11

The The HealthBound HealthBound Policy Simulation GamePolicy Simulation GameAn Adventure in U.S. Health ReformAn Adventure in U.S. Health Reform

The The HealthBound HealthBound Policy Simulation GamePolicy Simulation GameAn Adventure in U.S. Health ReformAn Adventure in U.S. Health Reform

…In support of Healthiest Nation

Bobby MilsteinBobby MilsteinCenters for Disease Control Centers for Disease Control

and Preventionand PreventionBMilstein@cdc.govBMilstein@cdc.gov

International System Dynamics ConferenceInternational System Dynamics ConferenceJuly 27, 2009July 27, 2009

Albuquerque, NMAlbuquerque, NM

Jack HomerJack HomerHomer ConsultingHomer Consulting

JHomer@comcast.netJHomer@comcast.net

Gary HirschGary HirschIndependent ConsultantIndependent ConsultantGBHirsch@comcast.netGBHirsch@comcast.net

The name “HealthBound” is used courtesy of Associates & WilsonThe name “HealthBound” is used courtesy of Associates & Wilson

Michael Bean, Billy Schoenberg, & Will Glass-HusainMichael Bean, Billy Schoenberg, & Will Glass-HusainForio Business SimulationsForio Business Simulations

http://www.forio.comhttp://www.forio.com

in cooperation within cooperation with

22

Poised for Transformation…Poised for Transformation…Poised for Transformation…Poised for Transformation…

• America has a national health America has a national health shortageshortage: we pay the most for : we pay the most for health care, yet suffer comparatively health care, yet suffer comparatively poor health, especially among poor health, especially among disadvantaged residentsdisadvantaged residents

• High cost of poor health drives High cost of poor health drives personal bankruptcy and business personal bankruptcy and business failurefailure

• Over 75% think the current Over 75% think the current systemsystem needs fundamental changeneeds fundamental change

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

Commission to Build a Healthier America. America is not getting good value for its health dollar. Princeton, NJ: 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. <http://www.healthreform.gov/reports/hccd/>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.

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Cognitive and experiential learning for health leadersFour simultaneous goals: save lives, improve health, achieve health equity, and lower health care costIntervene without expense, risk, or delayNot a prediction, but a way for diverse stakeholders to explore how the health system can change

HealthBound

HealthBoundHealthBound is a Simplified Health System is a Simplified Health System to be Explored Through Game-based Learningto be Explored Through Game-based Learning

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.

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Exploratory Insight Goal SettingLeadership Development

Selected CDC Models of Health System DynamicsSelected CDC Models of Health System DynamicsAcross a Continuum of PurposesAcross a Continuum of Purposes

Centers for Disease Control and Prevention. Dynamic models. Syndemics Prevention Network, 2009. Available at 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.

Causal diagrams with practical definitions of

states, rates, and interventions

Inflationary trends and self-sustaining

tendencies of the downstream healthcare

industry

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

HealthBoundGame

Important Structures

EmpiricalData

Creative policies for moving out of an entrenched and unhealthy state

Experiential learning to devise strategies, interpret dynamics, and weigh tradeoffs

55

Deaths

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

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

Death rate per thousand

Unhealthy days per month 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?

Unhealthy Days

Health Inequity

Healthcare costs

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The Science Behind the GameThe Science Behind the GameThe Science Behind the GameThe Science Behind the Game

Integrating prior findings and estimatesIntegrating prior findings and estimatesOn health care costs, disease prevalence, risk factors, health On health care costs, disease prevalence, risk factors, health disparities, service utilization, insurance, quality of care, etc. disparities, service utilization, insurance, quality of care, etc. (8 databases and professional literature)(8 databases and professional literature)

Previous SD modeling (such as SDR, Summer/Fall, 2007)Previous SD modeling (such as SDR, Summer/Fall, 2007)

Recognizing sources of dynamic complexityRecognizing sources of dynamic complexityReal-world accumulations, resource constraints, Real-world accumulations, resource constraints, time delays, and side effects of interventionstime delays, and side effects of interventions

Simplifying as appropriateSimplifying as appropriateThree states of health: Disease/injury, Three states of health: Disease/injury, Asymptomatic disorder, No significant health problemAsymptomatic disorder, No significant health problem

Two socioeconomic categories: Advantaged, Disadvantaged Two socioeconomic categories: Advantaged, Disadvantaged (allowing study of equity)(allowing study of equity)

Twelve areas of intervention Twelve areas of intervention

Start in equilibrium (all scorecard variables unchanging), Start in equilibrium (all scorecard variables unchanging), approximating the U.S. in 2003approximating the U.S. in 2003

Game model excludes some complicating trends for clarity: Game model excludes some complicating trends for clarity: aging, migration, technology, economy, etc.; an extended model aging, migration, technology, economy, etc.; an extended model incorporates such factorsincorporates such factors

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

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.

