Consequently, data modelers are partial to using mean scores since our models typically involve the entire rating scale as inputs.  However, our clients often prefer to measure ratings in terms of the percent of respondents who gave the highest rating (Top Box) or the percent of respondents who gave the two highest ratings (Top 2 Box).   In order to bridge the difference between models built around mean ratings and the need for results focused on top box and top two box scores, we researched how best to link these two concepts.

We evaluated numerous  studies, but focused on one particular study that contains two question batteries covering 21 separate items.  Each item uses a 6-point anchored scale where 6 means “Agree Completely” and 1 means “Disagree completely.”  Unlike many satisfaction studies, the mean scores are distributed over a wide range.  The lowest mean score is 2.07, and the highest is 4.75.

Raw data points from 21 questions

Rating frequencies compared to Gamma distribution

Variance in question ratings peaks in the middle of range

Estimated curve matches true data points

DSS has been collecting information on individuals’ health status and their satisfaction with their personal doctor and their health insurance company for the past 9 months as part of the DSS Health Care Engagement Index (HCEI)™.  The HCEI data shows a very weak, but positive correlation between health status and these two satisfaction measures.

• 0.133  Spearman correlation between self-reported health status and overall satisfaction with health insurance carrier (p = 0.001 in Q4 2011)
• 0.037  Spearman correlation between self-reported health status and overall satisfaction with personal doctor (p = 0.357 in Q4 2011)

However, the weak correlation indicates that their are many satisfied individuals who are in poor health.  Amongst those who rate their satisfaction with their health insurance carrier as a “10″ on the 0 to 10 point scale, 7% say their overall health is “poor” and 17% say it is “fair” while only 10% say it is “excellent.”

While desired positive correlations between satisfaction and health status are weak at best, negative correlations were found between overall satisfaction with their health plan and some health care usage measures.  Individuals who are more satisfied with their health insurance company have significantly more doctor visits (1.1 versus 3.1 visits per year) and significantly more overnight hospital stays (0.00 versus 0.59 visits per year).

Less than one-third of the individuals who consider themselves to be “definitely engaged“ in their health were classified by the HCEI as highly Engaged.   Almost half of these individuals who believe they are “definitely engaged” are classified as Involved and another 16% are classified as Reactive.

44% of consumers who said they are “not engaged” in their health when asked to respond directly to this question are also identified as Disengaged by the HCEI.  However, 39% of those who do not think they are engaged are classified as Reactive, or moderately engaged and 14% are classified one category higher as Involved consumers.

Likewise, 14% of consumers who think they are “somewhat engaged” in their health are classified by the HCEI as Disengaged and almost as many (13%) are classified as Engaged.

The table below shows a summary for this study.  All percentages are calculated down the columns.

Some of the most common terms used to describe an engaged consumer were:  research, active / involved, seek / seeking, doctor / physician, information, know or knowledge, regular / regularly, questions / questioning, ask / asking, and aware.

Four themes were each mentioned by at least 14% of respondents:

• Research health conditions, treatments, medications or the latest trends in health care (37% mentioned)
• Be active in the decision making for your personal health care (35%)
• Ask providers questions and follow their advice (16%)
• Visit a doctor regularly and participate in wellness visits (14%)

Some of the best individual comments are grouped into categories and listed below.

Straight forward descriptions:

• Being aware of what is healthy and good for you in all aspects of your life.
• Someone who seeks out the best of everything where their health is concerned.
• Someone who knows what they have, what they need, and how to get it.

Describes the tasks of an engaged person:

• A person who is aware of the type of medications they take and why.
• Someone who knows if their preventative health care is up to date.
• Someone who takes the effort to read labels on products and checks nutritional values.
• Someone who looks up information of doctors, asks friends for referals, is aware of any issues with doctor practices, knows if the doctor takes certain insurances, calls the insurance company about coverage, and claims, etc.
• Knows what health care costs; takes reponsibility for own health, takes maintenance medication precisely as directed, tries to minimize health care by preventative habits.
• One who keeps up on the latest in health care, eats right, exercises and visits their doctor annually.

