CHAT
CHAT (Choosing Healthplans All Together) is a simulation board game designed to promote participatory decision making that is inclusive, deliberative and accessible to a diverse lay audience, and to promote communal values while preserving individual autonomy.
The elements of the game:
The CHAT board is circular, similar to a pie chart, and contains a wedge for each health service category that can be chosen by participants. The circular design minimizes any presentation of a hierarchy of categories that might unduly influence selections, and the relative sizes of the wedges graphically reflect approximate relative cost. Categories have varying levels of coverage (low, medium and high) that can be chosen by placing pegs in holes located within the wedges in the board. Participants in the exercise receive fifty pegs, which allows them to fill in about 60 percent of the holes on the CHAT board. Peg requirements are additive – one must fill in the basic level first before adding pegs to choose the medium level. Dollar amounts are omitted purposefully to minimize numeracy requirements and avoid concern about he “pricelessness of life” that occur during discussion of health care rationing. Each peg represents two percent of an average managed care plan premium. Health insurance actuaries provided initial cost data and reviewed final (rounded) estimates.
A player’s manual describes the basic, medium and high levels in each category, in language rated at a sixth-grade reading requirement or below. Categories are in alphabetical order and colour-coded to match the board.
A roulette wheel is used to randomly assign health events to participants after they make their initial insurance choices. The roulette wheel includes landing spaces for each health service category; hypothetical health events experienced by participants are thus framed as influenced by chance.
The health event cards (also colour-coded to match the player’s manual and board) describe health and illness scenarios and range from the mundane to the catastrophic. Hearing the consequences of various choices within a benefit category makes benefit selections salient to participants.
The process:
In the first round, using the board, player’s manual, and fifty pegs, individual participants begin by choosing which categories of services to include in a health plan for themselves and their families. They make choices about their desired level of coverage given available resources. The roulette wheel and the event cards are then used to assign the participants randomly occurring health events, and they have the opportunity to see how effective, or misguided, their coverage choices had been. At the end of this first round participants share with the others the consequences of their choices and are encouraged to reflect aloud upon the selections in light of their health event experiences.
In the second, the triad, cycle, groups of three are asked to design a health plan for their neighborhood (or division in a company) considering themselves representatives for that group. The earlier process is repeated.
In the third cycle, the entire group decides together upon features for a single health plan after being told they represent their community (or company). The facilitator invites each participant to propose a coverage choice. This is followed by extensive discussion of that selection’s relative merits. If there is disagreement the option of placing that peg at a lower level of coverage is discussed. If there is no agreement on this either, the suggestion is moved onto a list of unresolved issues to be dealt with later. The objective is to have all decisions reached by full consensus of the group. If it appears to the facilitator that consensus will not be reached, votes can be used to resolve disagreements. When voting is used, typically it occurs only at the very end in distributing the last few pegs onto the board from the list of unresolved issues.
In the final round, the participants again as individuals repeat the choices for themselves and their families.
A debriefing occurs at the conclusion of the game in which participants are encouraged to discuss the choices they made, the changes in their choices from first to final round, why those changes occurred, and their perception of the overall benefits or impacts on their thinking of the simulation exercise.
While designed specifically for deliberating on health plan allocations, the CHAT model has the potential to be of benefit in any context where a deliberative and educational process is considered of benefit in weighing the merits of varied choices in the allocation of scarce resources. It also could be of benefit when used by public administrators responsible for similar decision processes.
Goold, Susan Dorr, et al. "Choosing Healthplans All Together: A deliberative exercise for allocating limited health care resources," Journal of Health, Policy and Law, 30(4) August 2005, 563-601
CHAT (Choosing Healthplans All Together) is an exercise in participatory decision making designed to engage the public in health care priority setting. Participants work individually and then in groups to distribute a limited number of pegs on a board as they select from a wide range of insurance options. Randomly distributed health events illustrate the consequences of insurance choices. In 1999-2000, the authors conducted fifty sessions of CHAT involving 592 residents of North Carolina. The exercise was rated highly regarding ease of use, informativeness, and enjoyment. Participants found the information believable and complete, thought the group decision-making process was fair, and were willing to abide by group decisions. CHAT holds promise as a tool to foster group deliberation, generate collective choices, and incorporate the preferences and values of consumers into allocation decisions. It can serve, they argue, to inform and stimulate public dialogue about limited health care resources.
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