“Choosing All Together” (CHAT) is a small group simulation exercise that engages groups of people in informed deliberations about spending priorities related to health.
Problems and Purpose
Values. Voice. Individual differences. CHAT aims to engage ordinary persons in informed, inclusive deliberation about complex and value-laden allocation decisions.
“Choosing All Together” (CHAT) is a small group simulation exercise (a serious game) that engages groups of people in informed deliberations about spending priorities related to health.[1] While it may be straightforward to identify injustice in the distribution of limited resources, defining the “right” allocation is difficult. Should we prioritize research on common diseases over rare ones? Quality of life over prolonging life? Preventing “bad” outcomes, curing minor ailments, improving or restoring basic human functioning, or relieving suffering? How should we trade-off research that tests promising interventions and research that aims to improve delivery of proven interventions? These trade-offs require attention to justice and science. Justice is enhanced by the participation in decision making of those most affected by the decisions.
CHAT aims to give the public, particularly communities with less voice, a voice in setting health or health care spending priorities. It has been used for research, policy and teaching purposes. The exercise can be tailored and adapted to the needs of the populations/communities. Departments of Insurance in various states in the U.S. have used CHAT to determine public opinion about what should be included in basic health insurance packages for the uninsured.[2,3] Some U.S. municipalities have used it to assess public priorities for direct service delivery to the uninsured. CHAT has been used in the U.S. and other countries to engage the public in decisions about health, health research [4,5] or healthcare spending.[2,3,6-13]
CHAT has been translated into Spanish, Arabic, French, German, Italian and other languages. Now able to be used for virtual and/or in-person group deliberations.
Origins and Development
Developed and designed by Susan Dorr Goold and Marion Danis [1], CHAT originally used physical boards, pegs and paper materials.[2] Over time it was transitioned to CD-based software and then a web-based program, still used for in-person deliberations led by trained facilitators. In 2024 we now have software that allows us to convene people for virtual deliberations about priorities.
How it Works
CHAT depicts spending options as layered wedges on a pie chart. There are up to 16 possible categories of spending, and each category has up to 3 or 4 levels that could be selected. Higher levels cost more, but potentially provide more benefits. Participants use markers to choose among spending options, but there are more marker spaces from which to choose than there are markers. Thus, participants must set priorities for the use of limited resources. Each CHAT session, involving 9-15 individuals led by a professional facilitator, consists of four rounds: 1) Individually, participants choose priorities based on their own concepts of what is most important; 2) Groups of 2-3 work together; 3) The whole group (ideally 9-15 people if in person, 5-10 if virtual, but can accommodate larger groups) attempts to reach consensus on spending priorities on behalf of the community; and 4) Individuals again select their own priorities. Repeating individual choices in the final round enables an examination of how participants’ views are affected by group deliberations and the exercise. After rounds one and two, participants receive hypothetical health “events,” exposing them to the consequences of their allocation choices. Participants learn from other members of the group, the illustrative events, and embedded resources and are asked to make fair decisions on behalf of fellow community members.
Analysis and Lessons Learned
Research demonstrates that participants finds CHAT informative, easy to use, and a fair process, and, consistently, over 85% would be willing to abide by the decision reached by their groups. Participants also increase in their understanding of limited resources and necessary tradeoffs.
See Also
References
[1] Susan Dorr Goold, Andrea K. Biddle, Glenn Klipp, Charles N. Hall, Marion Danis; Choosing Healthplans All Together: A Deliberative Exercise for Allocating Limited Health Care Resources. J Health Polit Policy Law 1 August 2005; 30 (4): 563–602. doi: https://doi.org/10.1215/03616878-30-4-563
[2] (De)Constructing "Basic" Benefits: Citizens Define The Limits of Coveragehttps://doi-org.proxy.lib.umich.edu/10.1377/hlthaff.25.6.1648
[3] Experience in the United States With Public Deliberation About Health Insurance Benefits Using the Small Group Decision Exercise, CHAT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3691997/
[4] Goold SD, Myers CD, Danis M, Abelson J, Barnett S, Calhoun K, Campbell EG, LaHAHNN L, Hammad A, Rosenbaum RP, Kim HM, Salman C, Szymecko L, Rowe ZE. Members of Minority and Underserved Communities Set Priorities for Health Research. Milbank Q. 2018 Dec;96(4):675-705. doi: 10.1111/1468-0009.12354. PMID: 30537366; PMCID: PMC6287077.
[5] Goold, S. D., Myers, C. D., Szymecko, L., Cunningham Collins, C., Martinez, S., Ledón, C., ... & Rowe, Z. (2017). Priorities for patient‐centered outcomes research: the views of minority and underserved communities. Health services research, 52(2), 599-615.
[6] Danis M, Biddle AK, Dorr Goold S. Insurance benefit preferences of the low-income uninsured. J Gen Intern Med. 2002 Feb;17(2):125-33. doi: 10.1046/j.1525-1497.2002.10609.x. PMID: 11841528; PMCID: PMC1495009.
[7] Evans-Lacko, S.E., Baum, N., Danis, M. et al. Laypersons’ Choices and Deliberations for Mental Health Coverage. Adm Policy Ment Health 39, 158–169 (2012). https://doi.org/10.1007/s10488-011-0341-4
[8] Myers CD, Kieffer EC, Fendrick AM, Kim HM, Calhoun K, Szymecko L, LaHahnn L, Ledón C, Danis M, Rowe Z, Goold SD. How Would Low-Income Communities Prioritize Medicaid Spending? J Health Polit Policy Law. 2020 Jun 1;45(3):373-418. doi: 10.1215/03616878-8161024. PMID: 32084263; PMCID: PMC9450686.
[9] A decision exercise to engage cancer patients and families in Deliberation about Medicare Coverage for advanced Cancer Care: https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-315
[10] Hurst, S. A., Schindler, M., Goold, S. D., & Danis, M. (2018). Swiss-CHAT: citizens discuss priorities for Swiss health insurance coverage. International journal of health policy and management, 7(8), 746.
[11] David Mark Dror, Ruth Koren, Alexander Ost, Erika Binnendijk, Sukumar Vellakkal, Marion Danis. Health insurance benefit packages prioritized by low-income clients in India: Three criteria to estimate effectiveness of choice, Social Science & Medicine, Volume 64, Issue 4, 2007, Pages 884-896,
[12] Julianna E. Pesce, Chinwe S. Kpaduwa, Marion Danis. Deliberation to enhance awareness of and prioritize socioeconomic interventions for health. Social Science & Medicine,. Volume 72, Issue 5,2011,Pages 789-797
[13] Tugendhaft, Aviva, Nicola Christofides, Nicholas Stacey, Kathleen Kahn, Agnes Erzse, Marion Danis, Marthe Gold, and Karen Hofman. "Moving towards social inclusion: Engaging rural voices in priority setting for health." Health Expectations 27, no. 1 (2024): e13895.
External Links
https://deciders-project.med.umich.edu/about-chat