Abstract
Background. With rising healthcare costs, there is a need to transform
Intervention & Methods. We describe the design of our
Discussion & Conclusion. We envisage that some
Introduction
Healthcare costs are rising and many health systems are finding ways to transform care and funding models to make healthcare more sustainable (Healthcare Transformation Task Force [HCTTF], 2017; National Audit Office [NAO], 2018; Ontario Chamber of Commerce [OCC], 2016). There is increasing emphasis on value-driven care fuelled by value-based payment models which are regarded as more sustainable alternatives to volume-driven, fee-for-service financing arrangements. Nevertheless, for such transformation to work, the mindsets and culture among providers must change (Becker’s Hospital Review, 2016; Nilsson et al., 2017). Likewise, patients must change their expectations of care processes and standards and be more empowered and pro-active in their pursuit for better health (Lateef, 2018; Marzorati & Pravettoni, 2017). One potential barrier could be the lack of common understanding of what value-based care entails, including the financial risks for providers (American Academy of Family Physicians [AAFP], 2017; Pendleton, 2018). To address this, it is possible to gamify concepts and principles of sustainable care and value-based financing in order to spark interest among providers and healthcare consumers in this perceivably dry and complex subject. Most people may not fully appreciate the significance and potential impact of sky-rocketing healthcare costs until they are personally affected by catastrophic health conditions and huge bills. Hence, enhancing people’s understanding of value-based care through games may facilitate their early adoption of value-seeking behaviours which in the long-term could help moderate overall healthcare spending at the population level.
To educate providers and healthcare consumers on the complex subjects of value-based care and financing, we can use games to make learning simpler and more fun, and enhance appreciation and assimilation of these subjects. One can design “serious games” (defined broadly as “games that do not have entertainment, enjoyment or fun as their primary purpose” [Chen & Michael, 2005, p. 21]) to raise awareness and educate on value-based healthcare and financing. Such games may be conducted through educational workshops for providers, with simpler and perhaps more consumer-oriented versions for the general public. Alternatively, one can also introduce game elements in the daily work of providers or patients’ navigation in the healthcare system, which is classically referred to as gamification (defined as “the use of game design elements in non-game contexts” [Deterding et al., 2011, p. 2]). Figure 1 summarizes our perspective of two broad gaming concepts, namely non-game in game (game with a serious purpose) or game in non-game (gamification). The concept of non-game in game refers to the use of games to educate players on serious themes such as value-based care financing which helps players appreciate how financing innovations spur value-driven care approaches. Different types of games including board games, video games, simulation games, puzzles, etc. can be used to convey serious themes. On the other hand, a game in non-game concept refers to gamifying real-life experiences in a way that motivates people to adopt behaviours that will satisfy the gamification objective. We often see this being used in the context of health promotion, for example, where people are motivated by an interplay of competition and rewards to stay active and track their step-counts through their pedometers. Referencing the Gameplay/Purpose/Scope classification by Djaouti et al. (2011), we could deem Health$en$eTM as using a non-game in game concept of gameplay designed for the purpose of raising awareness of value-based healthcare financing targeted at healthcare providers and consumers (scope).
The “non-game in game” and “game in non-game” concepts of gamification.
There are certain key factors to consider when designing a game for learning. A meta-analysis of games in education showed that factors such as simplicity, clarity of goals, realism, enjoyment and the relationship between learning attributes and game mechanics were important in influencing learning using games (Yu, 2019). In addition, it is shown that surprise events in a game could foster deeper learning among participants (van der Spek et al., 2013; Wouters et al., 2017). Murphy (2016) further described the ingredients for achieving simplicity and good game flow. Simplicity involves narrowing the set of game goals, make them easier to understand and help players correlate the feedback to their actions (Murphy, 2011). This improves game flow, which in turn increases motivation and improves learning. Where realism is concerned, the intended theme, principles and lessons to be learned should be relatable to players. Nonetheless, any simulation of a real-life role in a game should be intuitive to all players without the need for actual experience in the role, otherwise it could affect the game flow and also limit participant outreach. This is where transcendence comes into play to help simplify the otherwise complex real-life role and make players “more powerful in the game world than they are in the real world” (Schell, 2008, p. 272), so that they can still play the challenging role and achieve the goals more easily than in real life. Fun and enjoyment should constitute a prominent aspect of the game so that it may continue to engage and motivate the player to keep playing the game. Although some research pointed out that enjoyment in a game does not necessarily lead to learning success (Iten & Petko, 2016), we believe it plays a critical role in maintaining players’ involvement and their interest to learn what the game has to teach. Without such involvement, players may simply fail to learn (Hofstede et al., 2010).
