Tradeoffs in healthcare decision-making

A view of the CHAT online decision-making tool

Informing tough choices when you can’t have it all

We all know that healthcare resources are finite, and deciding how to spend these resources most effectively is a complex, often emotionally charged, and not always well-informed process. Tradeoffs are necessary, and priorities can vary greatly between groups, communities, and individuals.

Insurers, hospitals, and policymakers engage in this kind of decisionmaking all the time, so why not ask healthcare beneficiaries – the people most affected by these decisions – for their input on the healthcare priorities that are most important to them?

Susan Dorr Goold, M.D., MHSA, M.A., professor of Internal Medicine, and Health Management and Policy, recently received a two-year, $391,000 grant from the federal Agency for Healthcare Research and Quality to do just that. Working with community partners, Goold’s team will engage Michigan communities in informed deliberations about the kinds of care Medicaid should prioritize using a customized version of a game-like tool called Choosing Health Plans All Together, or CHAT.

Options in Medicaid-CHAT, which will be developed in consultation with a state-wide network of community collaborators, could include variations in covered benefits or out of pocket spending; public health programs; incentives for healthy behaviors; and changes in eligibility. Goold says, "Michigan, like all states, faces budget constraints, and Medicaid is a substantial portion of the state's budget. We want to know from people in Michigan, especially those most affected by Medicaid policy decisions, given limited resources, what do they think Medicaid should prioritize?

These discussions will happen while the state continues to roll out its expansion of the Medicaid program under the Healthy Michigan Plan, and as IHPI begins a five-year, federally mandated study to evaluate how well the new plan is working. Goold expects the CHAT exercise will dovetail nicely with the ongoing IHPI evaluation, by informing state and community leaders, insurers, and other stakeholders about “the views and perspectives of those who are most affected by the decision making in Medicaid,” she says, and she also hopes the research will facilitate some positive changes in the overall Medicaid budget.

Goold and collaborators developed the CHAT exercise [interact with it here] as a tool to help people better understand health insurance options by engaging them in a “game” that illustrates the consequences of tradeoffs and spending actions under a fixed budget and limited “menu” of options for benefits. By guiding participants in the basic mechanisms of designing elements of a health insurance plan, the exercise allows researchers and policymakers to collect informed feedback in a way that a simple opinion poll cannot. “What do they think? What do they prioritize? What are they willing to give up to have something else? One of the things CHAT recognizes is that you can’t have it all,” Goold explains.

In addition, using CHAT as a group exercise vividly illustrates to participants that these difficult choices involve tradeoffs that affect other people, too, and equips them to reason with each other about decisions that may affect their community. When one group of people wants to prioritize things like high levels of coverage for dental benefits, specialty care, and tests such as x-rays and blood work, what resources are left for options around hospitalization or long-term care for themselves, their loved ones, and others in their community? CHAT illustrates the consequences.

The tool provides structure, feedback and adaptability, has been used by multiple policy makers and community organizations, and a solid record of published research. In 2011, the Institute of Medicine (IoM) recommended CHAT as one program for determining and updating the essential health benefits package that will be required for qualified health plans offered through exchanges created by the Affordable Care Act (in the same report, the IoM also endorsed another U-M-developed initiative, Value-Based Insurance Design).

CHAT has been used for everything from soliciting public input on competing needs in the area of essential benefits for cancer care under Medicare, to assessing priorities for health research in underserved communities (under a PCORI grant). Goold hopes that guiding deliberations around Medicaid spending will help make some of the tough decisions more just and more aligned with community needs and values.