HealthBound Get in the Game to Re-direct the U.S. Health System

Syndemics

Prevention Network

HealthBound Get in the Game to Re-direct the U.S. Health System

…In support of Healthiest Nation

Bobby MilsteinCenters for Disease Control

and [email protected]

Jack HomerHomer Consulting

[email protected]

Gary HirschIndependent [email protected]

The name “HealthBound” is used courtesy of Associates & Wilson, Inc.

More Money for Shorter LivesPersistent Gaps in Health by IncomePercent of Adults with Activity Limitation

Poised for Transformation…• America has a national health

shortage: we pay the most for health care, yet suffer comparatively poor health

• The disadvantaged fare worse

• 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. America is not getting good value for its health dollar. 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.

• Failure to foresee

• Inability to enact higher leverage policies

• Failure to foresee

• Inability to enact higher leverage policies

“Sad History of Health Care Cost Containment: 1961-2001”

http://www.cdc.gov/index.htm

Exploratory Insight Goal SettingLeadership Development

Selected CDC Models of Health System DynamicsAcross 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 Overthe Lifecourse

Fetal & Infant Health

Neighborhood Transformation

Game

National Health Economics & Reform

Syndemics

Local Context of Chronic Disease Prevention and

Control

HealthBoundGame

Important Structures

EmpiricalData

Creative policies for moving out of an entrenched and unhealthy state

Experiential learning to devise strategies, interpret dynamics, and weigh tradeoffs


• 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.


HealthBound Presents a Navigational ChallengeGet Out of a Deadly, Unhealthy, Inequitable, and Costly Predicament

Starting Values for Mortality, Morbidity, Inequity, Cost (~2003)

Death rate per thousand

Unhealthy days per capitaHealth 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?

Deaths

Unhealthy Days

Health Inequity

Healthcare costs


The U.S. health system is dense

with diverse issues and opportunities

Healthier behaviorsHealthier behaviors

Adherence to care guidelines Adherence to

care guidelines

Insurance coverageInsurance coverage

Insurance overheadInsurance overhead

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


Major Causal Pathways


Science Behind the GameIntegrating prior findings and estimates• On costs, prevalence, risk factors, inequity,

utilization, insurance, quality of care, etc. (8 databases and large professional literatures)

Using sound methodology• Reflecting real-world accumulations, resource

constraints, delays, behavioral feedback

Simplifying as appropriate• Three states of health:

Healthy, Asymptomatic disorder, Disease/injury

• Two SES categories: Advantaged, Disadvantaged (allowing study of disparities and equity)

• Some complicating trends not included in simplified game (e.g., aging, technology, economy); an extended model incorporates such factors


Combining Information into a Single Testable Framework


Concept Proxy Initial Values (~2003) Sources

Advantaged & Disadvantaged

Prevalence Household income (< or ≥ $25,000)

Advantaged = 78.5% Disadvantaged = 21.5%

Census

Some key concepts and measures


Concept Proxy Initial Values (~2003) Sources

Advantaged & Disadvantaged

Prevalence Household income (< or ≥ $25,000)

Advantaged = 78.5% Disadvantaged = 21.5%

Census

Disease & InjuryPrevalence

Adults: 22 specific conditions Kids: 12 specific 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 Fraction of unhealthy days attributable to disadvantage

Attributable fraction = 14.3% (calculated)

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

Survey response: “My neighborhood is not safe”

Overall = 26% D/A Ratio = 2.5

BRFSS PCD

Some key concepts and measures


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 ratesExpand insurance coverage

Enable healthier behaviors

Build safer environments

Create pathways to advantage

Strengthen civic muscle

Improve primary care efficiency

Coordinate care


Three Intervention ScenariosExpand Insurance CoverageReduces the uninsured fraction by 90%Implementation Cost = $20 per person helped per year

