The Health Bound Policy Simulation Game An Adventure

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

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 is not getting good value for its health dollar. Princeton, NJ: Robert Wood Johnson Foundation 2008. Nolte E, Mc. Kee 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: Health. Reform. gov; March, 2009. <http: //www. healthreform. gov/reports/hccd/> 2 Altman DE, Levitt L. The sad history of health care cost containment as told in one chart. Health Affairs 2002; Web Exclusive: hlthaff. w 2. 83.

Health. Bound is a Simplified Health System to be Explored Through Game-based Learning Health. Bound 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 "Health. Bound" policy simulation game: an adventure in US health reform. International System Dynamics Conference; Albuquerque, NM; July 26 -30, 2009. 3

Selected CDC Models of Health System Dynamics Across a Continuum of Purposes Important Structures Neighborhood Transformation Game Upstream. Downstream Dynamics Exploratory Insight Empirical Data Health. Bound Game National Health Economics & Reform Leadership Development Goal Setting Syndemics Inflationary trends and Experiential learning Creative policies for Causal diagrams with self-sustaining to devise strategies, moving out of an practical definitions of tendencies of the interpret dynamics, entrenched and states, rates, and downstreamtradeoffs and weigh healthcare unhealthy state interventions industry Diabetes Action Labs Local Context of Chronic Disease Prevention and Control Obesity Over the Lifecourse Fetal & Infant Health Centers for Disease Control and Prevention. Dynamic models. Syndemics Prevention Network, 2009. Available at http: //www 2. 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. 4

Health. Bound Presents a Navigational Challenge Get Out of a Deadly, Unhealthy, Inequitable, and Costly Predicament Starting Values for Mortality, Morbidity, Inequity, Cost (~2003) 8 6 0. 2 7, 000 Deaths Unhealthy Days Health Inequity Healthcare costs How far can you move the system ? 4 3 0. 1 5, 000 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 5

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 ( nder review). u 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. 6

Population Stock and Flow Structure 7

U. S. Health Policy is Dense with Diverse Issues and Opportunities Healthier behaviors Insurance complexity Extent of care ER use Adherence to care guidelines Safer environments Access to care Socioeconomic disadvantage Insurance coverage Reimbursement rates Provider income Provider capacity Provider efficiency Citizen Involvement 8

Health. Bound Intervention Options A Short Menu of Major Policy Proposals Expand insurance coverage Improve quality of care Change reimbursement rates Coordinate care Expand primary care supply Enable healthier behaviors Improve primary care efficiency Build safer environments Simplify insurance Create pathways to advantage Change self pay fraction Strengthen civic muscle 9

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

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

Some Policy Insights Value. Expanded coverage and higher Foreground Tradeoffs Come to the 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). 12

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. 13

General Design of a Health. Bound 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 Relevance extends beyond this moment of national legislative effort Think tanks Philanthropists 14

Health. Bound 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? Health. Bound 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 15

Development & Dissemination Plan Phase 1: Design and Early Adoption ü Begin engaging stakeholders ü Iterative modeling and game design (v 4) ü Documentation, publication, scientific vetting ü 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 16

Play Health. Bound 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: 00 AM Where: Potters Teams: 10 teams (3 -4 each) Bring: Laptop (if possible) Sign-up sheet at Forio Exhibit Booth 17

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

Extras/Alternatives 19

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, Level 2 and higher and food options * 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. 20

General Approach to Model Calibration Parameter Advantaged & Disadvantaged Prevalence Proxy Household income (< or ≥ $25, 000) Initial Values (~2003) Advantaged = 78. 5% Disadvantaged = 21. 5% Milstein B, Homer J, Hirsch G. Are coverage and quality enough? a dynamic systems approach to health policy. AJPH (under review). Sources Census 21

General Approach to Model Calibration Parameter Advantaged & Disadvantaged Prevalence Proxy Initial Values (~2003) Sources Household income (< or ≥ $25, 000) Advantaged = 78. 5% Disadvantaged = 21. 5% Census Adults: 22 serious/persistent conditions Kids: 12 serious/persistent conditions Overall = 38% D/A Ratio = 1. 60 (= 53. 6%/33. 5%) NHIS JAMA 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 Disease & Injury Prevalence Asymptomatic Disorder Prevalence Milstein B, Homer J, Hirsch G. Are coverage and quality enough? a dynamic systems approach to health policy. AJPH (under review). 22

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. 23