)
6

7. September 26, 2013
September 27, 2013
Seigal Bernard T. A Guide to the New Exchanges for Health Insurance. New York Times 2014 September 27.
Abelson R. As Some Companies Turn to Health Exchanges, G.E. Seeks a New Path. New York Times 2013 September 26.
7

8. General Electric. Building Better Healthcare Value in Cincinnati: How Employers are Collaborating with Other Healthcare
Stakeholders to Improve Health and Reduce Costs in the Queen City. Fairfield, CT: Healthymagination; 2013.
Available at http://www.ge.com/globalimpact/pdf/Building_Better_Healthcare_Value_in_Cincinnati.pdf
8

9. Anytown, USA
Action
Regional Pilots
(2010-2013)
Formal Models
(N=8)
Results
ReActing
Thinking
ReThinking
9

10. 10

11. Variations in Health and Risks
The County Health Rankings
Variations in Practice and Spending
The Dartmouth Atlas of Health Care
2013 Variations in Care for Advanced Cancer
11

12. Nation to Nested

13. Core Members (N=15)
• Health Department and Board of Health
• Community Health Center
• Medical Centers and Hospitals
• Mental Health Center
• Kaiser Permanente
Wider Area Stakeholders (N=30+)
• Commerce, Schools, University,
Local Government, Philanthropy,
Community Organizations
Population = 160,000
Uninsured = 15%
Poverty = 40%
County Health Rank = 57th out of 59
Primary Care Providers = 7 per 10,000
Healthcare expenditures = $1B/year

14. “Most Triple Aim projects start with a
project and build up from there.”
“We have been thinking big picture and
ReThink Healthspecific projects yet.”
haven't selected Dynamics
Triple Aim
Collective
Impact
Pueblo’s
Health
System
• How is the health system
structured?
“We are building governance, structure,
andHow and first becauseit change our
• strategy when does we believe
work will change)?
(or resist be more successful and
sustainable with this approach.”
• Where is the greatest leverage?
-- Donald Moore,
• What trade-offs are involved?
CEO Pueblo Community Health Center
Milstein B, Hirsch G, Minyard K. County Officials Embark on New, Collective Endeavors to ReThink Their Local
Health Systems. Journal of County Administration, March – April 2013.
Available at http://tinyurl.com/RTH-County-Officials
Milstein B. ReThinking Health in Pueblo, Colorado: A Stewardship Strategy to Advance the Triple Aim. Improving
Population Health. August 21, 2012. Available at http://tinyurl.com/RTH-Pueblo-Story
Kindig D, Milstein B. From ACOs to Accountable Health Communities: Delivering on Population Health in the
Triple Aim. Institute for Clinical Systems Improvement Reinertsen Lecture. October 25, 2012; Minneapolis, MN.
Available at https://www.icsi.org/education__services/reinertsen_lecture/
14

15. Planning for System-wide Impact
Draft Business Plan
• Strategic Priorities
•
Coordinate care
•
Post-discharge planning
•
Support adherence
•
Recruit safety net PCPs
•
Healthier behaviors
•
Pathways to advantage
•
Capture and reinvest savings
•
Share savings with providers
Favorite
• Backbone Organization
• Shared Measurement System
• Sustainable Funding
• Governance & Communications
$742,000 investment

16. Sectors to System

17. Atlanta Regional Collaborative for Health Improvement. Who we are. Atlanta, GA; 2013 June 5.
Available at http://www.archicollaborative.org/

18. Form a serious regional collaborative
Gather and assess quantitative data
Gather and assess qualitative data
• Set priorities with diverse
stakeholders?
• Enact high-leverage strategies
• Etc….
18

19. …Raising Many
Practical, Strategic, Ethical Questions
•
•
•
•
•
Which to prioritize?
How to pay…and sustain?
Consequences and tradeoffs?
Who decides?
Etc…
Relevant Methodologies
• Many innovators want to play out and pursue
Decision science
bold• system-change strategies.
• Comparative effectiveness research
• New teams, new tools, new ways of thinking
• Health impact assessment
are often required& implementation scale and
• Integration to succeed at this sciences
in context
• Dynamic policy modeling

