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The HealthBound Policy Simulation Game An Adventure in U.S. Health Reform. Jack Homer Homer Consulting [email protected] Gary Hirsch Independent Consultant [email protected] Bobby Milstein Centers for Disease Control and Prevention [email protected] in cooperation with.

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the healthbound policy simulation game an adventure in u s health reform
The HealthBound Policy Simulation GameAn Adventure in U.S. Health Reform

Jack HomerHomer [email protected]

Gary HirschIndependent [email protected]

Bobby MilsteinCenters for Disease Control and [email protected]

in cooperation with

Michael Bean, Billy Schoenberg, & Will Glass-HusainForio Business Simulationshttp://www.forio.com

International System Dynamics ConferenceJuly 27, 2009Albuquerque, NM

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

…In support of Healthiest Nation

poised for transformation
Poised for Transformation…
  • America has a national health shortage: we pay the most for health care, yet suffer comparatively poor health, especially among disadvantaged residents
  • High cost of poor health drives personal bankruptcy and business failure
  • 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. 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.

healthbound is a simplified health system to be explored through game based learning

HealthBound

HealthBoundis a Simplified Health System to be Explored Through Game-based Learning
  • 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

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.

slide4

Goal Setting

Exploratory Insight

Causal diagrams with practical definitions of states, rates, and interventions

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

Inflationary trends and self-sustaining tendencies of the downstream healthcare industry

Creative policies for moving out of an entrenched and unhealthy state

Selected CDC Models of Health System DynamicsAcross a Continuum of Purposes

Important Structures

Empirical

Data

Upstream-Downstream Dynamics

Neighborhood Transformation Game

HealthBound

Game

National Health Economics & Reform

Leadership Development

Syndemics

Diabetes Action Labs

Local Context of Chronic Disease Prevention and Control

Obesity Overthe Lifecourse

Fetal & Infant Health

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.

slide5
HealthBound Presents a Navigational ChallengeGet Out of a Deadly, Unhealthy, Inequitable, and Costly Predicament

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

8

Deaths

6

0.2

Unhealthy Days

7,000

Health Inequity

Healthcare costs

How far can you move the system?

4

3

0.1

5,000

0

0

0

3,000

-5

0

5

10

15

20

25

Death rate per thousand

Unhealthy days per month per capita

Health inequity index

Healthcare spend per capita

the science behind the game
The Science Behind the Game

Integrating prior findings and estimates

  • On health care costs, disease prevalence, risk factors, health disparities, service utilization, insurance, quality of care, etc. (8 databases and professional literature)
  • Previous SD modeling (such as SDR, Summer/Fall, 2007)

Recognizing sources of dynamic complexity

  • Real-world accumulations, resource constraints, time delays, and side effects of interventions

Simplifying as appropriate

  • Three states of health: Disease/injury, Asymptomatic disorder, No significant health problem
  • Two socioeconomic categories: Advantaged, Disadvantaged (allowing study of equity)
  • Twelve areas of intervention
  • Start in equilibrium (all scorecard variables unchanging), approximating the U.S. in 2003
  • Game model excludes some complicating trends for clarity: aging, migration, technology, economy, etc.; an extended model incorporates 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.

slide8

U.S. Health Policy is Dense with Diverse Issues and Opportunities

Insurance complexity

Extent of care

Healthier behaviors

ER use

Reimbursement rates

Adherence to care guidelines

Safer environments

Access to care

Provider income

Socioeconomic disadvantage

Provider capacity

Insurance coverage

Provider efficiency

CitizenInvolvement

slide9

Expand insurance coverage

Improve quality of care

Coordinate care

Enable healthier behaviors

Expand primary care supply

Simplify insurance

Improve primary care efficiency

Build safer environments

Change self pay fraction

Create pathways to advantage

Change reimbursement rates

Strengthen civic muscle

HealthBound Intervention OptionsA Short Menu of Major Policy Proposals

players may test single interventions combinations or sequences with decisions every 5 years
Players may test single interventions, combinations, or sequences, with decisions every 5 years
winning involves not just posting high scores but understanding how and why you got them

Scorecard

Results in Context

CompareRuns

ProgressReport

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

HealthBound

HealthBound

HealthBound

HealthBound

some policy insights value tradeoffs come to the foreground
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
  • Cutting reimbursement rates may reduce costsbut worsens health outcomes and equity
  • Upstream health protection (through better behavioral and environmental conditions) could reduce costs, elevate health, and improve equity, with a time delay, but 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).

why a game to build foresight experience and motivation to act
Why a Game?To Build Foresight, Experience, and Motivation to Act

Expert Recommendations

Wayfinding Dialogues

Potential champions need more than authoritative advice. They want to see plausible pathways and feel the full consequences of different intervention options.

general design of a healthbound session
Best played in groups with a trained facilitator

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

Study single interventions or combinations

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

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

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

Relevance extends beyond this moment of national legislative effort

General Design of a HealthBound Session
healthbound in action re think health collaborative
HealthBound in Action“Re>Think Health” Collaborative
  • Leading policy thinkers and researchers assembled in 2008 by Rippel Foundation
  • An effective & efficient health system: What is essential? How do we get there?
  • HealthBound game session Feb 2009
  • Extended model to include population aging, price inflation, and a cost-cutting “coordinated care” intervention
  • Model used to test ideas generated in scenario planning exercises
  • Group now united in pressing for both better care and community-level health protection...publications to follow
development dissemination plan
Development & Dissemination Plan

Phase 1: Design and Early Adoption

  • Begin engaging stakeholders
  • Iterative modeling and game design (v4)
  • Documentation, publication, scientific vetting
  • Convene early adopters

Phase 2: Diffusion

  • Enhance the game interface
  • Enable open access
  • Train facilitators
  • Convene “signature” gaming events
  • Support self-play and interaction
  • Provide links to intervention resources
  • Expand co-sponsors
play healthbound at isdc get in the game to redirect the u s health system
Play HealthBound at ISDCGet in the Game to Redirect the U.S. Health System

Exhibit AreaForio Business Simulations boothShort Gaming Session (N~40)Day: Wednesday, July 29Time: 10:00-11:00AMWhere: PottersTeams:10 teams (3-4 each)Bring: Laptop (if possible)

Sign-up sheet at Forio Exhibit Booth

slide20

How is the Game Setup?

Understanding How to Escape a National Health Shortage

  • A population in dynamic equilibrium (inflows=outflows), experiencing high starting levels of premature death, unhealthy life, inequity, and health care costs
  • Many factors are intentionally held constant, before confronting players with an even more complicated challenge*
    • Population growth and aging
    • Adoption of new technologies
    • “Tug of war” over billing between insurers and providers
    • Defensive medicine
    • Globalization of the medical marketplace
    • Medicalization of common ailments
    • Tobacco regulations
    • Trends affecting employment, transportation, recreation, and food options

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.

slide21

General 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).

slide22

General 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).

overview of model structure
Overview 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.

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