The HealthBound Policy Simulation Game An Adventure in U.S. Health Reform
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Transcript of The HealthBound Policy Simulation Game An Adventure in U.S. Health Reform
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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 [email protected]@cdc.gov
International System Dynamics ConferenceInternational System Dynamics ConferenceJuly 27, 2009July 27, 2009
Albuquerque, NMAlbuquerque, NM
Jack HomerJack HomerHomer ConsultingHomer Consulting
[email protected]@comcast.net
Gary HirschGary HirschIndependent ConsultantIndependent [email protected]@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
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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
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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.
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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).
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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
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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
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Extras/AlternativesExtras/AlternativesExtras/AlternativesExtras/Alternatives
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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.
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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).
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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).
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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.