To spread awareness and knowledge, the game must also be relatively accessible to people of different abilities and socio-economic backgrounds. In this context, “accessibility” does not merely denote catering to players with disabilities but also being free or easily affordable, available in both digital and non-digital platforms as well as in multiple language media.
One popular choice of game platform for learning is board games, probably because such a platform can readily satisfy the abovementioned key attributes and has historically appealed to people of all ages. Board games have been used in health and medicine for educational purposes (Nakao, 2019). In fact, a systematic review by Gauthier et al. (2019) suggested that board games resulted in significantly more knowledge attainment than other non-game conditions, and are apt for changing behaviours in people who lack the requisite knowledge. Nevertheless, there appears to be no literature about board games that educate people on healthcare costs and financing, not to mention board games for teaching value-based care and financing. This is ironical given that research, opinions and case studies on value-based healthcare are relatively abundant. Furthermore, there are several board games in the market on many aspects of finance (e.g. personal, investment, economic strategy, trading, etc.) but none on healthcare finance. Hence, Health$en$eTM aims to fill this void to educate and engage both healthcare providers and consumers on the subject of value in healthcare, and hopefully inspire them to contribute their perspectives on healthcare finance transformation. Any attempt to implement value-based financing is unlikely to succeed in the long term if healthcare providers do not understand their consumers’ needs, preferences and perspectives of value (Heath, 2016).
Materials and Methods
Game Concept and Development
This article describes how we conceptualize, develop and test a board game (Health$en$eTM) with the intent to introduce it in a workshop as part of an annual healthcare symposium. We theorized that a non-game in game concept will help attract more people to learn through play. The idea of a simple board game was hatched from a preliminary brainstorming session involving personnel from finance and health innovation quarters in our cluster organization. As work on finance transformation in healthcare was in progress, it was felt that launching a game could serve as a strategic move to engage the wider community on value-based care and finance transformation. We chose a board game format in lieu of a digital one so that it can be launched through a series of live workshops where mature participants from the healthcare sector can play in teams with more interaction and between-player discussions during the game. We believe this approach helps to increase social relatedness and enrich the players’ experience during the game. We anticipate that our prospective players, being mature learned adults, would be more familiar with board games (i.e. roll dice and move avatars) and able to assimilate the rules more quickly than digital games. Moreover, the opportunity for between-player discussion and collaboration has been postulated to help players master the intricacies of games with complex systems, augmented by the use of physical objects in non-digital games (e.g. avatars, cards) that will slow down play and give more room for players to engage in deeper thinking, resulting in more successful game play (Kaufman & Flanagan, 2016). Notwithstanding these reasons, we hope to launch digital versions of Health$en$eTM (e.g. in phone apps) to cater to younger players who are more digital-savvy and to allow greater ease of periodic game updates.
The game design of Health$en$eTM would embody the key attributes of game effectiveness discussed earlier. While the eventual target group is the general public, the plan was to focus on healthcare personnel in the initial phase. We believe that, in order to spread the awareness and appreciation of value-based care and financing effectively, the first step should be to mould and align healthcare personnel’s mental models and strengthen the community of practice in these areas within the organization. The next phase would entail harnessing the collective wisdom of our community of practice for further outreach to the wider population. The different phases of game evolution could see future customization of game elements to suit different player groups, thus potentially creating different game versions while maintaining the game’s central theme and learning objectives.