20. • Realistic yet simplified representations of a local health system
(N=8 to date)
• Place-based, wide-angle view; diverse scenario options; scores of
metrics to trace changes over decades
• Anchored to evidence from dozens of datasets, rendered in a
common—testable—framework
• Tool for open, experiential learning with diverse stakeholders
www.ReThinkHealth.org/Dynamics
20

21. •
2008-2011: HealthBound
US health reform strategy
Sponsor: CDC
Publications: HA 2011; AJPH 2010
•
Multiple chronic diseases, US & 60+ sites
Sponsors: CDC and NIH
Publications: HPP 2012; PCD 2010; AJPH 2010;
PCD 2008; PCD 2007; AJPH 2006
Selected Awards
•
2013 Society for Health Education,
Article of the Year
•
2011 System Dynamics Society
Best Application of SD Modeling
•
2008 ASysT Institute, Applied Systems
Thinking Prize
Refs: http://tinyurl.com/RTH-Related-Models
2005-2006: US Health Economy
Growth of US health sector, 1960-2010
Sponsor: CDC
Publications: SDR 2006
2009; CDC Honor Awards for
2005 Excellence in Innovation
•
•
2012 AcademyHealth, Public Health Systems
Research Article of the Year
•
2003-present: Diabetes; Obesity; PRISM
•
1995-1997: Health Care Microworld
Local health, health care, social policy
Sponsors: NEHA and Innovation Associates,
Dartmouth-Hitchcock
Publications: SDR 1999
•
1993: Transition to Capitation
Local healthcare financing
Sponsor: Healthcare Forum
Publication: Health Forum J 1994

22. Selected Geographic Focus
Productivity & Equity
Aging
Risk
Health
Care
Cost
Capacity
Other Trends
Initiatives
Payment
Scheme
Innovation
Funds
Captured
Savings
• Insurance eligibility
• Economic conditions
• Health care inflation
• Primary care slots
Population tracked separately in 10 segments
by age, insurance, and income
22

23. Atlanta sources
•US
Census and American Community Survey
•Vital Statistics
•Behavioral Risk Factor Surveillance Survey (BRFSS)
•National Survey of Children’s Health (NSCH)
•Georgia Hospital Discharge Data
•Georgia Department of Public Health
•Dartmouth Atlas
•Area Resource Files
•Georgia Department of Community Health
Small-area estimates based on national sources
•National Health
and Nutrition Examination Survey (NHANES)
•National (Hospital) Ambulatory Medical Care Survey (NAMCS, NHAMCS)
•National Hospital Discharge Survey (NHDS)
•National Nursing Home Survey (NNHS) and Home Health Care Survey (NHHS)
•Medical Expenditure Panel Survey (MEPS)
•National Health Expenditures (NHE)
23

24. In 2010, about how much
did Atlanta spend on
personal health care services?
1. $700 million
2. $3 billion
3. $11 billion
4. $6 billion
* Atlanta = Fulton + Dekalb county
24

25. In 2010, about how much
did Atlanta spend on
personal health care services?
1. $700 million
2. $3 billion
What could we accomplish
by devoting just 1% to
system change initiatives?
3. $11 billion
4. $6 billion
* Atlanta = Fulton + Dekalb county
25

26. Challenge: Craft your favorite scenario
to improve performance of the regional
health system over the next several
decades (2012-2040)
ReThink Health Atlanta
◦
◦
◦
◦
◦
Improve health
Enhance care
Lower health care costs
Achieve equity
Boost productivity
26

