understanding member behavior to maximize health outcomes
TRANSCRIPT
Understanding+Member+Behavior+to+Maximize+Health+Outcomes
Omid%B.%Toloui,%MPH%Senior'Director,'Product'Management'
“Positive+changes+in+individual+behavior+can+reduce+the+rates+of+chronic+disease+in+this+
country.”++!
0%The%Government…and%Most%Researchers
Source:%HealthyPeople.gov
“Positive+changes+in+individual+behavior+can+reduce+the+rates+of+and$improve$the$
management$of+chronic+disease+in+this+country.”++
!0%Me,%Altegra%Health…and%Most%Researchers
• US%Healthcare%Costs%Approaching%$3+Trillion%Annually
Source:'Osterberg'L,'Blaschke'T.'Adherence'to'medication.'N'Engl2
J'Med.'2005;353:487J97'&'McKinsey'&'Co,'2012
• How%much%of%that%is%contributed%to%member+behavior?%• 31%+of+total+costs%directly%contributed%to%behaviorally%influenced%chronic%conditions%
• All%in,%69%+of+total+costs%were%heavily%influenced%by%member%behaviors%
• Poor%medication%adherence%alone%accounts%for%+$100B+in+avoidable%spending.
UpsideIDown+Cost+Pyramid
7
“Everyone mouths the words, ‘One percent of the population spends 30 percent of the money, 5 percent spends 50 percent.’ But operating models and financing plans ignore this fact,” says Charlie Baker, former CEO of Harvard Pilgrim Health, now with venture capital firm General Catalyst.
Taking a patient-first approach to the population at the top of the pyramid is the first step toward change. Below, we describe two healthcare providers focused on distinct populations that have overcome today’s barriers to improve outcomes and reduce costs. Both of these organizations have taken out low-value-add activities while improving the patient experience and clinical outcomes.
CAREMORE: Rebuilding healthcare for frail elderly patients
CareMore exclusively serves a Medicare Advantage population, focusing its resources on the 15 percent of its patient panel that generates 60 percent of its healthcare costs. These are the frail elderly who are at risk of falling and breaking a bone or diabetic patients facing a potential amputation.
Medicare Advantage and risk-adjusted global payments helped to make CareMore’s patient-first business design really work. Fee-for-service cannot easily fix the problems in the top two layers of the pyramid because providers have no incentive to streamline care or cut costs. By receiving an age- and health-adjusted payment for its full patient panel, CareMore can allocate resources to provide the most overall value. In one case, as we’ve seen, that translated to buying air conditioners for frail elders during a heat wave.
A health provider for frail elders reduces costs by heading
off hospitalizations
The upside-down pyramid (Today): Cost by clinical segment
COST BREAKDOWN
PATIENT POPULATIONS
5%
20%
75%
45%
35%
20%
ER visits, overutilization,high care variation,
noncompliance
Infections, complications,rehospitalizations
Polychronic
At-risk for major procedures(e.g. cardiology, oncology)
Healthy,minor health issues
IMPLEMENT+HIGH+IMPACT,+MEMBERIFOCUSED+INTERVENTIONS
HELP+MEMBERS+MAKE+THE+RIGHT+CHOICES+FOR+THEIR+HEALTH/CONDITION
HELP+MEMBERS+SEEK+AND+RECEIVE+APPROPRIATE+PREVENTIVE+CARE+TO+MANAGE+THEIR+HEALTH+CONDITIONS
UNDERSTAND+(LIMITED)+++IMPACT+MEMBER+BEHAVIOR+TO…
ADDED+VALUE
WE’RE+UP+AGAINST+A+FORMIDABLE+ENEMY:+BIOLOGICAL+BEHAVIOR
BUT+FIRST+SOME+EXPERIMENTS
�10
Start+with+30+rats,+7+or+8+in+each+of+4+groups.+Hypothesis:'Too'much'carbohydrates'or'fat'in'the'environment'may'be'life'threatening
CARB Protein Fat
CARB Protein Fat
CARB Protein Fat
CARB Protein Fat
CARB CARB CARB
Fat Fat Fat
Protein Protein Protein
+
+
+
All+Do+Well
Half+Die
Half+Die
All+Do+Well
Source:'Tordoff'MG,'2002.'Obesity'by'choice:'the'powerful'influence'of'nutrient'availability'on'nutrient'intake.'American'Journal'of'Physiology'–Regulatory,'Integra\ve'and'Compara\ve'Physiology'282,'1536J1539.'
