11

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

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

…In support of Healthiest Nation

Bobby MilsteinBobby MilsteinCenters for Disease Control Centers for Disease Control

and Preventionand PreventionBMilstein@cdc.govBMilstein@cdc.gov

National Public Health Leadership InstituteNational Public Health Leadership InstituteMay 20, 2009May 20, 2009

Chapel Hill, NCChapel Hill, NC

Jack HomerJack HomerHomer ConsultingHomer Consulting

JHomer@comcast.netJHomer@comcast.net

Gary HirschGary HirschIndependent ConsultantIndependent ConsultantGBHirsch@comcast.netGBHirsch@comcast.net

DRAFTDRAFTPlease do not citePlease do not cite

Work-in-ProgressWork-in-Progress

22

Poised for Transformation…Poised for Transformation…Poised for Transformation…Poised for Transformation…

• Americans have a national health Americans have a national health shortage: pay the most for health shortage: pay the most for health care, yet suffer comparatively poor care, yet suffer comparatively poor health, especially among the health, especially among the disadvantageddisadvantaged

• About 16% lack insurance coverage About 16% lack insurance coverage

• Medical expenses drive personal Medical expenses drive personal bankruptcy and corporate failurebankruptcy and corporate failure

• Over 75% think the current Over 75% think the current systemsystem needs fundamental changeneeds fundamental change

• Some leaders are moving toward a Some leaders are moving toward a broader view of health, including broader view of health, including health protectionhealth protection and and health equityhealth 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. <http://www.healthreform.gov/reports/hccd/>

33

Experiential learning for health leadersFour simultaneous goals: save lives, improve health, achieve health equity, and lower health care costIntervene without expense, risk, or delayNot a prediction, but a way for multiple stakeholders to explore how the health system can change

HealthBound

HealthBoundHealthBound is a Simplified Health System is a Simplified Health System to be Explored Through Game-based Learningto 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.

44

Navigating Health FuturesNavigating Health FuturesGetting Out of a Deadly, Unhealthy, Inequitable, and Costly TrapGetting Out of a Deadly, Unhealthy, Inequitable, and Costly Trap

Four Problems in the Current System: High Mortality, Morbidity, Inequity, Cost

Death rate per thousandUnhealthy days per capita

Health inequity indexHealthcare spend per capita

8 6

0.2 7,000

4 3

0.1 5,000

0 0 0

3,000

-5 0 5 10 15 20 25

How far can you move the

system?

55

Options for Intervening in the Health SystemOptions for Intervening in the Health System

A Short Menu of Major Policy ProposalsA Short Menu of Major Policy Proposals Options for Intervening in the Health SystemOptions for Intervening in the Health System

A Short Menu of Major Policy ProposalsA Short Menu of Major Policy Proposals

Improve quality of careImprove quality of care

Expand primary care supplyExpand primary care supply

Simplify insuranceSimplify insurance

Change self pay fractionChange self pay fraction

Change reimbursement ratesChange reimbursement ratesExpand insurance coverage

Gatekeeper requirementGatekeeper requirement

Enable healthier behaviorsEnable healthier behaviors

Build safer environmentsBuild safer environments

Create pathways to advantageCreate pathways to advantage

Strengthen civic muscleStrengthen civic muscle

Improve primary care efficiencyImprove primary care efficiency

66

The Science Behind the GameThe Science Behind the Game

Integrating prior findings and estimatesIntegrating prior findings and estimates

Using sound methodologyUsing sound methodology

Accurate accounting of accumulations and Accurate accounting of accumulations and feedback over timefeedback over time

Resource constraints, time delays, and side Resource constraints, time delays, and side effects of interventioneffects of intervention

Simplifying as appropriateSimplifying as appropriate

Milstein B, Homer J, Hirsch G. Are coverage and quality enough? a dynamic systems approach to health policy. Health Affairs (under review).

77

Impossible to study every detail up close…Impossible to study every detail up close…

88

But a macroscopic view can be useful…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.

99

U.S. health policy is dense with diverse issuesU.S. health policy is dense with diverse issuesU.S. health policy is dense with diverse issuesU.S. health policy is dense with diverse issues

Healthier behaviorsHealthier behaviors

Adherence to care guidelines Adherence to

care guidelines

Insurance coverageInsurance coverage

Insurance complexityInsurance complexity

Socioeconomic disadvantage

Socioeconomic disadvantage

Provider capacityProvider capacity

Reimbursement rates

Reimbursement rates

Extent of care

Extent of care

Provider income

Provider income

Provider efficiencyProvider

efficiency

Access to careAccess to care

ER useER use

Safer environments

Safer environments

CitizenInvolvement

CitizenInvolvement

Documented Causal Pathways

Account for Results

in the Game

1010

Parameter Proxy Initial Values (~2003) Sources

Advantaged & Disadvantaged

Prevalence

Household income (< or ≥ $25,000)

Advantaged = 78.5% Disadvantaged = 21.5%

Census

General Approach to Model CalibrationGeneral 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).

1111

Parameter Proxy Initial Values (~2003) Sources

Advantaged & Disadvantaged Prevalence

Household income (< or ≥ $25,000) Advantaged = 78.5% Disadvantaged = 21.5%

Census

Disease & InjuryPrevalence

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 CalibrationGeneral 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).

