The Commonwealth of Massachusetts and MIT announced recently a joint initiative to tackle the enormous opportunities presented by Big Data. “The hour of big data has arrived in Massachusetts and it’s a very, very exciting time,” said Democratic Governor Deval Patrick. With a particular focus on creating jobs and promoting innovation, the initiative will be able to address some of the many questions posed by Big Data: How can we work smarter? How can we improve our processes? What are we leaving on the table?
The answers to these questions can be found precisely where the rubber hits the road: at the intersection of Big Data and business intelligence (“BI” or analytics). Moneyball, or the application of BI to uncover and leverage previously hidden or underappreciated data, is a concept already familiar to the Commonwealth. Almost a decade ago, former Boston Red Sox General Manager Theo Epstein borrowed its now-famous principles from Oakland A’s GM Billy Beane to bring Boston the first of two World Series crowns.
For Danvers, Massachusetts-based Eliza Corporation (“Eliza”), understanding Big Data and health care has always been a top priority. With over 700 million interactions with health care consumers under its belt, Eliza is mining its data to address through Health Engagement Management one of the most important questions in the health care space: How do we get Americans to make healthier choices? In order to understand this landscape more clearly, I caught up recently with Eliza’s Founder and Chief Visionary Officer, Ms. Alexandra Drane.
Alex, what makes it so difficult to engage health care consumers and modify behavior?
Often, it is what makes you strong that makes you weak. We in the health care space are very mission-driven people who want to change the world by helping people get healthier. That’s a good thing. But, because we have this obsession with health, we can project that onto the rest of the world, and fool ourselves into thinking every individual out there
Put this approach in perspective next to health care's competition – the food, tobacco, and beverage industries, which spend 200 times more in U.S.-based marketing than the health care industry. They have a much easier sell – sit down on the couch, eat a bacon double cheeseburger, and have a third glass of wine. Meanwhile, we’re saying, “Get up, don’t press snooze, go exercise, eat carrots instead of potato chips, and get your colon cancer screening.” We have a different problem to solve and we have to overcome a lack of both information and inspiration to get there.
The health care industry also is still very academic. We’ve grown up with peer review and double-blind trials in controlled environments that don’t necessarily reflect how real people think or live. Traditionally, the materials the health care industry has sent out to people—an informational brochure with a picture of a diseased kidney, for example—have had a certain finger-wagging dynamic to them and that can put people off. Individuals may feel condescended to on a problem that they’re really not inspired to address anyway – and since changing health-related behaviors is hard, we can be putting ourselves at a disadvantage out of the gate.
At Eliza, we know we have to push past that, and we do so successfully – even with some of health care’s biggest challenges. Let me give you a quick example. Patients who receive Eliza follow-up outreach after a hospital stay are 25% less likely to be readmitted to the hospital within 30 days of being discharged. Stats like these show that when Health Engagement Management is done correctly, we can have lasting effects on lives, and the health care system.
Where are you able to have the most impact? What segments of the population? Which diseases?
Overall, we’ve recognized a population-wide impact because we know that if you listen hard, people will tell you what they need to be inspired to make change. Sitting on top of more than 700 million interactions gives Eliza an opportunity to do a whole lot of listening, and we tailor our health engagement programs to those learnings in different ways—but always with a singular focus on improving an individual’s happiness, health, and productivity—regardless of their demographic, regardless of their condition. What we see is that if the message comes at the right time, using the right tone, and in the most appropriate medium, people will pay attention, and they’ll act accordingly. Some quick examples of our impact include:
- increasing the number of patients who get their recommended diabetes screenings by 76%;
- increasing colon cancer screening rates in a Medicare population by 137%;
- quadrupling participation in an online smoking cessation program; and
- we’ve even seen engagement among young, generally healthy individuals boost their perceptions of their health plans’ brands far beyond what more expensive, traditional advertising campaigns could deliver.