27. 27

28. Under what conditions is
it possible to alter
• Direction?
• Timing?
• Magnitude?
28

29. Goals to Pathways

30. Consider
Many
Pathways
Engage
in Deeper
Dialogue
Anticipate
Consequences
and Plausible
Futures
30

32. 1% of 2010 spend
$100M x 5 = $500M

33. Beginning in 2012, what will be the
• Direction?
• Timing?
• Magnitude?
33

35. Savings O
Initial
Innovation Fund
R
Capture &Reinvest Health Care
Savings
Costs
O
Funds Available
for Investment
O
B
Fund
Depletion
Spending on
Programs
Program
Investments
A common predicament for
costly investments that must be
sustained:
•
•
•
•
•
•
•
Healthier Behaviors
Family & Student Pathways
Mental Illness
Self-Care
Cut the program effort
Find more funding
Reinvest savings

36. “Savings generated from improved
[clinical] practice and performance could
also be reinvested in the community,
creating a reinforcing loop.”
-- Sanne Magnan, Elliott Fisher, David Kindig,
George Isham, Doug Wood, Mark Eustis,
Carol Backstrom, Scott Leitz
Magnan S, Fisher E, Kindig D, et al. Achieving Accountability for Health and
Health Care Minneapolis, MN; 2012 July 10. Available at
http://tinyurl.com/icsi-AHC

37. 50/50 Split with Insurers

38. $1.94B

39. Cumulative = $1.87B

40. Peak = $53
Low = - $519

41. Challenge: Craft a scenario that ought to
work well: a vision for Atlanta you might
be proud to enact
Some Tips
Discuss what you value and how to achieve it
Consider both actions and funding
Limit = 5 initiatives + any financing options
41

42. 42

43. 1.
2.
3.
4.
87%
Far-Reaching
Atlanta Transformation
Better Health Atlanta
Promote Health Today
6%
4%
1
2
3
2%
4
N = 70 respondents at ARCHI Workshop (November 14, 2012)
43

44. Enabling Healthy Behaviors
Family Pathways
Atlanta
Transformation
Coordinated Care
Global Payment
Capture and Reinvest
Expand Insurance
Innovation Fund

45. Atlanta Regional Collaborative for Health Improvement. ARCHI Playbook; 2013 Draft May.
Available at http://www.archicollaborative.org/archi_playbook.pdf

46. Scarcity to Abundance

47. Challenge: Fragmented, short-term investments—prone to reform and
rebound—are unable to alter trends in health system performance
-
Workforce Productivity
-
Temporary
Investment Fund
+
Disadvantage
+
Illness
Prevalence
and Severity
+ Utilization
of Care
+ Health Care
Costs
Funds
Available for
Investment
47

48. Challenge: Fragmented, short-term investments—prone to reform and
rebound—are unable to alter trends in health system performance
-
Workforce Productivity
-
Temporary
Investment Fund
+
Disadvantage
-
Illness
+
Prevalence
- and Severity
-
+ Utilization
of Care
+
Funds
Available for
Investment
+ Health Care
Costs
-
B1
Create Pathways
to Advantage
+
Enable Healthier
Behaviors
+
Improve
Routine Care
+
Coordinate
Care
+
Intervention Initially
Reduces Funds
Program
Investments
+
+
Intervention
Decisions
+
Pay for Value Not
Volume (CGP)
48

49. Challenge: Fragmented, short-term investments—prone to reform and
rebound—are unable to alter trends in health system performance
-
Workforce Productivity
-
Temporary
Investment Fund
Cost
Benchmarks
+
+
Disadvantage
-
Illness
+
Prevalence
- and Severity
-
+ Utilization
of Care
+
+ Health Care
Costs
-
- Savings to
Reinvest
+
Funds
Available for
Investment
B1
Create Pathways
to Advantage
+
Enable Healthier
Behaviors
+
Improve
Routine Care
+
Coordinate
Care
+
Intervention Initially
Reduces Funds
Program
Investments
+
+
Intervention
Decisions
+
Pay for Value Not
Volume (CGP)
49

