HealthBound Getting in the Game to Redirect the U.S. Health System Toward Greater Health, Equity, and Cost-effectiveness

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HealthBoundGetting in the Game to Redirect the
U.S. Health System Toward Greater Health, Equity,
and Cost-effectiveness
Work-in-Progress
Jack HomerHomer ConsultingJHomer_at_comcast.net
Gary HirschIndependent ConsultantGBHirsch_at_comcas
t.net
Bobby MilsteinCenters for Disease Control and
PreventionBMilstein_at_cdc.gov
DRAFTPlease do not cite
National Public Health Leadership InstituteMay
20, 2009Chapel Hill, NC
In support of Healthiest Nation
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Poised for Transformation

• Americans have a national health shortage pay
  the most for health care, yet suffer
  comparatively poor health, especially among the
  disadvantaged
• About 16 lack insurance coverage
• Medical expenses drive personal bankruptcy and
  corporate failure
• Over 75 think the current system needs
  fundamental change
• Some 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
2008358(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. lthttp//www.healthr
eform.gov/reports/hccd/gt
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HealthBound is a Simplified Health System to be
Explored Through Game-based Learning

• 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

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.
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Navigating Health FuturesGetting Out of a
Deadly, Unhealthy, Inequitable, and Costly Trap
Four Problems in the Current System High
Mortality, Morbidity, Inequity, Cost
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6

0.2

7,000

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 capita
Health inequity index

Healthcare spend per capita


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Options for Intervening in the Health SystemA
Short Menu of Major Policy Proposals
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The Science Behind the Game

• Integrating prior findings and estimates
• 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).
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Impossible to study every detail up close
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But a macroscopic view can be useful
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.
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U.S. health policy is dense with diverse issues
Documented Causal Pathways Account for Results
in the Game
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
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General Approach to Model Calibration
Parameter Proxy Initial Values (2003) Sources
Advantaged Disadvantaged Prevalence Household income (lt or 25,000) Advantaged 78.5 Disadvantaged 21.5 Census
Milstein B, Homer J, Hirsch G. Are coverage and
quality enough? a dynamic systems approach to
health policy. Health Affairs (under review).
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General Approach to Model Calibration
Parameter Proxy Initial Values (2003) Sources
Advantaged Disadvantaged Prevalence Household income (lt 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
Milstein B, Homer J, Hirsch G. Are coverage and
quality enough? a dynamic systems approach to
health policy. Health Affairs (under review).
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• Models are inexact representations of the real
  thing

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
200218(4)501-531. Available at
lthttp//web.mit.edu/jsterman/www/All_Models.htmlgt
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.
lthttp//web.mit.edu/jsterman/www/Skeptic27s_Guide
.htmlgt
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Questioning Intervention Strategies
Where is the leverage?
What are the tradeoffs?

• Direction (same for all goals?)
• Timing
• Pattern (better-before-worse, or vice versa)
• Effect size
• Cost
• Cost-effectiveness (net benefit)

• Single interventions
• Intended effects
• Unintended side effects
• Combinations or Sequences
• Complementary
• Detrimental
• Synergistic

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Winning Involves Not Just Posting High Scores,
But Understanding How and Why You Got Them
HealthBound
HealthBound
HealthBound
HealthBound
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Instructions for Team Play

• Test Single Interventions (N2-5 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 happenedand why
• Fill out the worksheet

You have 1 hour to craft a strategy you are proud
of and can explainMake sure it has a unique,
descriptive name Return with a completed
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 happenedand why
• Fill out the worksheet

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Go To the Game
Intervention Limit 4 Areas/Icons (per 5-year
round) Civic Muscle
HealthBound
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Pressing Questions?Technical Difficulties?Call
404.563.2053
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Insights Reflections
SYSTEM DYNAMICSCausal mapping Simulation
modelingGame-based learning
HEALTH POLICY
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What Did You Learn About Individual Intervention
Strategies?

• Expanding coverage improves health but, if done
  alone, would likely raise costs and worsen equity

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What Did You Learn About Combined Intervention
Strategies

• Complimentary?
• Detrimental?
• Synergistic?

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What Did You Learn About System Dynamics

• Dynamic dilemma?
• Boundary judgments?
• Causal mapping?
• Simulation modeling?
• Game-based learning?

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Thinking in Systems
Conventional Thinking Systems 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).
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 19939(2)113-134. Richmond B.
The "thinking" in systems thinking seven
essential skills. Waltham, MA Pegasus
Communications, 2000.
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Serious Games Go Beyond Analysis to Build
Foresight, Experience, and Motivation
Expert Recommendations
Wayfinding Dialogues
Potential champions need more than authoritative
advice. They want to see plausible pathways and
discover what theyand otherscan do to help
steer a course toward a healthier, more
equitable, and more prosperous future.
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For Further Informationhttp//www.cdc.gov/syndemi
cs