Understanding how engagement can vary by population segment is an important ingredient to effecting change – and segments don’t always reflect the big broad swaths that we sometimes cut, for example, grouping people simply because they have a condition. Specifically, let’s say that I have congestive heart failure (CHF). Naturally, that’s more likely to be top of mind because I can feel the negative consequences of this condition all day, every day. On an engagement level, we are successful if we can get people to start thinking about new approaches to their challenges. But in terms of creating outcomes for that particular population, it’s more difficult because they can be really, really sick. So, the success metric for the CHF population in particular might be to help them to stay home, to keep them out of the hospital, to respect their feelings and to keep them feeling as physically and emotionally positive as possible.
Now, let’s look at the other end of the spectrum – a young adult with high cholesterol. Most people with high cholesterol in its early stages don’t have any symptoms at all. Their lives are not defined in any way by their condition, and so, naturally, it’s more difficult to engage them in conversations about their health. Now, the fix for high cholesterol you could say is actually somewhat simple – just get them to take medication. But the process of telling someone that they’re
going to take medication—and maybe for the rest of their life—is a harder sell for the average American who wants to see him or herself as incredibly healthy. We’ve all seen the numbers showcasing how abysmal adherence rates are – hovering around 50% for most conditions. That’s because while the idea of telling someone to take a medication sounds easy, the reality of being the one who actually takes it every day—particularly for a condition that is asymptomatic—is quite the opposite. So while the engagement process for someone with high cholesterol is more challenging, and we might think that the treatment is simple, the actual process of getting someone to adhere to taking their medication in this situation is likely to be more difficult. But not impossible.
We tested many approaches and learned that a multimodal approach tailored to individuals’ barriers can be very impactful, in fact we saw a 16% increase in Statin medication adherence over a six-month period. Through that testing process, we also learned things like 58% of people think they can stop taking their Statin once their cholesterol is reduced. That is data we all should be paying attention to.
We also can share that we’ve found that the most defining and predictive variables driving health behavior are frequently not even associated with disease (as traditionally defined) in the first place. We call these The Unmentionables.
So net, net, it’s tough to offer a brief answer to your question about the success of different campaigns because they’re all so unique. We never presume that a broad-sweep solution is going to work on an individual level. That’s precisely why we come in and try to encourage an individual to share what’s specifically going on with them. We know that individuals need to be supported in ways that are tailored and relevant to them.
Eliza has moved beyond just speech recognition technology. But how does Health Engagement Management make up the gap that remains between it and speaking with a nurse, for example?
That's a great question. Technology is never going to be able to replace a nurse, or doctor, or social worker, or anyone else who has devoted their life’s work to helping people better manage their health and wellbeing. Period, end of story. And so Eliza’s job, because it cannot be a human, is to do the very best we can with the tools we do have – tools that enable us to recognize how to help each individual to the extent they need—and to link those individuals back to the supportive infrastructure that exists—including humans. For example, we can figure out on a mass scale the specific individuals who would benefit the most from having a conversation with a nurse or a doctor or a behavior specialist or a pharmacist, and in real-time we can connect them with those resources – resources they might not have known how to access otherwise. Surrounding a care team with trusted and time-tested technology that extends their reach outside the doctor’s office and creates more constant feedback and interaction is a key part of driving sustainable health behavior change.
After more than ten years of reaching out to people, we listen hard to the data and the emotion –you can hear the opportunity to help. And it’s not always a call – it might be an email, a text, a mobile app, or a pointer to a web site where individuals can connect with people ‘like them’. Eliza captures and respects the ability to tie everything back to the individual. Every communication, every utterance, every claim, visit, or mailing is tracked in a longitudinal way so we can see what each person responds to, specifically and individually.