77

Population Stock and Flow StructurePopulation Stock and Flow StructurePopulation Stock and Flow StructurePopulation Stock and Flow Structure

Popn with nosignif health

prob Adv

Popn with ADno DI Adv

Popn with DIAdv

AD onset AdvDI onset after

AD Adv

DI onset afterNSHP Adv

Deaths AdvBirths and netimmig Adv

<Fatal fraction ofurgent events Adv>

Popn with nosignif healthprob Disadv

Popn with ADno DI Disadv

Popn with DIDisadv

AD onset Disadv DI onset afterAD Disadv

DI onset afterNSHP Disadv

Deaths DisadvBirths and netimmig Disadv

<Fatal fraction ofurgent events

Disadv>

Popn with NSHPbecome Disadv

Popn with NSHPbecome Adv

Popn with AD no DIAdv become Disadv

Popn with ADno DI Disadvbecome Adv

Popn with DIbecome Disadv

Popn with DIbecome Adv

Death rate for DIDisadv

Death rate forDI Adv

DI recovery toNSHP Adv

DI recovery toAD Adv

DI recovery toNSHP Disadv

DI recovery toAD Disadv

<Urgent event ratefor DI Disadv>

<Urgent event ratefor DI Adv>

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U.S. Health Policy is Dense U.S. Health Policy is Dense

with Diverse Issues and Opportunitieswith Diverse Issues and OpportunitiesU.S. Health Policy is Dense U.S. Health Policy is Dense

with Diverse Issues and Opportunitieswith Diverse Issues and Opportunities

Healthier behaviorsHealthier behaviors

Adherence to care guidelines Adherence to

care guidelines

Insurance coverageInsurance coverage

Insurance complexityInsurance complexity

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

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HealthBound Intervention OptionsHealthBound Intervention OptionsA Short Menu of Major Policy ProposalsA Short Menu of Major Policy Proposals HealthBound Intervention OptionsHealthBound Intervention OptionsA Short Menu of Major Policy ProposalsA Short Menu of Major Policy Proposals

Improve quality of careImprove quality of care

Expand primary care supplyExpand primary care supply

Simplify insuranceSimplify insurance

Change self pay fractionChange self pay fraction

Change reimbursement ratesChange reimbursement ratesExpand insurance coverage

Enable healthier behaviorsEnable healthier behaviors

Build safer environmentsBuild safer environments

Create pathways to advantageCreate pathways to advantage

Strengthen civic muscleStrengthen civic muscle

Improve primary care efficiencyImprove primary care efficiency

Coordinate careCoordinate care

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Players may test single interventions, combinations, Players may test single interventions, combinations, or sequences, with decisions every 5 yearsor sequences, with decisions every 5 years

Players may test single interventions, combinations, Players may test single interventions, combinations, or sequences, with decisions every 5 yearsor sequences, with decisions every 5 years

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““Winning” Involves Not Just Posting High Scores, Winning” Involves Not Just Posting High Scores, But Understanding But Understanding How and Why How and Why You Got ThemYou Got Them

““Winning” Involves Not Just Posting High Scores, Winning” Involves Not Just Posting High Scores, But Understanding But Understanding How and Why How and Why You Got ThemYou Got Them

ScorecardScorecardScorecardScorecard

ProgressProgressReportReport

Results in ContextResults in Context

CompareCompareRunsRuns

HealthBound

HealthBound

HealthBound

HealthBound

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Some Policy InsightsSome Policy InsightsValue Tradeoffs Come to the ForegroundValue Tradeoffs Come to the Foreground

Some Policy InsightsSome Policy InsightsValue Tradeoffs Come to the ForegroundValue Tradeoffs Come to the Foreground

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

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

Cutting reimbursement rates may Cutting reimbursement rates may reduce costsreduce costs but but worsens health outcomes and equityworsens health outcomes and equity

Upstream health protection (through better behavioral Upstream health protection (through better behavioral and environmental conditions) could and environmental conditions) could reduce costs, reduce costs, elevate health, and improve equity, elevate health, and improve equity, with a time delaywith a time delay, , but the benefits would grow over timebut the benefits would grow over time

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

1313

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

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

Potential champions need more than authoritative advice. Potential champions need more than authoritative advice.

They want to see plausible pathways and feel the full consequences They want to see plausible pathways and feel the full consequences

of different intervention options. of different intervention options.