Personally involved in their own care:

• Someone that is their own advocate for their health issues, you do the homework with all issues.
• One that is involved in their own health care, keeps up on the latest innovations, researches conditions they are said to have and actively involves themselves in their own treatment of said conditions, and regularly visit their doctor and writes down in advance any questions they want to ask.
• Someone who accepts responsibility for their health care; asking questions; participating in the decisions; seeking complete information; take a proactive stand.
• Someone who actively informs themselves about health-related issues and acts on the knowledge gained to improve their health.

Works closely with their personal doctor:

• Someone who keeps track of their health, understands what their doctors recommend, and takes their doctors’ advice.
• Someone who puts effort into the doctor they chose and what kind of health benefits they receive.
• Someone who researches any concerns and actively discusses issues with their providers.

Avoids reliance on doctors:

• Someone who is pro-active and seeks information about their own care and does not rely on doctors to know what they are doing.
• One that goes the extra mile to double check their doctor’s treatment, and advice.
• Someone who doesn’t just do what the doctor says, but does the research and asks questions as to why a particular treatment, or non treatment is best.
• Someone who actively researches doctors and treatments, who isn’t afraid to seek second opinions or ask for tests and treatments the doctor does not offer.

Cost and value considerations:

• Someone who checks the cost for medical treatments, checks their bills for errors and also tries to stay healthy by doing the right things.
• Someone that looks into health care to receive the best service at the best price.

Unrealistic expectations:

• A person who knows about every medical condition a person could have and the pill for every ailment.
• I believe that every American should be well informed of all charges being made by physicians and health care providers on behalf of each individual to help keep health care costs in line and to be an informed consumer.

Many stores are offering wellness and education programs, health risk assessments, and biometric screenings.   Some are offering physicals, flu shots and related preventive care.  Customers might have the opportunity to talk with a nurse, select a network physician or even receive medical care at the location.

Consumers can pick up ancillary benefits such as dental and life insurance at some stores.  These benefits are either sold through subsidiaries or benefit partners.

A few independent brokers consider the idea valuable enough to have established their own retail store to service their clients.

Here are some organizations currently offering retail stores:

• Bernard Health – Independent organization operating in Nashville, TN
• Blue Cross Blue Shield of Florida – 8 stores in Fort Lauderdale, Fort Meyers, Jacksonville, Miami, Orlando, Pensacola, Tallahassee and Tampa.
• Blue Cross Blue Shield of South Carolina – Mount Pleasant, SC
• Blue Shield of California – Opened store in San Francisco in November, 2011
• HealthPlan Headquarters – Independent organization operating in Baltimore, MD
• Highmark Blue Cross Blue Shield – Operates 8 stores in Pittsburgh and Central PA
• Humana – Operates 18 guidance centers in AZ, FL, IL, MN, MO, NV, OH, TN, TX and WI
• UnitedHealthCare – Huge center opened Nov 2, 2011 to serve the Asian community in Flushing, Queens.  Also operate stores in Chinatown, Hempstead, Long Island, Alhambra, CA, and Kingsport, TN
• Wellpoint – Opened a store in Littleton, CO in 2011 under Anthem name

• Public health insurance exchanges. They are an obvious source of uncertainty and research lately.  We have conducted numerous studies with employers and consumers looking at product preferences and likelihood to drop (employers) or not purchase (consumers) coverage.  We have tested the impact of changes in penalty levels, as well as, changes in federal and employer subsidies on consumer and employer choices.  We have also looked at the impact of branding, product naming and presentation order in terms of product selection in an exchange environment.
• Private exchanges. These are also getting some attention in terms of which employers are most likely to consider moving to a defined contribution or benefit allowance coupled with a private exchange that constrains product selection for employees.
• Ancillary benefits. Particularly how ancillary benefits can differentiate and add value in competitive situations like exchanges has been addressed in many recent studies.
• Risk attraction and adverse selection. This has also been a hot topic with clients either looking at identifying plan designs that attract consumers with more favorable risks or they are looking at measuring risk levels between themselves and competitors.
• Market segmentation in general and risk-based segmentation specifically. We are conducting more market segmentation studies than in years past.  Many clients have been looking at risk-based segmentation to segment their market and/or their current members on medical risks and related health status issues.  In some cases we are looking at conducting multiple studies on a target market to create product-based and risk-based segmentation solutions that can be executed independently, as well as, looking at the cross-section of these segments for very specific target marketing.
• Health care engagement. We have included the DSS Health Care Engagement Index (HCEI) in numerous studies related to segmentation (risk-based, behavior-based and traditional product-based segmentation).  The instrument has been useful in providing insights on members’ and prospects’ level of health care engagement, as well as,  providing benchmarks for these groups.  HCEI has been a core component in many segmentation studies looking to target less engaged, at risk members for interventions.
• Medicare star ratings. This has been top-of-mind for many clients, but as of yet, very few are tracking results year-round rather than waiting for the annual reporting period to determine if any changes have had an effect.
• Predictive modeling. We are using a lot more predictive modeling to score prospects lists and member databases with segment identifiers for targeted marketing.  Appended data from KBM and Acxiom has provided the data source for most of these models, along with clients’ available internal data.  We have also created models for Medicare and Commercial plans to identify potential disenrollees based on certain behaviors identifiable in claims data so that those individuals can be contacted prior to their disenrolling rather than trying to win them back after disenrollment.
• Network restrictions. Research around network reductions and tiered networks has also been prevalent as more carriers are forced to reduce network size due to contracting problems or are looking to gain more control over network costs.

