1. 1 HealthBound Getting in the Game to Redirect the U.S. Health System Toward Greater Health, Equity, and Cost-effectiveness …In support of Healthiest Nation Bobby Milstein Centers for Disease Control and Prevention BMilstein@cdc.gov National Public Health Leadership Institute May 20, 2009 Chapel Hill, NC Jack Homer Homer Consulting JHomer@comcast.net Gary Hirsch Independent Consultant GBHirsch@comcast.net DRAFT Please do not cite Work-in-Progress

2. 2 Poised for Transformation… Americans have a national health shortage: pay the most for health care, yet suffer comparatively poor health, especially among the disadvantagedAmericans have a national health shortage: pay the most for health care, yet suffer comparatively poor health, especially among the disadvantaged About 16% lack insurance coverageAbout 16% lack insurance coverage Medical expenses drive personal bankruptcy and corporate failureMedical expenses drive personal bankruptcy and corporate failure Over 75% think the current system needs fundamental changeOver 75% think the current system needs fundamental change Some leaders are moving toward a broader view of health, including health protection and health equitySome leaders are moving toward a broader view of health, including health protection and health equity 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. Gerberding JL. CDC: protecting people's health. Director's Update; Atlanta, GA; July, 2007. White House. Americans speak on health reform: report on health care community discussions. Washington, DC: HealthReform.gov; March, 2009.

3. 3 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 multiple 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.

4. 4 Navigating Health Futures Getting Out of a Deadly, Unhealthy, Inequitable, and Costly Trap Four Problems in the Current System: High Mortality, Morbidity, Inequity, Cost 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?

5. 5 Options for Intervening in the Health System 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 Gatekeeper requirement Enable healthier behaviors Build safer environments Create pathways to advantage Strengthen civic muscle Improve primary care efficiency

6. 6 The Science Behind the Game Integrating prior findings and estimates Integrating prior findings and estimates Using sound methodology Using sound methodology  Accurate accounting of accumulations and feedback over time  Resource constraints, time delays, and side effects of intervention Simplifying as appropriate Milstein B, Homer J, Hirsch G. Are coverage and quality enough? a dynamic systems approach to health policy. Health Affairs (under review).

7. 7 Impossible to study every detail up close…

8. 8 But a macroscopic view can be useful… Trajectory of Hurricane Andrew: August 23, 24 and 25, 1992 Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991. Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008. Rosnay J. The macroscope: a new world scientific system. New York, NY: Harper & Row, 1979. White F. The overview effect: space exploration and human evolution. 2nd ed. Reston VA: American Institute of Aeronautics and Astronautics, 1998.

9. 9 U.S. health policy is dense with diverse issues Healthier behaviors Adherence to care guidelines Insurance coverage Insurance complexity Socioeconomic disadvantage Provider capacity Reimbursement rates Extent of care Provider income Provider efficiency Access to care ER use Safer environments Citizen Involvement Documented Causal Pathways Account for Results in the Game

10. 10 ParameterProxyInitial Values (~2003)Sources Advantaged & Disadvantaged Prevalence Household income (< or ≥ $25,000) Advantaged = 78.5% Disadvantaged = 21.5% Census General Approach to Model Calibration Milstein B, Homer J, Hirsch G. Are coverage and quality enough? a dynamic systems approach to health policy. Health Affairs (under review).

11. 11 ParameterProxyInitial Values (~2003)Sources Advantaged & Disadvantaged Prevalence Household income (< or ≥ $25,000) Advantaged = 78.5% Disadvantaged = 21.5% Census Disease & Injury Prevalence 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 Calibration Milstein B, Homer J, Hirsch G. Are coverage and quality enough? a dynamic systems approach to health policy. Health Affairs (under review).

12. 12 Models are inexact representations of the real thing They help us understand, explain, anticipate, and make decisions “All models are wrong, some are useful.” -- George Box “All models are wrong, some are useful.” -- George Box Meadows DH, Robinson JM. The electronic oracle: computer models and social decisions. New York, NY: Wiley, 1985. Sterman JD. All models are wrong: reflections on becoming a systems scientist. System Dynamics Review 2002;18(4):501-531. Available at Sterman J. A sketpic's guide to computer models. In: Barney GO, editor. Managing a Nation: the Microcomputer Software Catalog. Boulder, CO: Westview Press; 1991. p. 209-229.

