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Transcript of 1 HealthBound Getting in the Game to Redirect the U.S. Health System Toward Greater Health, Equity,...
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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 [email protected]@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
[email protected]@comcast.net
Gary HirschGary HirschIndependent ConsultantIndependent [email protected]@comcast.net
DRAFTDRAFTPlease do not citePlease do not cite
Work-in-ProgressWork-in-Progress
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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/>
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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.
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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?
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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
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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).
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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.
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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
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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).
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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>
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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)
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““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
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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
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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
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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
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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
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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?
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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?
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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).
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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