1. 1 The HealthBound Policy Simulation Game An Adventure in U.S. Health Reform …In support of Healthiest Nation Bobby Milstein Centers for Disease Control and Prevention BMilstein@cdc.gov International System Dynamics Conference July 27, 2009 Albuquerque, NM Jack Homer Homer Consulting JHomer@comcast.net Gary Hirsch Independent Consultant GBHirsch@comcast.net The name “HealthBound” is used courtesy of Associates & Wilson Michael Bean, Billy Schoenberg, & Will Glass-Husain Forio Business Simulations http://www.forio.com in cooperation with

2. 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 residentsAmerica 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 failureHigh cost of poor health drives personal bankruptcy and business failure Over 75% think the current system needs fundamental changeOver 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 resistanceAnalyses 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. 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. 3 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.

4. 4 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

5. 5 Deaths 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 month 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? Unhealthy Days Health Inequity Healthcare costs

6. 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. 7 Population Stock and Flow Structure

8. 8 U.S. Health Policy is Dense with Diverse Issues and Opportunities 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

9. 9 HealthBound 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

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

11. 11 “Winning” Involves Not Just Posting High Scores, But Understanding How and Why You Got Them ScorecardScorecard Progress Report Results in Context Compare Runs HealthBound

12. 12 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 Cutting reimbursement rates may reduce costs but 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. 13 Why a Game? To Build Foresight, Experience, and Motivation to Act Potential champions need more than authoritative advice. They want to see plausible pathways and feel the full consequences of different intervention options. Wayfinding Dialogues Expert Recommendations

14. 14 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

15. 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 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. 16 Development & Dissemination Plan Phase 1: Design and Early Adoption Begin engaging stakeholders Begin engaging stakeholders Iterative modeling and game design (v4) Iterative modeling and game design (v4) Documentation, publication, scientific vetting Documentation, publication, scientific vetting Convene early adopters 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. 17 Play HealthBound at ISDC Get in the Game to Redirect the U.S. Health System Exhibit Area Forio Business Simulations booth Short Gaming Session (N~40) Day: Wednesday, July 29 Time: 10:00-11:00AM Where: Potters Teams: 10 teams (3-4 each) Bring: Laptop (if possible) Sign-up sheet at Forio Exhibit Booth

18. 18 For Further Information http://www.cdc.gov/syndemics

19. 19 Extras/AlternativesExtras/Alternatives

20. 20 How is the Game Setup? 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 Understanding 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.

21. 21 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. AJPH (under review).

22. 22 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. AJPH (under review).

23. 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.