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Repeat+the+experiment+with+the+22+survivors+to+see+what+and+how+much+they+will+eat+and+the+effect.
CARB Protein Fat
CARB Protein Fat
CARB Protein Fat
CARB CARB CARB
Fat Fat Fat
+
+
Eat+a+third+of+each+and+do+well.
Eat+more+carbohydrates.
Eat+more+fat.
Human+Correlation:+We’re+impacted+by+availability/convenience.+We’re+programmed+to+maximize.
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Marshmallow+ExperimentGiven%a%choice%between%a%small%reward%now%and%a%larger%reward%in%a%later,%people%typically%opt%for%the%small%reward.
Our%Maximizing%Biology%(consume%or%do%now%the%future%is%uncertain)%strongly%affects%our%decision0making%in%ways%that%affect%our%health.
Luckily,%we%have%a%rational%brain.
BUT+HOW+RATIONAL+ARE+WE?
FALSE.+IT’S+A+MYTH.
INDIVIDUALS+ACTUALLY+UNDERSTAND+THEIR+OWN+HEALTH+ISSUES+AND+ACT+RATIONALLY+TO+ADDRESS+THEM+
TRUE+or+FALSE?
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67Changing patient behavior: the next frontier in healthcare value
than reaching those who need help before they can take proactive steps to improve their health.
What does good design look like? With regard to behavior-change interventions, three inno-vations appear to be most important.
Behaviorally based segmentation should be XVHG�WR�GHHSHQ�LQVLJKWV�LQWR�VSHFL¿F�JURXSV� Current approaches to patient segmentation and predictive modeling tend to center on clinical conditions. However, change inter-ventions are more likely to be successful if they take into account additional factors, such DV�D�SHUVRQ¶V�EHKDYLRUDO�SUR¿OH�RU�PRWLYDWLRQ� to change. These insights enable more focused targeting of the groups of people for whom impact is most likely to be achieved. They also make it possible to design programs that more H̆HFWLYHO\�DGGUHVV�SUDFWLFDO�EDUULHUV�WR�FKDQJH��
design of most health-related products, services, and interventions remains remark- DEO\�XQD̆HFWHG�E\�WKHVH�GLVFRYHULHV�LQWR�KRZ� humans make decisions. For example, tradi-tional clinically driven interventions assume that individuals understand their own health issues and usually act rationally to address them; however, this is often far from the case. In a survey we recently conducted, 76 percent of the participants with high-risk clinical conditions described themselves as being in excellent, very good, or good health (Exhibit 2). 3URJUDPV�WKDW�IDLO�WR�DFFRXQW�IRU�WKLV�JDS�EH-tween individuals’ actual health status and how they understand and experience their health on a day-to-day basis (and thus how willing they are to change their behavior) miss the boat in terms of design. Often, these programs simply attract individuals who are already “activated” to change their behavior, rather
Exhibit 2 Most people think they are significantly healthier than they are
7
24
33
12
2829 43
57 31
26 41
34 42
66 27
Respondents’ self-assessment of their health status by different risk categories,1 %
1Based on derived health profile.
Source: McKinsey Retail Healthcare Consumer Survey
BMI >30
BMI <30
Chronic
High-risk
Low-risk
Excellent/very good Good Fair/poor
Health International #12 December 2012 — Patient Behavior
Exhibit 2 of 2
SINCE+IT’S+HARD+TO+CHANGE+OUR+BIOLOGICAL+(INSTINCTUAL)+BEHAVIOR,+WE+NEED+TO+THINK+ABOUT+
CHANGING+OUR+APPROACH.
