Imagine letting your employees design the company health plan.

You’d give them a fixed budget and let them decide which features are truly most important to them and at what coverage levels: Primary care? Hospital care? Pharmacy? Mental health?

That’s the idea behind a health benefits computer game developed by physician ethicists at the National Institutes of Health and the University of Michigan Medical School. Called “Choosing Healthplans All Together” (CHAT), the game asks a small group of participants to create a hypothetical group health plan.

Participants receive 50 markers to “buy” coverage in 99 spaces on the circular game board. Each space corresponds to different coverage levels (basic, medium and high) within 16 categories: pharmacy, mental health, long-term care, “last chance” treatments, infertility, hospital care, dental care, complementary, vision, uninsured, tests, specialty care, scans and x-rays, rehab services, quality of life, and primary care.

It takes about two hours to play the game. A small group of participants – 9 to 12, ideally – first design a health plan for themselves, then for their business or organization, then for their entire state. They may then be asked to reconsider their own health plan coverage as a final round. They must work together and achieve consensus on creating plans for their business and state.

After creating their plans, participants draw random “health events” from a computer-generated lottery to see the consequences of their coverage decisions. Events range in seriousness from grave (cancer) to mundane (heartburn).

New perspectives

The entire CHAT exercise often gets participants to reassess their own health coverage priorities and those they deem best for the community.

“They clearly get the message that anything could happen to me or to you, that you can’t have it all, and that sometimes you have to give something up because somebody else in the group needs something,” says Susan Goold, M.D., associate professor of internal medicine and director of the Bioethics Program at the University of Michigan Medical School.

Goold is a co-creator of the CHAT program, which began as a board game in 2000, but quickly morphed into a computer game and is now being developed for the Internet.

“If you look at the U.S. health system, it’s a little odd in the sense that buyers are generally the employers and sellers are the insurance companies or the providers,” says Goold. “The real customers, the employees, are nowhere to be found in that equation. We wanted a way for folks to have more input into the decisions made by others that so dramatically affect them once they get sick.”

That said, Goold admits that CHAT game results don’t translate directly into coverage decisions for employers.

“There’s no perfect mechanism for making those difficult choices, but you can learn a lot about perspectives that could substantially differ from that of the insurer or the human resources personnel or your upper management in terms of what are the biggest priorities for health coverage and why.”

Making trade-offs

Sacramento Healthcare Decisions, a non-profit, non-partisan organization based in Rancho Cordova, Calif., recently engaged 750 people from private businesses, public agencies and other organizations in northern California to participate in CHAT sessions.

Study results reveal that CHAT participation has the potential to change fundamental attitudes about health care coverage. Prior to the game, for example, 47% of participants agreed either “strongly” or “somewhat” that it is reasonable to limit health insurance coverage, given the rising cost of health care. Afterwards, that figure jumped to 72%.

“That is a real indication of how a tool like this can be used to at least develop a sense of awareness by employees that, wow, maybe insurance can’t provide us everything we want,” says Marge Ginsburg, executive director of Sacramento Healthcare Decisions.

Participants were also willing to be swayed by other group members about the relative importance of coverage selections. Fully 82% changed their personal coverage selections for at least one of the 16 benefit categories to conform to what the group had selected for the state in round three. Categories most likely to come up for reconsideration were rehabilitation services, last-chance treatments and mental health.

Results also show participants giving more consideration at the end of the game to catastrophic health events, broadening their prior view of insurance as merely intended to cover expected needs like vision care. Eighty-five percent of participants ultimately said they would be content with their group’s decision on a statewide health plan.

Comprehensiveness of coverage emerged as the most important priority for CHAT participants in California, sometimes at the expense of convenience, cost-sharing and choice. A free copy of the final report, “When Options Exceed Resources: Making Trade-Offs in Healthcare Benefits,” may be downloaded at www.sachealthdecisions.org.

Employee eye-opener

Teichert Inc., a construction company based in Sacramento, Calif., last year hired Sacramento Healthcare Decisions to customize the CHAT program for use with its own employees. The company held CHAT games with 75 of its roughly 3,550 employees.

“We are a very paternalistic company,” says Kelly Cleveland, employee benefits manager for Teichert. “Employees have paid very little of their benefit costs for a long, long time. Our executive group is looking at the cost and thinking we have to do something, but we know it’s going to be a very slow change for our folks.”

Cleveland wanted the CHAT sessions to build awareness among employees about the company’s health benefits decision-making process.

“It was an eye-opener for almost everybody who attended,” says Cleveland. “People now realize how difficult my job is – that a benefit plan isn’t going to satisfy everybody. But the most important piece was that people realize how generous our benefits are, that they’re probably going to have to pay more, and that they’re okay with that.”

Employers interested in purchasing CHAT should e-mail chat-info@umich.edu. It costs $100 for the basic program disk and facilitator’s manual. Customizing the game for a particular company’s benefit program entails a higher cost. – J.E.