Improve Quality of Care Raises provider adherence to guidelines for preventive, chronic and urgent care (eliminating non-adherence by 50%)Implementation Cost = $10k/MD/yr.; $500k/hospital/yr. Expand Primary Care SupplyRaises the number of primary care providers per capita to the Disadvantaged by 60% over 15 yearsImplementation Cost = $300k/additional MD Improve Primary Care EfficiencyRaises the fraction of primary care offices that run efficiently (eliminating inefficiency by 90%)Implementation Cost = $10k/MD/yr. Enable Healthier BehaviorsIncreases the fraction with healthier behavior (eliminating unhealthy behavior by 40% over 15 years)Implementation Cost = $2,000 per person helped Build Safer EnvironmentsIncreases the fraction living in safer environments(eliminating unsafe environments by 50% over 15 years)Implementation Cost = $500 per person helped

Capacity

Protection

Coverage & Quality


Simulated Results: Morbidity Average Unhealthy Days per Month

Days per month (average over entire population)6

5.25

4.5

3.75

3-5 0 5 10 15 20 25

Coverage + Quality

Coverage + Quality + Capacity

Coverage + Quality + Capacity + Protect

Year

HealthBound is designed for training purposes. Simulated scenarios cannot be interpreted as predictions for the future.


Simulated Results: Health Inequity Index Fraction of Morbidity Attributable to Disadvantage

Health Inequity Index (Fraction)

Year

Coverage + Quality



0.2

0.15

0.1

0.05

0

-5 0 5 10 15 20 25



Simulated Results: Total Costs*Health Care Costs + Intervention Program Costs

Dollars per capita per year

600

300

0

-300

-600

-5 0 5 10 15 20 25

Coverage + Quality




* Undiscounted, constant 2003 dollars


Simulated Results: Net Social BenefitNet Benefit = (QALYs*$75k – Total Costs)*

Dollars per capita per year8,000

6,000

4,000

2,000

0-5 0 5 10 15 20 25

Year

Coverage + Quality



* Undiscounted, constant 2003 dollars



Some Policy InsightsValue 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

• Upstream health protection (behavioral + environmental remedies) could reduce costs, elevate health, and improve equity, with an initial investment and 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).


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

Scorecard

ProgressReport

Results in Context

CompareScenarios

HealthBound

HealthBound

HealthBound

HealthBound


Syndemics

Prevention Network

Why a Game?To Build Foresight, Experience, and Motivation to Act

Experiential Learning“Wayfinding”

Expert Recommendations

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

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

Syndemics

Prevention Network

How Strong is Civic Muscle in the Real World?

• Only 8% tried to change policies in their local communities

• 12% contacted public officials about issues

• 33% tried to persuade friends

In the aftermath of the intense 2008 presidential campaign…

National Conference on Citizenship. Civic health index: civic health in hard times. Washington, DC: National Conference on Citizenship; August 27, 2009. <http://www.ncoc.net/index.php?tray=series&tid=top5&cid=2gp54>.

Syndemics

Prevention Network

Conversations Around the Model

Other health

priorities

Available information

Health inequities

Local interventionopportunities and costs

Communitythemes and strengths

Political willStakeholder

relationships

• What’s in the model does not define what’s in the room

• Simulations intentionally raise questions to spark broader thinking and judgment

• Narrower boundaries tend to be more empirically grounded

• Wider boundaries may legitimize “invisible” processes

• Boundary judgments follow from the intended purpose and users

SYSTEMDYNAMICS MODEL

STRATEGICPRIORITIES

Researchagenda

Healthcare costs

Sufficiency ofprimary care

providers

PCP netincome

Reimbursementrates

Disease& injury

Morbidity &mortality

Receipt of qualityhealth care

- -

Health careaccess

Primary careefficiency

Insurancecoverage

-Health

inequity

Behavioralrisks

Quality ofcare delivered

- -

Number ofprimary care

providers

-

Socioeconomicdisadvantage

-

Environmentalhazards

PCP training& placement

programs

Insurancecomplexity

Use of specialists& hospitals for

non-urgent care-

-

-

-

Self-pay fractionfor the insured

-

Asymptomaticdisorders

Carecoordination

-

Health careprice inflation

Documents

HealthBound Get in the Game to Re-direct the U.S. Health System