13. 13 Questioning Intervention Strategies Where is the leverage? What are the tradeoffs? Single interventions –Intended effects –Unintended “side effects” Combinations or Sequences –Complementary –Detrimental –Synergistic Single interventions –Intended effects –Unintended “side effects” Combinations or Sequences –Complementary –Detrimental –Synergistic Direction (same for all goals?) Timing Pattern (better-before-worse, or vice versa) Effect size Cost Cost-effectiveness (net benefit) Direction (same for all goals?) Timing Pattern (better-before-worse, or vice versa) Effect size Cost Cost-effectiveness (net benefit)

14. 14 “Winning” Involves Not Just Posting High Scores, But Understanding How and Why You Got Them ScorecardScorecard Progress Report Results in Context Compare Runs HealthBound

15. 15 Instructions for Team Play Test Single Interventions (N=2-5; ~15-20 minutes) Deliberate and decide which intervention to study Anticipate the likely consequences Test the intervention for a full 25 years Review the Progress Report and Big Picture to learn what happened—and why Fill out the worksheet Explore Combinations or Sequences (~40-45 mins) Deliberate and decide how to mix interventions (Synergies? Complementary effects?) LIMIT = 4 areas/icons per round (+ Civic Muscle) Anticipate the likely consequences Test for full 25 years, or revise each 5-year round Give your scenario a unique descriptive name Review the Progress Report and Big Picture to learn what happened—and why Fill out the worksheet You have 1 hour to craft a strategy you are proud of and can explain Make sure it has a unique, descriptive name Return with a completed worksheet

16. 16 Go To the Game… Intervention Limit = 4 Areas/Icons (per 5-year round) + Civic Muscle HealthBound

17. 17 Pressing Questions? Technical Difficulties? Call 404.563.2053

18. 18 Insights & Reflections HEALTH POLICY SYSTEM DYNAMICS Causal mapping Simulation modeling Game-based learning

19. 19 What Did You Learn About Individual Intervention Strategies? Expanding coverage improves health but, if done alone, would likely raise costs and worsen equity

20. 20 What Did You Learn About Combined Intervention Strategies Complimentary?Detrimental?Synergistic?

21. 21 What Did You Learn About System Dynamics Dynamic dilemma? Boundary judgments? Causal mapping? Simulation modeling? Game-based learning?

22. 22 Thinking in Systems Meadows DH, Wright D. Thinking in systems: a primer. White River Junction, VT: Chelsea Green Pub., 2008. Karash R. The essentials of systems thinking and how they pertain to healthcare and colorectal cancer screening. Dialogue for Action in Colorectal Cancer; Baltimore, MD; March 23, 2005.. Richmond B. Systems thinking: critical thinking skills for the 1990s and beyond. System Dynamics Review 1993;9(2):113-134. Richmond B. The "thinking" in systems thinking: seven essential skills. Waltham, MA: Pegasus Communications, 2000. Conventional ThinkingSystems Thinking Static Thinking: Focusing on particular events.Dynamic Thinking: Framing a problem in terms of a pattern of behavior over time. System-as-Effect Thinking: Focus on individuals as the sources of behavior. Hold individuals responsible or blame outside forces. System-as-Cause Thinking: Seeing the structures and pressures that drive behavior. Examine the conditions in which decisions are made, as well as their consequences for oneself and others. Microscopic Thinking: Focusing on the details in order to “know.” Macroscopic Thinking: Seeing beyond the details to the context of relationships in which they are embedded. Engaging in active boundary critique. Factors Thinking: Listing factors that influence, or are correlated with, a behavior. To forecast milk production, consider economic elasticities. Operational Thinking: Understanding how a behavior is actually generated. To forecast milk production, you must consider cows. Straight-Line Thinking: Viewing causality as running one way, treating causes as independent and instantaneous. Root-Cause thinking. Closed-Loop Thinking: Viewing causality as an ongoing process, not a one-time event, with effects feeding back to influence causes, and causes affecting each other, sometimes after long delays. Measurement Thinking: Focusing on the things we can measure; seeking precision. Quantitative Thinking: Knowing how to quantify, even though you cannot always measure. Proving-Truth Thinking: Seeking to prove our models true by validating them with historical data. Scientific Thinking: Knowing how to define testable hypotheses (everyday, not just for research).

23. 23 Serious Games Go Beyond Analysis to Build Foresight, Experience, and Motivation Potential champions need more than authoritative advice. They want to see plausible pathways and discover what they—and others—can do to help steer a course toward a healthier, more equitable, and more prosperous future. Wayfinding Dialogues Expert Recommendations

24. 24 For Further Information http://www.cdc.gov/syndemics