50. Challenge: Fragmented, short-term investments—prone to reform and
rebound—are unable to alter trends in health system performance
-
Workforce Productivity
-
Temporary
Investment Fund
Cost
Benchmarks
+
+
Disadvantage
R4
Equity Reduces
Vulnerability
Create Pathways
to Advantage
+
Illness
+
Prevalence
- and Severity
R3
Healthier Behavior
Reduces Illness
Routine Care
Reduces Illness
Enable Healthier
Behaviors
+
+ Utilization
+ Health Care
of Care
Costs
+
B2
R2
Routine Care
Increases Visits
& Meds
Improve
Routine Care
+
- Savings to
Reinvest
+
Funds
Available for
Investment
-
R1
Cutting Waste
Lowers Cost
Coordinate
Care
+
B1
Intervention Initially
Reduces Funds
Program
Investments
+
+
Intervention
Decisions
+
Pay for Value Not
Volume (CGP)
50

51. Established and Emerging Financing Options
Challenge: Few innovators appreciate the variety and potential
stakes involved when deciding among financing options
•
Government grants/agreements
•
Investment portfolio re-allocation
•
Foundation grants
•
Operating budget re-allocation
•
Hospital Community Benefit
•
Co-op insurance plans
•
Social Impact Bonds
(Pay for Success)
•
•
Population Health Trusts
•
Insurance alignment and investment,
particularly self-insured employers and
Medicaid support for community prevention
and non-clinicians
Tax Credits and Incentives
•
•
Business investment in worksites and region
Community Development Financing
•
•
Accountable Care Organizations
Venture capital investment to open and
establish new markets
•
Accountable Care Communities
•
Prizes (X-Prize)
•
Collective Impact Organizing
•
Others, as appropriate
•
Health Care Payment Reform
(Getting to Global Payment)

52. Challenge: Few regions have sturdy multi-stakeholder teams to negotiate
agreements and serve as stewards of their common health system
Ostrom E. Beyond Markets and States: Polycentric Governance of Complex Economic Systems.
The Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel; Stockholm; 2009 December 8.
Available at http://www.nobelprize.org/nobel_prizes/economic-sciences/laureates/2009/ostrom-lecture.html
McGinnis MD. Caring for the Health Commons: What it is and Who's Responsible for it: Social Science Research
Network; 2013 February 20. Available at http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2221413
52

53. Ostrom’s Design Principles
1.
Clearly defined boundaries
2.
Rules adapted to local conditions
3.
Collective-choice arrangements that allow participation in
the decision-making process
4.
Effective monitoring by those related to the monitored
5.
Graduated sanctions for violating community rules
6.
Mechanisms of conflict resolution that are cheap and easy
7.
Self-determination recognized by higher-level authorities
8.
Organization in multiple layers of nested enterprises
Ostrom E. Governing the commons: the evolution of institutions for collective action. New York, NY: Cambridge
University Press; 1990.
Ostrom E. Beyond Markets and States: Polycentric Governance of Complex Economic Systems.
The Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel; Stockholm; 2009 December 8.
Available at http://www.nobelprize.org/nobel_prizes/economic-sciences/laureates/2009/ostrom-lecture.html
53

54. Three Central Challenges
•
Fragmented, short-term investments—prone
to reform and rebound—are unable to alter
trends in health system performance
•
Few innovators appreciate the variety and
potential stakes involved when deciding
among financing options
•
Few regions have multi-stakeholder teams to
negotiate agreements and serve as stewards
of their common health system
54

55. Learn with leaders in context
• How are innovators devising new ways to
pay for and sustain necessary investments?
• Who decides?
Two-phase, exploratory project
• Refine framing and narrative
• Characterize conditions, opportunities, and
obstacles in different contexts
• Develop tools and guides for groups at different
stages of readiness, with insights from other
countries and sectors
• Craft hypotheses for directed tests
• Expand a learning network
55

56. More Money for Shorter Lives
Four Promising Shifts…
 Nation to Nested
 Sectors to System
 Goals to Pathways
 Scarcity to Abundance
56

57. Dialogue
57

58. www.ReThinkHealth.org

59. 59