The most “Engaged” consumers continue to be significantly different from “Disengaged” consumers.  The chart below summarizes some of the biggest differences between these two groups.  Almost all Engaged consumers have a personal doctor, have a wellness visit each year, eat healthy and visit a dentist while only one-half the Disengaged consumers have a personal doctor, one-third had a wellness visit in the past year and even fewer eat healthy or visit a dentist.

Significant differences between Engaged and Disengaged consumers can be seen in Q4 2011 HCEI.

Engaged consumers are much more satisfied with their health plan with 40% of them rating their plan a “9″ or “10″ on a 10-point scale and over 40% would “definitely recommend” their plan.  Disengaged consumers are much more likely to be obese (61%), to have had an ER visit in the past year (26%) and smoke cigarettes (43%).

Normally, we provide importance/performance matrices which plot the importance to patients and the relative performance of the physician/medical group/clinic on each item.  This approach points to specific things that need attention.  For example, if a particular item is highly important to patients and the particular physician or medical group or clinic is doing poorly in that area then that represents an area where improvement can have a high positive impact on the patient experience.

For example, in various studies, showing respect to the patient is important and physicians often don’t do well in that area.  If you want to improve performance in that area then the obvious question is how does a physician convey respect to patients?  To provide this level of guidance DSS conducts focus groups, using the quantitative results to give our clients more tailored guidance in the various targeted improvement areas.  Taking the “respect” issue, for example, some of the generalized results from one of our focus groups are discussed below.

Patients know their physician is listening to them through eye contact, tone of voice, paying attention, asking questions and answering their questions.  Listening carefully vs. showing respect – they basically overlap and go hand-in-hand and most agree that listening is a key component of showing respect.  Patients would like to have a say in their care.  It should be a two-way conversation, not a one-sided lecture.

Selected patient comments:

• He has always given me respect. We talk as friends. Although he is the expert, he still carefully listens to my thoughts and suggestions. If I ask him something that he is not completely “up” on, he actually takes the time to research the subject and discusses it with me on our next visit.
• It is much more than showing a simple concern for a particular ailment. My doctor makes sure that, not only is the specific ailment tended to, but that anything else that could be affected is tended to as well. Not just a simple cure, but an improvement to my quality of life. I think your term is just another way of defining caring.
• He always listens to me and tries to answer any questions or concerns I may have. He has a very good bedside manner.
• Listening carefully IS showing respect.
• Definitely, listening carefully is part of respect and good communication.
• These are all aspects of caring and serving the needs of consumers. There are entirely too many ways in which a medical consumer can be treated like a number – part of a herd. There is nothing more personal than touching another person’s body. Something this personal must be done in a caring and humane manner. I consider “listening carefully” and “showing respect” to be minimum expectations. If they are not met, I demand them. If my demands are ignored, I will take my business elsewhere.
• Listening carefully is a sign of respect. But even if your doctor listens carefully to you, it doesn’t necessarily mean they show respect for you or what you have to say. Some doctors are great at listening but they pass off your questions as obvious or silly. A doctor should show respect to their patients always and even if they think a specific concern or question is silly, they should never say so or act like it is.
• Yeah, I’d say listening carefully is definitely a part of showing respect. Because the opposite, not listening, would be very disrespectful.
• Listening is part of showing respect. But it also entails how they respond to you.
• By greeting the patient, showing concern, going over the last visit and discussing improvement actions.
• You talk, he listens. He asks for your thoughts and opinions and he takes them into consideration. If he doesn’t agree or has a different opinion, he explains why. He doesn’t just rush through everything, looking at his watch every two minutes.
• By showing respect they are listening to you and not lecturing, give you the options for your care and ask what one you think would be best and then he tells you what he would do.
• Spend the appropriate amount of time explaining conditions and treatments and allowing for questions and answer time. Not be in a hurry to get out of the room.

