The HealthBound Policy Simulation Game An Adventure in U.S. Health Reform

1. The HealthBound Policy Simulation GameAn Adventure in U.S. Health Reform Jack HomerHomer ConsultingJHomer@comcast.net Gary HirschIndependent ConsultantGBHirsch@comcast.net Bobby MilsteinCenters for Disease Control and PreventionBMilstein@cdc.gov 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

2. 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.

3. 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.

4. 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.

5. 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

6. 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.

7. Population Stock and Flow Structure

8. 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

9. 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

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

11. 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

12. 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).

13. 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.

14. 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

15. 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

16. 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

17. 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

18. For Further Informationhttp://www.cdc.gov/syndemics

19. Extras/Alternatives

20. 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.

21. 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).

22. 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).

23. 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.