BUT+WHAT+CAN+WE+IMPACT?
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Policy%Making
Social%Factors
Health%Services
Individual%Behavior
Biology%&%Genetics
DETERMINANTS+OF+HEALTH
Diabetes+is+the+leading+cause+of+adult+blindness,+amputations+and+kidney+failure.++
True+or+False?
False.+Poorly$controlled+diabetes+is+the+leading+cause+of+adult+blindness,+amputations+and+kidney+failure.+
Let’s+jump+back+to+the+focus+of+what+we’re+trying+to+impact+through+behavior+change:+Chronic+Conditions
OLD+• Reactive+System+
• Treat+Acute+Illnesses+After+the+Fact+
• Treatment+finite+in+duration
NEW+• Centered+on+patients+
• Prevention+• Ongoing+management+of+chronic+conditions+
• Treatment+indefinite+in+duration
Paradigm$Shift
Behavior+Change+Can+Succeed:
MemberICentric+Paradigm
PRINCIPLES
Increasing+Burden+of+Illness
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TAKE+A+HOLISTIC+APPROACH+TO+A+MEMBERS+NEEDS
Contributions+to+Health+Status
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Other+12%
Genekc+13%
Medical+Care+34%
Behavior+41%
Source:'Kaplan,'Sallis'&'Patterson,'1991'Health'and'Human'Behavior
ADDRESS+BARRIERS+TO+THE+DESIRED+BEHAVIOR+CHANGE
INTERVENTIONS+THAT+TARGET+MULTIPLE+DETERMINANTS+OF+HEALTH+ARE+MOST+LIKELY+TO+BE+
EFFECTIVE.
Communication
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Care%doesn’t%stop%when%members%leave%the%doctor’s%office.%Communication%becomes%a%lot%more%important.
FREQUENT+FEEDBACK+AND+COMMUNICATION+ENCOURAGES+BEHAVIOR+CHANGE+
++COMMUNICATION+MUST+BE+TWOIWAY++
!
RIGHT+MESSAGES+AT+THE+RIGHT+TIME+AND+FREQUENCY
ACTIVE+COMMUNICATION
PROVIDE+CLEAR+ADVICE+ON+THE+BEHAVIOR+TO+CHANGE+
EVOKE+SELFIEFFICACY+(YOU+CAN+DO+IT)+TO+ENHANCE+CONFIDENCE
MEMBERS+MUST+FEEL+THAT+THERE+IS+HOPE+AND+BENEFIT+IN+DOING+A+GOOD+JOB+
EXPRESS+EMPATHY+TO+MOBILIZE+CHANGE
BehaviorIBased+Segmentation
+Organized+&+Intelligent+Outreach++
%Create%behavioral%segments%by%stratifying%members%by%selected%predictors%%Match%or%provide%the%right%intervention%to%the%right%member
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Additional+Data,+Additional+Insight
+Incorporate+as+many+additional+behavioral+insights+when+stratifying+the+population+for+outreach++For+Example:+
+Demographic+Data++Government+Program+Eligibility++++Zipcode++Resource+Utilization++Receptivity+to+Various+Types+of+Communication++Inclusion+in+Other+Programs++Family+Structure+(Social+Isolation)
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UTILIZE+DIFFERENT+CHANNELS+OF+COMMUNICATION
ENSURE+COMMUNICATION+IS+PERSONALIZED
BEHAVIORALLY+BASED+INCENTIVES+CAN+BE+USED+TO+ENCOURAGE+CHANGE
According+to+research,+disease+management+programs+designed+under+the+new,+patientI
centered+paradigm+can+reduce+costs+by+3X+to+5X+more$than+traditional+disease+management+
programs.+!
This+is+in+addition+to+gains+in+productivity,+retention,+better+outcomes+and+quality+of+life.
Source:'McKinsey'&'Company,'2012
If+this+sounds+like+something+you+need…
Check$Out:$$!
+SMART+Connect++SMART+Appointment+Scheduling++COMMUNITY+Link
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