1. Syndemics Prevention Network HealthBound Get in the Game to Re-direct the U.S. Health System …In support of Healthiest Nation Bobby Milstein Centers for Disease Control and Prevention BMilstein@cdc.gov Jack Homer Homer Consulting JHomer@comcast.net Gary Hirsch Independent Consultant GBHirsch@comcast.net The name “HealthBound” is used courtesy of Associates & Wilson, Inc.

2. More Money for Shorter Lives Persistent Gaps in Health by Income Percent of Adults with Activity Limitation Poised for Transformation… America has a national health shortage: we pay the most for health care, yet suffer comparatively poor health The disadvantaged fare worse 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. 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. 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. Failure to foresee Inability to enact higher leverage policies Failure to foresee Inability to enact higher leverage policies “Sad History of Health Care Cost Containment: 1961-2001”

3. Exploratory Insight Goal Setting Leadership Development Selected CDC Models of Health System Dynamics Across 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 Over the Lifecourse Fetal & Infant Health Neighborhood Transformation Game National Health Economics & Reform Syndemics Local Context of Chronic Disease Prevention and Control HealthBound Game Important Structures Empirical Data Creative policies for moving out of an entrenched and unhealthy state Experiential learning to devise strategies, interpret dynamics, and weigh tradeoffs

4. 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 HealthBound HealthBound is a Simplified Health System to 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.

5. HealthBound Presents a Navigational Challenge Get Out of a Deadly, Unhealthy, Inequitable, and Costly Predicament Starting Values for Mortality, Morbidity, Inequity, Cost (~2003) Death rate per thousand Unhealthy days per capita Health inequity index Healthcare spend per capita 8 6 0.2 7,000 4 3 0.1 5,000 0 0 0 3,000 -50510152025 How far can you move the system? Deaths Unhealthy Days Health Inequity Healthcare costs

6. The U.S. health system is dense with diverse issues and opportunities Healthier behaviors Adherence to care guidelines Insurance coverage Insurance overhead Socioeconomic disadvantage Provider capacity Reimbursement rates Extent of care Provider income Provider efficiency Access to care ER use Safer environments Citizen Involvement

7. Major Causal Pathways

8. Science Behind the Game Integrating prior findings and estimates On costs, prevalence, risk factors, inequity, utilization, insurance, quality of care, etc. (8 databases and large professional literatures) Using sound methodology Reflecting real-world accumulations, resource constraints, delays, behavioral feedback Simplifying as appropriate Three states of health: Healthy, Asymptomatic disorder, Disease/injury Two SES categories: Advantaged, Disadvantaged (allowing study of disparities and equity) Some complicating trends not included in simplified game (e.g., aging, technology, economy); an extended model incorporates such factors

9. Combining Information into a Single Testable Framework

10. ConceptProxyInitial Values (~2003)Sources Advantaged & Disadvantaged Prevalence  Household income (< or ≥ $25,000)  Advantaged = 78.5%  Disadvantaged = 21.5%  Census Some key concepts and measures

11. ConceptProxyInitial Values (~2003)Sources Advantaged & Disadvantaged Prevalence  Household income (< or ≥ $25,000)  Advantaged = 78.5%  Disadvantaged = 21.5%  Census Disease & Injury Prevalence  Adults: 22 specific conditions  Kids: 12 specific 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  Fraction of unhealthy days attributable to disadvantage  Attributable fraction = 14.3%  (calculated) 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  Survey response: “My neighborhood is not safe”  Overall = 26%  D/A Ratio = 2.5  BRFSS  PCD Some key concepts and measures

12. Intervention Options A Short Menu of Major Policy Proposals Improve quality of care Expand primary care supply Simplify insurance Change self pay fraction Change reimbursement rates Expand insurance coverage Enable healthier behaviors Build safer environments Create pathways to advantage Strengthen civic muscle Improve primary care efficiency Coordinate care