1212

Models are inexact representations Models are inexact representations of the real thingof the real thing

They help us understand, explain, They help us understand, explain, anticipate, and make decisionsanticipate, 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 <http://web.mit.edu/jsterman/www/All_Models.html>

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. <http://web.mit.edu/jsterman/www/Skeptic%27s_Guide.html>

1313

Questioning Intervention StrategiesQuestioning Intervention Strategies

Where is the leverage?Where is the leverage? What are the tradeoffs?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?)TimingPattern (better-before-worse, or vice versa)Effect sizeCostCost-effectiveness (net benefit)

Direction (same for all goals?)TimingPattern (better-before-worse, or vice versa)Effect sizeCostCost-effectiveness (net benefit)

1414

““Winning” Involves Not Just Posting High Scores, Winning” Involves Not Just Posting High Scores, But Understanding But Understanding How and Why How and Why You Got ThemYou Got Them

ScorecardScorecardScorecardScorecard

ProgressProgressReportReport

Results in ContextResults in Context

CompareCompareRunsRuns

HealthBound

HealthBound

HealthBound

HealthBound

1515

Instructions for Team PlayInstructions for Team PlayTest Single Interventions (N=2-5; ~15-20 minutes)Test Single Interventions (N=2-5; ~15-20 minutes)

Deliberate and decide which intervention to studyDeliberate and decide which intervention to study

Anticipate the likely consequencesAnticipate the likely consequences

Test the intervention for a full 25 yearsTest the intervention for a full 25 years

Review the Progress Report and Big Picture to learn Review the Progress Report and Big Picture to learn what happened—and whywhat happened—and why

Fill out the worksheetFill out the worksheet

Explore Combinations or Sequences (~40-45 mins)Explore Combinations or Sequences (~40-45 mins)

Deliberate and decide how to mix interventions (Synergies? Deliberate and decide how to mix interventions (Synergies? Complementary effects?)Complementary effects?)LIMIT = 4 areas/icons per round (+ Civic Muscle)LIMIT = 4 areas/icons per round (+ Civic Muscle)

Anticipate the likely consequences Anticipate the likely consequences

Test for full 25 years, or revise each 5-year roundTest for full 25 years, or revise each 5-year round

Give your scenario a unique descriptive nameGive your scenario a unique descriptive name

Review the Progress Report and Big Picture to learn what Review the Progress Report and Big Picture to learn what happened—and whyhappened—and why

Fill out the worksheetFill out the worksheet

You have 1 hour to craft a You have 1 hour to craft a strategy you are proud of strategy you are proud of

and can explainand can explain

Make sure it has a Make sure it has a unique, descriptive nameunique, descriptive name

Return with a Return with a completed worksheetcompleted worksheet

You have 1 hour to craft a You have 1 hour to craft a strategy you are proud of strategy you are proud of

and can explainand can explain

Make sure it has a Make sure it has a unique, descriptive nameunique, descriptive name

Return with a Return with a completed worksheetcompleted worksheet

1616

Go To the Game…Go To the Game…Intervention Limit = 4 Areas/Icons (per 5-year round)Intervention Limit = 4 Areas/Icons (per 5-year round)

+ Civic Muscle+ Civic Muscle

HealthBound

1717

Pressing Questions?Pressing Questions?Technical Difficulties?Technical Difficulties?

CallCall404.563.2053404.563.2053

Pressing Questions?Pressing Questions?Technical Difficulties?Technical Difficulties?

CallCall404.563.2053404.563.2053

1818

Insights & ReflectionsInsights & Reflections

HEALTH POLICYHEALTH POLICYHEALTH POLICYHEALTH POLICY

SYSTEM DYNAMICSSYSTEM DYNAMICS

Causal mapping Causal mapping

Simulation modelingSimulation modeling

Game-based learningGame-based learning

SYSTEM DYNAMICSSYSTEM DYNAMICS

Causal mapping Causal mapping

Simulation modelingSimulation modeling

Game-based learningGame-based learning

1919

What Did You Learn About What Did You Learn About IndividualIndividual Intervention Strategies? Intervention Strategies?

What Did You Learn About What Did You Learn About IndividualIndividual Intervention Strategies? Intervention Strategies?

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

2020

What Did You Learn About What Did You Learn About CombinedCombined Intervention StrategiesIntervention Strategies

What Did You Learn About What Did You Learn About CombinedCombined Intervention StrategiesIntervention Strategies

Complimentary?Complimentary?

Detrimental?Detrimental?

Synergistic?Synergistic?

2121

What Did You Learn About What Did You Learn About System DynamicsSystem Dynamics

What Did You Learn About What Did You Learn About System DynamicsSystem Dynamics

Dynamic dilemma?Dynamic dilemma?

Boundary judgments?Boundary judgments?

Causal mapping?Causal mapping?

Simulation modeling?Simulation modeling?

Game-based learning?Game-based learning?

2222

Thinking in SystemsThinking 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 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).

2323

Serious Games Go Beyond Analysis Serious Games Go Beyond Analysis to Build Foresight, Experience, and Motivationto Build Foresight, Experience, and Motivation

Potential champions need more than authoritative advice. Potential champions need more than authoritative advice.

They want to see plausible pathways and discover what they—and others—can do to 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.help steer a course toward a healthier, more equitable, and more prosperous future.

Potential champions need more than authoritative advice. Potential champions need more than authoritative advice.

They want to see plausible pathways and discover what they—and others—can do to 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.help steer a course toward a healthier, more equitable, and more prosperous future.

Wayfinding DialoguesWayfinding DialoguesExpert RecommendationsExpert Recommendations

2424

For Further InformationFor Further Informationhttp://www.cdc.gov/syndemicshttp://www.cdc.gov/syndemics