For example, we can screen for indications of highly co-occurring conditions. Take diabetes, for example. It is highly co-occurring with depression, which can be critical. Someone who is depressed just may not have the personal capacity required to address their diabetes. And, so we often encourage our customers to let us screen for depression as part of our condition-specific outreach – providing crucial resources to a population that could really use the support. And we’ve learned how to do this effectively – because talking about depression is not necessarily a natural turn in a conversation. If we’re speaking with you about your diabetes, you might be uncomfortably surprised if we suddenly start asking you if you’ve been feeling down, depressed or blue. So, we open the topic by sharing with people that even though the questions we are about to ask may not seem directly related to diabetes, they are incredibly important to our ability to support them. We’ve found that not only does engagement increase, but in some cases over 50% of our targeted population screens positive for depression. This lets us offer optimal support, which can include transferring that individual to a behavioral health specialist, right at that moment.
How do you quantify Return on Investment (ROI) for your customers?
When you engage with people in conversations about their health and inspire positive behavior, two things happen. First, it drives people to do the right thing – whether that’s getting a flu shot, keeping up to date with preventive screenings, filling their prescriptions, or even just visiting a social networking site where they can share experiences with people ‘like them’. Second, the things we are focused on driving people to do have proven to dramatically reduce long-term care costs – not to mention positively impact satisfaction, quality of life, and loyalty metrics like net-promoter scores.
ROI isn’t just a matter of reaching out to individuals to change aspects of their health. It’s about using Eliza’s insights to help our customers establish legitimate, valuable, loyal relationships with individuals who then stay with them. Member retention is a key indicator. Since our customers are responsible for the dollars associated with health-related behaviors, our ability to create positive behavior change, in a way that sustains or builds brand loyalty, is enormously powerful for them.
Much of that insight comes from our proprietary technology and data assets. When we deliver back to our customers granular data about how people are behaving, they can use our business intelligence to redesign their strategies in a way that reflects how real people want to interact with the resources that exist – for example, some people don’t want help from their doctor, while others do. Some go online; others do not. Some are traditional; others favor holistic approaches.
We interact with a lot of individuals over time using technology that analyzes how people are behaving in that moment. It gives us an extraordinary amount of perspective that can be translated into better overall management of those populations – management that reflects how real people live and make decisions.
On the subject of data, how has data transformed Eliza’s mission and responsibilities? How has the playing field changed?
Data forces us and our partners to get really creative, really fast. We are sitting on a best-practices database and we listen hard to what the data tells us about how people want to interact when it comes to their health – learning what works and what doesn’t.
One of the most important consequences of access to data is that health organizations can no longer ignore the reality of people’s lives. For a long time, the health care space felt that if it educated people, they would act accordingly. But when you begin to amass large amounts of data about real behavior by individuals in the ‘wild,’ you discover things that are not explained by traditional economic theories. Guess what? Humans aren’t rational. We are extraordinarily complicated. That makes it difficult for health organizations to influence behavior if all they’re using are traditional means built around old-fashioned assumptions.
One of the challenges our industry faces is we presume access to large amounts of data also comes with a button that says “Insights”. In some cases, the volume of data is almost creating learned helplessness – now I have all the data I’ve always wanted to have and the answers still aren’t jumping out at me so I Give Up! The beautiful thing about millions of data points on millions of people is it highlights the challenges (but therefore also the opportunities) of getting real people to change their behavior in a sustainable, cost-effective way. I think we’re in the middle of a very messy period when folks are getting that just having a lot of data won’t get people to do what they should be doing when it comes to their health on a day-to-day basis. Data doesn’t magically make it possible for us to influence behavior. That’s so hard. We all have the best intentions and so too do the people we’re reaching out to. It’s about using data to better understand who people are in a way that reflects how they see themselves, then developing data-driving messaging approaches that actually inspire behavior, and finally, focusing all this power and intellect on solving problems that real people want solved, which aren’t always the problems the healthcare space focuses on.
Please tell me about The Unmentionables. What are they and how will they push the envelope in the health care industry?
The Unmentionables are at the heart of Eliza’s mission. The health care space needs to expand the definition of health to consider the influence on our health of factors such as workplace stress, financial stress, relationship stress, or the fact that you’re caring for an aging parent.