Game theme & mode
The chosen theme for Health$en$eTM was the management of funding for patients who flow through three different care settings of a healthcare system i.e. from an acute hospital through a community hospital to home care. Each player will play the role as a Financial Officer who oversees the utilization of a fixed budget for flowing a certain number of patients. Such a theme is familiar to most healthcare personnel whose work might, in some way or other, be plugged into the care journey of a typical hospital patient. Furthermore, our healthcare system is not totally new to post-acute community-based care, having already implemented several home-based care programmes for the past few years. The game introduces elements that represent existing or future efforts to optimize care utilization and right-site care to the community for better value.
As per most board games, Health$en$eTM operates on a competitive mode. To win the game, a player needs to achieve the best value for flowing each patient through different care settings. This is determined by having the least average expenditure per patient discharged within a specified duration of play. Patients who are not discharged cannot be counted towards the denominator for computing the value index. Consequently, players who discharge fewer patients are more likely to chalk up higher average expenditure per patient. This mirrors real-life situations where healthcare systems that incur higher costs are associated with patients who stay longer (Cyganska, 2016; Fine et al., 2000) or are readmitted more frequently (Goodwin et al., 2015; Kim et al., 2018).
Game layout & flow
Figure 2 shows the design of the game board layout. Direction of play is clockwise and different colours are used to depict the different care settings. Clear and concise rules in booklets on the use Funding Innovation (FI) cards enable quick reference during play, thus reducing pre-game time needed for digesting game rules. Players take turns to roll their dice and move their patient avatars consecutively, immersed in the thrill of watching each other’s progression in the game and trying to flow all given patients ahead of others. The randomness of dice throws makes the game less predictable as to who the ultimate winner might be. This helps to sustain players’ interest to complete the game. A designated game umpire will ensure players adhere to the game rules, while two controllers keep track of the players’ expenditure in the game, which is elaborated in a later section.
Design of the game board layout.
Patient mix concept
Besides dice throws, the random drawing of patients from a patient-mix deck of cards with known patient-mix ratios also injects unpredictability in the game. The deck of cards simulates the subpopulation of patients that seek care at the acute hospital. There are four categories of patients: well, comorbid, frail and end-of-life. These different categories are known to utilize healthcare resources to varying extents. In reality, one could use demographic and epidemiological information to estimate the probable patient mix that a particular hospital may encounter and then design innovative care and financing solutions to optimize potential utilization and costs. The game simulates this complexity for players to plan their funding innovation, albeit due to the much smaller number of patients being played the expected probabilities of patient encounters are likely to deviate more significantly from the card deck’s patient-mix ratios.
Value-based funding concepts
The highlight of the game is depicted by the FI cards that players can use to defray costs of flowing patients through the various care settings. These FI cards represent the spectrum of real-life care and funding innovations used in different healthcare systems that help generate better value care, such as bundled payments to encourage more hospital-to-community right siting and investment in primary and preventive care to reduce chronic disease deteriorations and complications that would otherwise require tertiary care intervention. The FI cards conceptually affect patient flow via two broad mechanisms: effects and coverage. The effects represent the impact of funding an alternative care approach (e.g. comprehensive primary care) that changes the patient’s health predisposition such that he needs less tertiary care intervention. On the other hand, the coverage represents the scope of care covered by the value of the funding innovation which is designed to be more efficient and less costly (e.g. bundled payment) than if care were to be funded ala carte (viz. fee-for-service). Table 1 summarizes the four FI cards, their corresponding effects and coverage, and the rationale for their design. The ala carte costs of admissions and home visits used in the game were calibrated to approximate actual care costs. The costs of various FI cards were initially estimated based on arbitrary projections of potential savings from ala carte rates, and subsequently adjusted following each trial and validated using programmed simulation.
Summary of Information Regarding the Four Funding Innovation (FI) Cards.
AH: Acute hospital; ACP: Advanced care planning; CH: Community hospital; EOL: End of life; LOS: Length of stay.