Potential champions need more than authoritative advice. Potential champions need more than authoritative advice.

They want to see plausible pathways and feel the full consequences They want to see plausible pathways and feel the full consequences

of different intervention options. of different intervention options.

Wayfinding DialoguesWayfinding DialoguesExpert RecommendationsExpert Recommendations

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General Design of a General Design of a HealthBound HealthBound SessionSessionGeneral Design of a General Design of a HealthBound HealthBound SessionSession

Best played in groups with a trained facilitatorBest played in groups with a trained facilitator

Teams deliberate, decide how to intervene, Teams deliberate, decide how to intervene, anticipate likely consequences, simulate their anticipate likely consequences, simulate their strategy, review what happened—and why. Repeat.strategy, review what happened—and why. Repeat.

Study single interventions or combinationsStudy single interventions or combinations

Sessions usually take about 3 hours Sessions usually take about 3 hours (only 1 of which is on the computer) (only 1 of which is on the computer)

Framing, debriefing, action planning, and Framing, debriefing, action planning, and leadership stories are essentialleadership stories are essential

Who Has Been Playing? (N~500)Who Has Been Playing? (N~500)

Federal, state, local health officialsFederal, state, local health officials

Public health leadership institutesPublic health leadership institutes

Citizen organizationsCitizen organizations

Labor unionsLabor unions

University faculty and studentsUniversity faculty and students

Think tanksThink tanks

PhilanthropistsPhilanthropists

Relevance extends Relevance extends

beyond this moment of beyond this moment of

national legislative effortnational legislative effort

Relevance extends Relevance extends

beyond this moment of beyond this moment of

national legislative effortnational legislative effort

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HealthBound in ActionHealthBound in Action“Re>Think Health” Collaborative“Re>Think Health” Collaborative

HealthBound in ActionHealthBound in Action“Re>Think Health” Collaborative“Re>Think Health” Collaborative

Leading policy thinkers and researchers Leading policy thinkers and researchers assembled in 2008 by Rippel Foundationassembled in 2008 by Rippel Foundation

An effective & efficient health system: An effective & efficient health system: What is essential? How do we get there? What is essential? How do we get there?

HealthBoundHealthBound game session Feb 2009 game session Feb 2009

Extended model to include population Extended model to include population aging, price inflation, and a cost-cutting aging, price inflation, and a cost-cutting “coordinated care” intervention“coordinated care” intervention

Model used to test ideas generated in Model used to test ideas generated in scenario planning exercisesscenario planning exercises

Group now united in pressing for both Group now united in pressing for both better care better care andand community-level health community-level health protection...publications to followprotection...publications to follow

Leading policy thinkers and researchers Leading policy thinkers and researchers assembled in 2008 by Rippel Foundationassembled in 2008 by Rippel Foundation

An effective & efficient health system: An effective & efficient health system: What is essential? How do we get there? What is essential? How do we get there?

HealthBoundHealthBound game session Feb 2009 game session Feb 2009

Extended model to include population Extended model to include population aging, price inflation, and a cost-cutting aging, price inflation, and a cost-cutting “coordinated care” intervention“coordinated care” intervention

Model used to test ideas generated in Model used to test ideas generated in scenario planning exercisesscenario planning exercises

Group now united in pressing for both Group now united in pressing for both better care better care andand community-level health community-level health protection...publications to followprotection...publications to follow

1616

Development & Dissemination PlanDevelopment & Dissemination Plan

Phase 1: Design and Early AdoptionPhase 1: Design and Early Adoption

Begin engaging stakeholdersBegin engaging stakeholders

Iterative modeling and game design (v4)Iterative modeling and game design (v4)

Documentation, publication, scientific vetting Documentation, publication, scientific vetting

Convene early adoptersConvene early adopters

Phase 2: DiffusionPhase 2: Diffusion

Enhance the game interfaceEnhance the game interface

Enable open accessEnable open access

Train facilitatorsTrain facilitators

Convene “signature” gaming eventsConvene “signature” gaming events

Support self-play and interactionSupport self-play and interaction

Provide links to intervention resourcesProvide links to intervention resources

Expand co-sponsorsExpand co-sponsors

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Play Play HealthBound HealthBound at ISDCat ISDCGet in the Game to Redirect the U.S. Health SystemGet in the Game to Redirect the U.S. Health System

Play Play HealthBound HealthBound at ISDCat ISDCGet in the Game to Redirect the U.S. Health SystemGet in the Game to Redirect the U.S. Health System

Exhibit AreaExhibit Area

Forio Business Simulations boothForio Business Simulations booth

Short Gaming Session (N~40)Short Gaming Session (N~40)