We started a research and analysis initiative designed to investigate the extent to which these things are influencing people’s lives – and therefore their health. Forty percent (40%) of people said that they were experiencing between four and six Unmentionables at any point in time; 95% said that they had at least one.
Then we asked them to define on a scale of one to seven (1-7) how much these factors were defining their lives. Most responses were pegged up toward seven and then when we asked how well they felt supported by the health care space on these issues, the responses were in the 1-2 range. This led Eliza to create The Ostrich Index, which measures the delta between how much something negatively affects your life and the support you’re getting for it. The Unmentionables are off the charts on The Ostrich Index.
The reason Eliza has become so obsessed with this notion of The Unmentionables is that when we look at our data for the past 13 years, it supports with laser focus our theory that such factors create bad health outcomes, negatively impact productivity, and lead to the misuse of health care resources – a direct counter to our mission to help people be happier, healthier, and more productive. We’ve also found that when you give people an opportunity to speak about these issues in non-judgmental way, individuals are eager to share the extent to which these things are affecting their lives. And they want help. Eighty percent (80%) of people want help from their doctor, health plan or employer on financial stress – 95% do for the stress of being a caregiver.
Quantitatively, the data shows that if you look at the combination of these unmentionable life challenges coupled with your positive and negative coping factors, you get what we call The Vulnerability Index. In fact, The Vulnerability Index is more than three times as predictive of a person’s self-reported health than traditional health factors, which is our industry’s default approach. We think this kind of impact can’t be ignored by those of us responsible for helping people live their happiest, healthiest, most productive lives. Imagine the ROI of an approach that not only allowed us to focus our limited resources on those who needed it most – but enabled us to capture attention and influence behavior because we were addressing the fundamental issues that don’t only drive actual health and productivity – they reflect the issues on which we are begging for help!
Is it fair to say that you need to make Health Care more seductive?
People aren’t sitting around waiting for the health care industry to lecture them into better behavior. We have to start learning from our brothers over in tobacco, food, and beverage industries who do a much better job seducing. We need to learn how to be worthy of the mind share that we are asking people to give us in our efforts to seduce them into making healthier choices on a daily basis. Our goal is to harness the incredible creativity and passion in all of us who are working so hard to effect change and to use that creativity and passion to bring joy and inspiration back into the conversation we are having with the public about their health and wellbeing. Couple that philosophy with a data-driven approach and you will be amazed what you can do.
How has Health Care Reform changed Health Engagement Management?
The Affordable Care Act has had a tremendous impact on our industry – we are being forced to respond to real problems with real solutions. No more fluff. If the industry can’t create measurable, demonstrable, sustained, better health outcomes, it won’t get paid. We had a meeting about seven months ago during which a health care executive stood up and told us, “Quite honestly, I don’t care what you do – you just need to get started doing it right now because if we don’t get these measurements up, we are not going to make a profit next year.”
Whether the Supreme Court upholds health reform or not, many of the changes being made in preparation have set off a sequence of events that will continue regardless – and that’s a good thing. Take the idea of health care exchanges. If reform is upheld, most people believe some version of the exchanges will come into play in 2014. Many would also say that even if reform is repealed, the idea of creating a transparent marketplace driven by consumer choice is an idea whose time has come. The idea of an exchange changes everything because historically, the way that health plans have gotten volume—the way that they have amassed lives to care for—is by selling to benefits managers based on cost, etc. The decision of which health plan to choose for coverage has not been up to individuals. Health insurers are realizing that if they want to stay relevant in a world driven by consumer choice, they have to be relevant not just to the benefits manager who previously purchased plans on behalf of thousands of individuals, but rather to the thousands of individuals themselves.
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I am the founder of BKC3 Consulting Group. Please follow me on Twitter @BenKerschberg and LinkedIn. Please also feel free to email me.