Real-world complexities
For greater realism, we layered in three game elements. Firstly, there is the risk of patients being readmitted, thus prolonging their flow through the board. To avoid dampening the game flow, we limited to 3 readmissions beyond which a lump sum payment is needed before patients exit the board. This represents the final high-cost admission before death. Secondly, for players who fail to leverage on any FI card on patients who are co-morbid, frail or at end-of-life, additional spending is obliged due to greater amount of resources needed to manage the sicker patients. This is because sicker patients often rake up higher healthcare costs compared to their healthier counterparts. Thirdly, we introduce the principle of patient choice when it comes to right siting to home care. Locally, patients often decline to be transferred to home-based care for various social and financial reasons such as the lack of caregiver support and high out-of-pocket expenditure. To reflect this reality, players need to roll dice to reflect whether their patients consent to home care before continuing their game accordingly.
Game name
The name Health$en$e was coined to reflect the healthcare financing nature of the game. Furthermore, it also connotes the intent of the game to improve understanding of patient care costs and making sense of various funding innovations to optimize healthcare spending. The name is currently protected under trademark.
Game Trials and Logistics
Following the completion of the prototype game design, we planned a series of game trials with the intention to review, reflect and refine the game before launching it in a workshop. Apart from the prototype designer who served as the game-master, a total of 20 people with various job functions and professional backgrounds in the organization participated in up to 3 game trials. Basic board game logistics included printing of the game board on A1-sized paper, printing of patient cards and FI cards, and acquiring of game avatars and dice. Advanced logistics included the running of programme simulation and developing a system of expenditure tracking during gameplay.
Programmed simulation
A game simulation using Python programming was run to test the probabilities of potential costs and savings for flowing 100,000 patients per player. Table 2 shows the predicted outcomes of the programmed simulation for flowing different patient types with and without the use of appropriate FI cards. The outcomes were based on recalibrated costs of FI cards prior to the third trial. It is observed that there are significant savings for every patient type at the median (50th percentile) expenditure when FI cards are used. This is aligned to our intent to portray the advantage of funding innovation in reducing care expenditure, be it the use of value-based bundled payments or investment in primary and community-based care. However, we recognise that some players may also suffer losses despite using FI cards, which reflects real-world situations of unexpectedly high utilization (e.g. hospital overstayers) or excessive investment in care resources relative to actual needs (e.g. overspending in manpower or infrastructure). Notwithstanding that, we determined that the cost figures used in the game were reasonable and could provide some element of unpredictability and surprise to thrill players.
Predicted Costs and Savings Using Programmed Simulation of Gameplay.
(Negative numbers represent losses instead of savings).
Expenditure tracking
Microsoft Excel worksheets were formulated to calculate and track the expenditure for two scenarios per player during actual gameplay: one scenario where the actual expenditure of patients is tracked with the exercise of FI cards, and another on the presumption that no FI card was used. The intent was to compare the expenditure between the two scenarios to assess the reasonableness of the care costs and FI card costs used in the game. Table 3 summarizes the expenditures and savings for each player in the third game trial. All the players managed to yield some savings and most players spent less than $18K per patient on average. This enabled us to gauge a reasonable budget quantum per patient to inject some chance of a player busting his budget (we chose $30K). The winner was the one with the least average expenditure per patient i.e. Player 2, even though his savings per patient was the lowest. Assuming every patient’s outcome was equally optimal, Player 2 would have achieved the highest care value defined by patient outcome per dollar spent.
Summary of Expenditure and Savings Among Four Players in the Third Game Trial.
(Numbers in brackets represent incremental expenditure with the use of the FI card instead of cost savings; N/C means patient was not discharged when the game time is up).
Discussion
Health$en$eTM is intended to foster interest in learning how funding innovations may improve healthcare value and cost sustainability. Arguably, this may cater more to prospective players who are keen to understand how value-based funding relates to actual patient management, and those who are exploring the use of games to help educate their care partners and patients in this area. The game could also potentially motivate healthcare providers to adopt the right mental models about healthcare value and translate these into practice. Healthcare consumers who have played the game may potentially change their perspectives and expectations about healthcare, including care delivery transformation and value-based outcomes.
