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…In support of Healthiest Nation

HealthBound Getting in the Game to Redirect the U.S. Health System Toward Greater Health, Equity, and Cost-effectiveness. Work-in-Progress. Jack Homer Homer Consulting JHomer@comcast.net. Gary Hirsch Independent Consultant GBHirsch@comcast.net.

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…In support of Healthiest Nation

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  1. HealthBoundGetting in the Game to Redirect the U.S. Health System Toward Greater Health, Equity, and Cost-effectiveness Work-in-Progress Jack HomerHomer ConsultingJHomer@comcast.net Gary HirschIndependent ConsultantGBHirsch@comcast.net Bobby MilsteinCenters for Disease Control and PreventionBMilstein@cdc.gov DRAFTPlease do not cite National Public Health Leadership InstituteMay 20, 2009Chapel Hill, NC …In support of Healthiest Nation

  2. 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 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/>

  3. HealthBound HealthBoundis 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.

  4. Navigating Health FuturesGetting Out of a Deadly, Unhealthy, Inequitable, and Costly Trap Four Problems in the Current System: High Mortality, Morbidity, Inequity, Cost 8 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

  5. Expand insurance coverage Gatekeeper requirement Improve quality of care Enable healthier behaviors Expand primary care supply Simplify insurance Improve primary care efficiency Build safer environments Change self pay fraction Create pathways to advantage Change reimbursement rates Strengthen civic muscle Options for Intervening in the Health SystemA Short Menu of Major Policy Proposals

  6. 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).

  7. Impossible to study every detail up close…

  8. Trajectory of Hurricane Andrew: August 23, 24 and 25, 1992 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.

  9. 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

  10. General 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).

  11. General 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).

  12. They help us understand, explain, anticipate, and make decisions “All models are wrong, some are useful.” -- George Box Models are inexact representations of the real thing 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>

  13. 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

  14. Scorecard Results in Context CompareRuns ProgressReport “Winning” Involves Not Just Posting High Scores, But Understanding How and Why You Got Them HealthBound HealthBound HealthBound HealthBound

  15. Test Single Interventions (N=2-5; ~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 happened—and why Fill out the 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 happened—and why Fill out the worksheet Instructions for Team Play You have 1 hour to craft a strategy you are proud of and can explainMake sure it has a unique, descriptive nameReturn with a completed worksheet

  16. Go To the Game… Intervention Limit = 4 Areas/Icons (per 5-year round)+ Civic Muscle HealthBound

  17. Pressing Questions?Technical Difficulties?Call404.563.2053

  18. Insights & Reflections SYSTEM DYNAMICSCausal mapping Simulation modelingGame-based learning HEALTH POLICY

  19. What Did You Learn About Individual Intervention Strategies? • Expanding coverage improves health but, if done alone, would likely raise costs and worsen equity

  20. What Did You Learn About CombinedIntervention Strategies • Complimentary? • Detrimental? • Synergistic?

  21. What Did You Learn About System Dynamics • Dynamic dilemma? • Boundary judgments? • Causal mapping? • Simulation modeling? • Game-based learning?

  22. Thinking 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.

  23. 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 they—and others—can do to help steer a course toward a healthier, more equitable, and more prosperous future.

  24. For Further Informationhttp://www.cdc.gov/syndemics

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