syndemics prevention network healthbound get in the game to re-direct the u.s. health system …in...
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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
Jack HomerHomer Consulting
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”
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
Coverage + Quality + Capacity
Coverage + Quality + Capacity + Protect
0.2
0.15
0.1
0.05
0
-5 0 5 10 15 20 25
HealthBound is designed for training purposes. Simulated scenarios cannot be interpreted as predictions for the future.
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
Coverage + Quality + Capacity
Coverage + Quality + Capacity + Protect
HealthBound is designed for training purposes. Simulated scenarios cannot be interpreted as predictions for the future.
* 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
Coverage + Quality + Capacity
Coverage + Quality + Capacity + Protect
* Undiscounted, constant 2003 dollars
HealthBound is designed for training purposes. Simulated scenarios cannot be interpreted as predictions for the future.
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