Ideally, we want to be able to incorporate the right game elements that will enhance the effectiveness of our serious game in achieving its goals. We view game success as broadly classified into 2 levels: firstly, success in attracting more people to play the game or encouraging existing players to continue playing the game; and secondly, success in having players adopt new perspectives and behavioural changes about healthcare finance transformation promulgated by the game and taking constructive actions to change the real world for the better, including educating others and building a community of practice for change.
There are several factors and game elements that could influence how well a game works. Sailer et al. described six game elements namely badges, leaderboards, performance graphs, avatars, meaningful story and teammates that could potentially satisfy psychological needs of competence, autonomy and social relatedness for better game effectiveness in fostering human motivation and performance (Sailer et al., 2017). However, these elements were more relevant to online or digital gamification in a real-world context. Shi and Shih (2015) described a more general set of game factors based on a game-based learning design model that includes game goals, challenges, narratives, sociality and mystery. These factors are needed to make educational game design more fun as a principal source of motivation and stickiness rather than influencing learning outcomes. Closer to our context, Pornel (2011) described the factors that will make board games more engaging to students, which include aesthetics, game mechanics, variety of experience, interaction among players, and control. These factors are also important for engaging players of computer and educational games. Yu (2019) conducted a meta-analysis of serious games in education which revealed five specific factors influencing assisted learning, namely backstory and production, realism, artificial intelligence and adaptivity, interaction, and feedback and debriefing. Other factors from the meta-analysis include gaming easiness and instruction. Murphy (2016) elaborated on the important attributes of simplicity and flow, each of which has a list of sub-attributes that are collectively fundamental for games to engage their players.
We review the game elements in Health$en$eTM to analyse how they are deployed and how they might increase the prospects of game success. We use the taxonomy of gamification techniques developed by Hoffmann et al. (2017) as a framework for our analysis. Table 4 describes the various game elements and how they have or could have been used in Health$en$eTM. We also made reference to the Octalysis framework of psychological core drives (Chou, 2015) to define the range of motivations that our game might engender, primarily to drive success at the two levels mentioned earlier (Table 5). Putting all these together, we derive a “element X core-drive” (eXcd) matrix to relate the game elements in Health$en$eTM to the potential core drives of its players (Table 6).
Deployment of Game Elements in Health$en$eTM.
Potential Psychological Core Drives Relevant to Health$en$eTM.
An “Element X Core Drive” Matrix That Envisages Associations Between Game Elements in Health$en$eTM and Possible Psychological Core Drives for Game Success.
“+” represents the potential for each game element to influence a player of Health$en$eTM through the respective core drive.
The eXcd matrix suggests that many of the game elements could potentially motivate players to keep playing Health$en$eTM (i.e. Level 1 success goal) and that such postulation applies to other board games as well. Extrinsic motivators play a key role in maintaining players’ interest in Health$en$eTM, such as being able to win and maintain lead (i.e. accomplishment) and owning the game and controlling the patient avatar (i.e. ownership). The secondary game objective (2GO) of not busting the allocated budget actually involves another psychological core drive i.e. avoiding loss, but this per se may not motivate a player’s stickiness to the game since there is no risk of actual monetary loss. Rather, the 2GO may indirectly increase the player’s sense of ownership and obligation to keep the game going so as to avoid the embarrassment of overspending and getting forfeited from playing the game.
Social influence and relatedness can motivate stickiness in the game but could exist in a positive or negative form. During the Health$en$eTM trials, players had fun interacting and amusing themselves about each other’s progress in the game. The motivation to win the game was not evident among the players. However, those players’ primary objective was to look for areas of improvement, so the social influence was positive. When launched to a wider playgroup in an actual workshop where players may be more competitive, the nature of social influence could be less positive. For example, Asian players may be socially pressured to play the game well due to their consciousness about face (Han, 2016), particularly if their actual jobs involve managing funds for patient care.
