How Modeling Can Inform Strategies to Improve Population Health Workshop Summary (2016) / Chapter Skim
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4 What Would Public Health Decision Makers Like from Models?
4 What Would Public Health Decision Makers Like from Models?
Pages 39-56
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From page 39... ...
After that the workshop participants broke into four groups to discuss what odelers working in four different areas of public health m would most want from models. The four areas were • health risk factors, such as obesity and substance abuse; • natural and built environments, including air and water quality, transit, and housing; • social and economic conditions, including such factors as education, income, and discrimination; and • integrated health systems, including such influences as community conditions and available clinical services.
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(Macchione) • Using health and wellness in all policies as a tool forces stakeholders to look at these issues through many lenses and helps identify the essential data ele ments that need to be collected to create models that are as robust and useful as possible.
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Results First has been using data in national research clearinghouses relating to a number of policy areas as well as the work of the Washington State Institute for Public Policy, which has been developing a portfolio-based cost–benefit analysis model over the past 15 years, focusing on outcomes and return on investment. Currently, Results First can assess interventions in some areas of health care as well as interventions for adult and juvenile justice, child welfare, substance abuse, mental health, and education ranging from early education through 12th grade.
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. Some of these programs, TABLE 4-1 Cost–Benefit Analysis for Community-Based Functional Family Therapy Outcomes from Participation Amount Main Source of Benefits Reduced crime $29,340 Lower state and victim costs Increased high school graduation $9,530 Increased Earnings Reduced health care costs $398 Low public costs Total benefits $37,587 Cost $3,333 Net present value $34,254 Benefits per dollar of cost $11.28 SOURCE: VanLandingham presentation, April 9, 2015, based on benefit–cost data eported r by the Washington State Institute for Public Policy (see http://www.wsipp.wa.gov/ BenefitCost [accessed September 25, 2015]
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From page 43... ...
The model allows the users to do what-if scenario testing using Monte Carlo simulations which produce a probability distribution for achieving a positive return on investment. VanLandingham noted that sometimes there are political reasons for choosing one program over another, but the goal of the Results First program is to make a compelling case for not making bad policy decisions.
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For example, program evaluations rarely include information about implementation cost. In response to a question from Catherine Baase about how Results First selected which states to work with, VanLandingham said that when the program started 4 years ago he and his colleagues made presentations at policy forums such as the National Conference of State Legislatures and the Council of State Governments and then asked anyone who was interested in participating in the program to get in touch.
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From page 45... ...
"We are seeing our best states asking those questions now, and what we want to see is for that to happen across the country." REPORTS FROM THE WORKING GROUPS After VanLandingham's presentation participants broke into four working groups to explore how modeling could be used to inform population health decisions. As noted earlier in this chapter, the four working group topics were • health risk factors, such as obesity and substance abuse; • natural and built environments, including air and water quality, transit, and housing; • social and economic conditions, including such factors as education, income, and discrimination; and • integrated health systems, including such influences as community conditions and available clinical services.
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During his comments Woolf asked the groups to make note of data gaps and barriers, of communication requirements and challenges, of ideas on how to build trust in results and capitalize on the information from models to drive change, and of opportunities for policy makers be involved in the modeling process. Health Risk Factors -- Report Back2 George Miller, a fellow at the Altarum Institute's Center for Sustainable Health Spending, presented the report from the health risk factors group.
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From page 47... ...
To stimulate the group's discussion, Karen Minyard from the Georgia Health Policy Center prepared a list of guiding principles for modeling health risk factors that Miller said would also be good guiding principles for modelers to remember when working with decision makers. This list Figure 4-1 highlighted the fact that models, which are tools to enable thinking about R02894 complex systems, are most effective, accepted, and useful in catalyzing raster uneditable change when the following factors hold • the purpose for using a model is clearly identified and supported by the client; • it is developed in a collaborative process among the modeler, the stakeholders, and the subject-matter experts; • the model is as simple as possible, but no simpler; • it can be tailored to the readiness and level of engagement of the participants as well as to the goals and outcomes of the process; • the modeler or facilitator has the adaptive and technical skills to use these tools; and • the model is used as part of a larger change process.
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From page 48... ...
In part, the need to inform decision makers about these trade-offs results from the way that legislators work, which is to make decisions about where to invest in different sectors such as health, education, and transportation, but it also arises from the fact that these upstream interventions will interact with one another to affect population health in complex ways that a model might help policy makers understand. The group engaged in some discussion about the interest and importance in understanding the longer-term impacts of some of the interventions, particularly those that operate on a population health level, where much of the value comes over the long term.
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Educating the policy community and the public about the use, value, and limits of modeling is also important. Lane said that one thing he has learned as a state health official is that policy makers often want to move forward on an initiative in large part because of the projections or modeling activities that they have been privy to, but that there is still a need to spend the time to go out to the public, sell that idea, and explain what the model means and does not mean.
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Social and Economic Conditions -- Report Back4 Nick Macchione, the director and deputy chief administrative officer for the County of San Diego's Health and Human Services Agency, served as the rapporteur for the social and economic conditions working group. This group first discussed data needs, he said, concerning the social and economic enablers of health, the relevant data need to be collected from many different sectors.
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Several members of the group commented that modeling can help bridge gaps across different professions, which generally each have their own educational background, intellectual biases, and approaches to problem solving. Modeling can also make it possible to have conversations across professional cultures, though several members of the discussion group said there is a need for translators who can move among subject matter experts, modelers, and policy makers.
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Macchione added that modeling in the domain of health and human services could also be useful in helping identify causal pathways, which might be more concrete to a policy maker. Integrated Health Systems -- Report Back5 The final working group's report was delivered by Louise Russell, a distinguished professor at the Institute for Health, Health Care Policy, and Aging Research and the Department of Economics at Rutgers University.
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In the real world, however, programs do not suddenly end, and new programs do not begin at full speed, There is usually a period which models do not consider when a new program is being put in place and the original program is being phased out, and the existence of this period means, among other things, that funds and resources cannot be shifted immediately from one program to the other. This group also discussed the importance of establishing good channels of communication among modelers, those who inform models, and the public, particularly with regard to the mental models that members of the public already have in their own heads, such as the public's model for breast cancer screening.
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People talked about these issues for years, he said, but it was not until funders such as the Patient-Centered Outcomes Research Institute started taking that discussion to a new level of sophistication that serious and genuine engagement started to occur. The thesis he heard from the four working groups, Woolf said, is that efforts to use modeling to improve population health have to get serious about engaging stakeholders at the very beginning of the process, getting them to define the problems that need addressing and to decide whether a model is even needed, and then keeping them engaged throughout the process.
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Getting boards of directors to understand this reality could change the way that they construct their business models to reach beyond health care delivery into the community to form partnerships to address the other 80 percent of the factors that influence health. Isham then wondered if there is a way to use this broader mental model to think about the research and rigor needed to model the relationships between education and health -- for example, to influence investment decisions by both the private and public sectors.
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