by Richard Hamer, Steve
Runfeldt, Adam Johnson 08-Oct-2019
In
our previous post,
we provided a working definition of Social Determinants of Health (SDoH) as
“the non-medical obstacles that prevent people from being as healthy as they
can be”. We also noted that SDoH’s were associated with health outcomes,
but that they didn’t explain rates of negative health outcomes as well as
needed, if they are to become part of health organization operations. We
hypothesized that there are important intervening factors which we have termed
“Frames of Reference” and "Engagement".
We
define Frames of Reference as “internalized concepts and experiences that
predict health behavior”. Frames of Reference may depend on the person’s
upbringing, their circle of friends, education, and experiences with health
care.
In our
terminology, “Engagement” reflects the degree to which the individual makes use
of the health care resources that are available to them from their insurer,
their doctors, and society at large.
Introduction
SDoH’s
have become important concepts in many health care and insurance
settings. As insurers and providers are pressed to control costs and
unnecessary utilization, these factors seem to play a critical role in
understanding how to manage population health and how to deploy
resources.
To
understand SDoH better, Deft Research fielded its own survey to measure SDoH
and the intervening factors – Frames of Reference and Engagement. The
study captured 675 responses from persons with Individual and Family Plans
(IFP), Medicaid, or no health insurance (uninsured). All respondents were
between the ages of 19 and 64. The average income of the sample is very
modest – about $41,000 or 236% of FPL.
Our
purpose was to learn so that future research would be of greater value to our
clients. The first iteration of new research addressing this subject will
be published soon under the title, “Individual and Family Plans -- Member
Experience and Engagement”. Stay tuned for more on that study as it nears
publication.
Our
survey included the following:
·
Over 30 measures of Health Outcomes.
·
Over 40 measures of Social Determinants of Health.
·
Over 90 measures of Engagement.
·
Over 100 measures of Frames of Reference.
Our
analysis led to the development of five groups of people, based on how their
responses to the domains described above clustered together. Membership
in one of the groups means that the individual’s responses demonstrated a
pattern like the responses of other individuals in that group; they were
substantially different from the responses of members of other groups.
For
this blog, we are focusing on one specific group of respondents. And so
we don’t trigger any unintended associations, we’re just going to refer to this
group as “Group 1”.
Group 1
Group 1
is of interest to insurers and providers because of higher reported rates of
using emergency rooms, ambulances, and in-patient hospitalizations. About
one-in-seven individuals in this group (14%) has heart disease -- more than
twice the rate of the overall study sample. Individuals in Group 1 also
reported diagnoses of diabetes and depression at higher rates than others.
One of
our findings is different from many SDoH texts which suggest that the problem
with high-cost healthcare utilization arises primarily from
low-income populations. We find that Group 1 is not
particularly poor. Their average household income is $47,800, or 262% of
the Federal poverty level. On average, Group 1 is eligible for some
premium subsidy under the ACA, but not eligible for cost sharing
reductions. Group 1 obtains insurance primarily from IFP plans (40%) or
goes without (40%). Medicaid is not an option for most.
Group 1
is the most racially/ethnically mixed of the groups. About half are
White. One third are African American, one sixth are Hispanic, one eleventh are
Asian/Pacific Islander, one in fifty is Native American. The
average age of Group 1 respondents is 31.
Group 1
presents a challenge to those who would use social data to identify
sub-populations for health interventions. Under many methods, this group
would not be targeted because its income is too high.
But
Group 1 would be considered “adverse selection” by a health plan. Whether
having heart disease or not, about two-thirds of the group used an emergency
room last year, 40% used an ambulance, and half were admitted into a hospital
overnight. The problem does not appear to be lack of access to primary
care. No doubt, it is true that some groups have greater hurdles when
accessing care, but this study does not support that for Group 1 – the number
of their reported annual visits to a doctor’s office is close to average for
the overall population. The problem is not co-morbidities; Group 1 has
the same number of health problems as the average for the population, and fewer
than other groups.
Having
health insurance is a key to understanding emergency room use. Within
Group 1, those with no insurance were twice as likely as those with either IFP
or Medicaid to use emergency rooms. But, even Group 1's insured
have higher than average rates of utilization of these high-cost health care
services.
The
question might be asked, “Why is this inefficient and probably low-quality
health care a feature of Group 1 lives?”. We can point to insurance
and the costs of care, but there may be a better way to orient our
thinking. Asking, “How might we nudge Group 1 toward health services
usage that is better for them and would cost less?” could create a
more productive direction. The intervening factors of Frames of Reference
and Engagement are helpful.
Group
1’s Frames of Reference
Frames
of Reference: At their core, Group 1 knows about health, but views
themselves as failures in the effort to be healthy. The members of Group
1 tend to have family and friends who talk about healthy practices regarding
exercise and nutrition, but they do not themselves follow those
practices.
They
tend toward fatalism; for instance, they are likely to believe that people’s
abilities are static and unchanging over time. They tend to doubt that
exercise really affects their health. They are twice as likely as
average, but only at a rate of 10%, to think that their health is not their own
responsibility.
Those
in Group 1 are more likely than other groups to have a varying trust of medical
science. For example, they tend to believe that immunizations for
measles, mumps, etcetera are risky for people, but, in contrast, they believe
in the effectiveness of cholesterol medications.
Overall,
individuals in Group 1 are twice as likely to describe their own health as
“poor” compared to others their own age.
Group
1’s Engagement
Engagement: There
are several areas where Group 1 members are engaged in health resources
available to them. The group tends to like insurers’ websites and use online
patient portals about twice as much as the average for the sample. They
use mobile apps and wearable devices. They report that they are likely to
switch to insurance plans that offer gym discounts, other wellness programs not
associated with a gym, and mental health counseling. These individuals
were more likely to seek customer service using technology than through a
traditional telephone call.
Individuals
in Group 1 reported that in the recent past, they have researched provider
costs and doctor ratings – and they report reading health magazines.
Overall,
Group 1, feels like they know their way around the health system and have
relevant experience in navigation and decision making.
Conclusion
Group 1
creates a challenging picture for population health managers. They
frequently use the ER, ambulances, and hospitals, and consequently are costing
more, creating debts that will be a problem to collect, and probably receiving
poor quality care. Yet they are not the disenfranchised,
very low-income persons often pictured as candidates for health
interventions.
Frames
of Reference and Engagement measures provide keys to reaching Group 1. At
the core of their frame of reference is the understanding that they are failing
to keep themselves healthy. Messages to Group 1 will likely bear stronger
meaning if they use this theme. The group is more likely to engage
through websites, apps, and other technology than they are to seek traditional
telephone interactions. For this group, addressing the inefficient use of
health services may start with the theme and channels identified here.
For
more information please contact us at info@deftresearch.com.
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