In contrast to Level 1 success goal, we perceive that fewer board game elements work through intrinsic psychological motivators that inspire players to apply serious non-game lessons in the real-world context (i.e. Level 2 success goal). One could argue that this is an inherent weakness of all board games, which are not designed to meet such objectives. Nonetheless, like many other educational tools and games, the transfer of knowledge and wisdom from classroom to the real world is often not direct and classroom experience merely provides the theoretical foundation upon which the practical real-world experience builds on. Likewise, the game elements of Health$en$eTM do not directly embed in real-world activities that some serious game apps do (e.g. digital steps tracker counting actual steps taken, game QR codes linked to real cash rebates, etc.). Instead, the few game elements that could potentially trigger intrinsic motivators may merely simulate activities, functions or principles in the real-world, but rely on players to become sufficiently activated to carry over their experiences to the real-world and create transformations with real outcomes. For example, the use of an imaginary budget and funding innovation cards in Health$en$eTM may help players relate to care cost issues and generate a calling in them (particularly healthcare professionals) to create better value for real patients and the system. Likewise, having control over a patient avatar may make a player realize that more could be done for actual patients in the real world, especially if he has autonomy in deciding care paths for patients (e.g. a primary physician, a main caregiver). Motivation through the epic meaning core drive is not limited to healthcare personnel but could also involve consumers and lay public who see themselves playing a greater role in improving the healthcare system for current and future generations, presumably creating legacies bigger than their own selves.
Alternatively, for certain players, the motivation to make real-world changes may not stem from a larger-than-life calling but rather a challenge or temptation to exercise their creativity beyond the game. This could be triggered through the competition, socialisation and feedback elements of the game. We also believe that some players may be inspired, not just to create new care or funding models, but also to introduce further games or gamification to influence others. Players may also be motivated to make real world changes if they can closely relate the serious game agenda or narrative directly to their job or expertise. Such non-game context may also trigger epic meaning and creativity core drives by feeding the context to players’ sense of meaning or imagination respectively. Meanwhile, we believe that players who are motivated through Health$en$eTM have the capacity to influence their peer players, particularly if they share similar real-world roles or professions.
In any game design, one almost always needs to strike a balance between injecting realism vis-a-vis pleasure in the game. In the design of Health$en$eTM, a conscious effort is made to preserve game pleasure to capitivate players and encourage their continuing participation. We also tried to avoid burdening the game with too many complex realities. This explains why the quality of care is assumed in the game. Likewise, all patients who are discharged are assumed to have equal health outcomes. This helps to ensure smooth game flow and pace while keeping players focused on the financing theme and objective. Moreover, the randomness of the dice throws and their impact on game outcomes are already sufficiently realistic in reflecting the real-life situations faced by healthcare providers. Nonetheless, in future value-based health financing games, incorporating health outcomes as a game feature could provide a different yet refreshing experience for people who have played Health$en$eTM. It would also be interesting to further study how different simulation games calibrate the probabilities of various gameplay outcomes and how far such calibration departs from real-life probabilities in return for maintaining game pleasure. Such studies would be useful for gaining deep insights in designing simulation games to learn about real-world issues.
Conclusion
Our next steps of work on Health$en$eTM would encompass executing the game in a workshop involving a wider group of players and evaluating their responses to the game to validate some of our anticipated mechanisms of motivational impact. With such data, we can then explore how Health$en$eTM can be further improved for better player experience in terms of realism and fun, better awareness of value-based healthcare financing, and better potential to motivate players for real-world transformations in this area.
Footnotes
Acknowledgements
We would like to thank all colleagues and staff of National Healthcare Group (NHG) Singapore who had participated and assisted in the game trials and offered invaluable suggestions to improve Health$en$eTM. We would also like to thank those who have kindly volunteered to be trained as umpires and controllers for the launch of the game in a conference workshop.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: All funding for Health$en$eTM is from National Healthcare Group.
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