Day:Day: Wednesday, July 29 Wednesday, July 29

Time:Time: 10:00-11:00AM 10:00-11:00AM

Where:Where: Potters Potters

Teams:Teams: 10 teams (3-4 each)10 teams (3-4 each)

Bring:Bring: Laptop (if possible) Laptop (if possible)

Exhibit AreaExhibit Area

Forio Business Simulations boothForio Business Simulations booth

Short Gaming Session (N~40)Short Gaming Session (N~40)

Day:Day: Wednesday, July 29 Wednesday, July 29

Time:Time: 10:00-11:00AM 10:00-11:00AM

Where:Where: Potters Potters

Teams:Teams: 10 teams (3-4 each)10 teams (3-4 each)

Bring:Bring: Laptop (if possible) Laptop (if possible)

Sign-up sheet at Forio Exhibit BoothSign-up sheet at Forio Exhibit Booth

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For Further InformationFor Further Informationhttp://www.cdc.gov/syndemicshttp://www.cdc.gov/syndemicsFor Further InformationFor Further Information

http://www.cdc.gov/syndemicshttp://www.cdc.gov/syndemics

1919

Extras/AlternativesExtras/AlternativesExtras/AlternativesExtras/Alternatives

2020

How is the Game Setup?

A population in dynamic equilibrium (inflows=outflows), experiencing high starting levels of premature death, A population in dynamic equilibrium (inflows=outflows), experiencing high starting levels of premature death, unhealthy life, inequity, and health care costsunhealthy life, inequity, and health care costs

Many factors are intentionally held constant, before confronting players Many factors are intentionally held constant, before confronting players with an even more complicated challenge*with an even more complicated challenge*

– Population growth and aging Population growth and aging

– Adoption of new technologies Adoption of new technologies

– ““Tug of war” over billing between insurers and providersTug of war” over billing between insurers and providers

– Defensive medicineDefensive medicine

– Globalization of the medical marketplaceGlobalization of the medical marketplace

– Medicalization of common ailmentsMedicalization of common ailments

– Tobacco regulationsTobacco regulations

– Trends affecting employment, transportation, recreation, Trends affecting employment, transportation, recreation, and food optionsand food options

Understanding How to Escape a National Health ShortageUnderstanding How to Escape a National Health Shortage

Level 2 and higher

* A related simulation model examines several of these drivers of growth in the U.S. health care industry; see, 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.

2121

Parameter Proxy Initial Values (~2003) Sources

Advantaged & Disadvantaged

Prevalence

Household income (< or ≥ $25,000)

Advantaged = 78.5% Disadvantaged = 21.5%

Census

General Approach to Model CalibrationGeneral Approach to Model Calibration

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

2222

Parameter Proxy Initial Values (~2003) Sources

Advantaged & Disadvantaged Prevalence

Household income (< or ≥ $25,000) Advantaged = 78.5% Disadvantaged = 21.5%

Census

Disease & InjuryPrevalence

Adults: 22 serious/persistent conditions Kids: 12 serious/persistent conditions

Overall = 38% D/A Ratio = 1.60 (= 53.6%/33.5%)

NHIS JAMA

Asymptomatic Disorder Prevalence

High blood pressure High cholesterol Pre diabetes

Overall = 51.5% D/A Ratio = 1.15

NHANES JAMA

Mortality Deaths per 1,000 Overall = 7.5 D/A Ratio = 1.80

Vital Statistics AJPH

Morbidity Unhealthy days per month per capita Overall = 5.26 D/A Ratio = 1.78

BRFSS

Health Inequity Unhealthy days (or deaths)

attributable to disadvantage Attrib. fraction (unhealthy days) = 14.3% Attrib. fraction (deaths) = 14.6%

Census BRFSS

Health Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82

Census

Sufficiency of Primary Care Providers

Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.76

AMA PCD

Unhealthy Behavior Prevalence

Smoking Physical inactivity

Overall = 34% D/A Ratio = 1.67

BRFSS JAMA PCD

Unsafe Environment Prevalence

“Neighborhood not safe” Overall = 26% D/A Ratio = 2.5

BRFSS JAMA PCD

General Approach to Model CalibrationGeneral Approach to Model Calibration

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

2323

Overview of Model StructureOverview of Model StructureOverview of Model StructureOverview of Model Structure

Many of the elements shown here are stratified in the model by socioeconomic status (advantaged vs. disadvantaged), including those related to behavioral risks, environmental hazards, health status, type and locus of care received, primary care providers, access, insurance coverage, and cost sharing.