What is risk-based segmentation?

In the past, you might have categorized individuals by how they used the health care system and what services they’ve received, but that strategy only gives you part of the picture.   Risk-based segmentation uses current and prospective medical costs, health status, attitudes and level of health care engagement¹ to stratify individuals from any population – plan members, patients or employees.

Why not use claims data?

Claims data is useful, but can only provide a glimpse into the potential risks and rewards of your population.   The data can reveal the prevalence of disease amongst those who seek treatment, but it cannot identify which individuals have undiagnosed conditions and which ones are avoiding treatment.   Claims data can indicate which preventive treatments are being followed, but cannot tell you how best to engage each individual in their personal health care and which wellness programs and incentives will resonate with each one.

By the time you receive claims data, it could be up to six months out of date, and new health plan members could be halfway through a 12-month coverage period before you know anything about their health and potential risks.   Risk-based segmentation provides immediate, actionable results.

How do you use risk-based segments?

Individuals are assigned to an initial segment based on available internal information and appended third-party demographic and psychographic data.   Once segmented, you can quickly identify high-risk individuals who could benefit from personalized, immediate intervention.

To maximize effectiveness, you should interact with each individual based on their communication preferences.   Individuals that tend to put their trust in provider relationships are encouraged to visit their personal doctor to receive specific preventive tests and screenings.   Information seekers are given educational materials and opportunities to interact with like-minded individuals.  The most confused and disengaged consumers are targeted for personal contact from case managers and disease management professionals to maximize the return on these expensive resources.

As additional information becomes available through medical claims and other sources, the risk-based segment assignments are adjusted to improve the accuracy of each designation.

Key deliverables.

There are a number of outcomes from a risk-based segmentation project:

• Understanding of the risk profile of your population relative to the overall market
• Stratification of your population (and the market) in terms of risk profile, level of engagement¹, attitudes and product preferences
• Prioritization of individuals for maximum effectiveness
• Product design and benefit preferences for each segment
• Receptivity to wellness programs and most effective incentive options by segment
• Targeted marketing and communication approaches for each segment
• Segment attribution models to be applied for list scoring, face-to-face and Internet selling situations

Why we recommend risk-based segmentation?

Using claims data alone only shows you who already has a health problem.   Preventing future illness and medical costs by catching diseases early and getting consumers more engaged is the best way to manage and minimize risks within your member, patient or employee population.   Risk-based segmentation makes it possible to identify future medical risks, prioritize those individuals most likely to respond and communicate with them in a manner that reaps long-term benefits for them and your organization.

The world’s population has grown exponentially in the last 100 years, but the rate of growth has declined drastically in recent decades and is expected to continue decreasing through the middle of the 21st century. The world’s population first surpassed 1 billion people in the early 1800′s and 2 billion people around 1930. In less than 30 years, the world population topped 3 billion (1959). It took less than 15 years to exceed 4 billion people (1974), 13 years to reach 5 billion (1987), 12 years to reach 6 billion (1999) and 12 to 13 years to top 7 billion (2011 or 2012). However, current projections estimate that it will take at least 14 years to reach 8 billion people (somewhere around 2025 or 2026) and 16 more years to reach 9 billion people (in 2041 or 2042).

The charts below are based on US Census Bureau and UN population estimates.

World population growth spiked after 1900 and has just started to flatten out.

Rapid growth in world population is expected to subside in the next 40 years