13. Three Intervention Scenarios Expand Insurance Coverage Reduces the uninsured fraction by 90% Implementation Cost = $20 per person helped per year Improve Quality of Care Raises provider adherence to guidelines for preventive, chronic and urgent care (eliminating non-adherence by 50%) Implementation Cost = $10k/MD/yr.; $500k/hospital/yr. Expand Primary Care Supply Raises the number of primary care providers per capita to the Disadvantaged by 60% over 15 years Implementation Cost = $300k/additional MD Improve Primary Care Efficiency Raises the fraction of primary care offices that run efficiently (eliminating inefficiency by 90%) Implementation Cost = $10k/MD/yr. Enable Healthier Behaviors Increases the fraction with healthier behavior (eliminating unhealthy behavior by 40% over 15 years) Implementation Cost = $2,000 per person helped Build Safer Environments Increases the fraction living in safer environments (eliminating unsafe environments by 50% over 15 years) Implementation Cost = $500 per person helped Capacity Protection Coverage & Quality

14. Simulated Results: Morbidity Average Unhealthy Days per Month Days per month (average over entire population) 6 5.25 4.5 3.75 3 -50510152025 Coverage + Quality Coverage + Quality + Capacity Coverage + Quality + Capacity + Protect Year HealthBound is designed for training purposes. Simulated scenarios cannot be interpreted as predictions for the future.

15. Simulated Results: Health Inequity Index Fraction of Morbidity Attributable to Disadvantage Health Inequity Index (Fraction) Year Coverage + Quality Coverage + Quality + Capacity Coverage + Quality + Capacity + Protect 0.2 0.15 0.1 0.05 0 -50510152025 HealthBound is designed for training purposes. Simulated scenarios cannot be interpreted as predictions for the future.

16. Simulated Results: Total Costs* Health Care Costs + Intervention Program Costs Dollars per capita per year 600 300 0 -300 -600 -50510152025 Coverage + Quality Coverage + Quality + Capacity Coverage + Quality + Capacity + Protect HealthBound is designed for training purposes. Simulated scenarios cannot be interpreted as predictions for the future. * Undiscounted, constant 2003 dollars

17. Simulated Results: Net Social Benefit Net Benefit = (QALYs*$75k – Total Costs)* Dollars per capita per year 8,000 6,000 4,000 2,000 0 -50510152025 Year Coverage + Quality Coverage + Quality + Capacity Coverage + Quality + Capacity + Protect * Undiscounted, constant 2003 dollars HealthBound is designed for training purposes. Simulated scenarios cannot be interpreted as predictions for the future.

18. Some Policy Insights Value 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 Upstream health protection (behavioral + environmental remedies) could reduce costs, elevate health, and improve equity, with an initial investment and 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).

19. “Winning” Involves Not Just Posting High Scores, But Understanding How and Why You Got Them Scorecard Progress Report Results in Context Compare Scenarios HealthBound

20. Syndemics Prevention Network Why a Game? To Build Foresight, Experience, and Motivation to Act Experiential Learning “Wayfinding” Expert Recommendations 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 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

21. Syndemics Prevention Network How Strong is Civic Muscle in the Real World? Only 8% tried to change policies in their local communities 12% contacted public officials about issues 33% tried to persuade friends In the aftermath of the intense 2008 presidential campaign… National Conference on Citizenship. Civic health index: civic health in hard times. Washington, DC: National Conference on Citizenship; August 27, 2009..

22. Syndemics Prevention Network Conversations Around the Model Other health priorities Available information Health inequities Local intervention opportunities and costs Community themes and strengths Political will Stakeholder relationships What’s in the model does not define what’s in the room Simulations intentionally raise questions to spark broader thinking and judgment Narrower boundaries tend to be more empirically grounded Wider boundaries may legitimize “invisible” processes Boundary judgments follow from the intended purpose and users SYSTEM DYNAMICS MODEL STRATEGIC PRIORITIES Research agenda