This document discusses strategies for understanding member behavior to maximize health outcomes. It notes that positive changes in individual behavior can significantly reduce chronic disease rates and healthcare costs in the US. Nearly 70% of total healthcare costs are heavily influenced by member behaviors, including poor medication adherence which accounts for $100 billion in avoidable spending annually. The document advocates for taking a holistic, member-centric approach that addresses barriers and utilizes principles like frequent communication and personalized, behaviorally-based incentives and interventions targeting multiple determinants of health to effectively change behaviors and manage chronic conditions. Research shows such new, patient-centered paradigms can reduce costs 3-5 times more than traditional disease management programs.

1. Understanding+Member+Behavior+
to+Maximize+Health+Outcomes
Omid%B.%Toloui,%MPH%
Senior'Director,'Product'Management'

2. “Positive+changes+in+individual+behavior+can+
reduce+the+rates+of+chronic+disease+in+this+
country.”++
!
0%The%Government…and%Most%Researchers
Source:%HealthyPeople.gov

3. “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

4. • US%Healthcare%Costs%Approaching%$3+Trillion%Annually
Source:'Osterberg'L,'Blaschke'T.'Adherence'to'medication.'N'Engl
2
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.

5. UpsideIDown+Cost+Pyramid
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.
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

6. 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…

7. ADDED+VALUE

8. WE’RE+UP+AGAINST+A+FORMIDABLE+ENEMY:+BIOLOGICAL+BEHAVIOR

9. BUT+FIRST+SOME+EXPERIMENTS

10. 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,'Integrave'and'Comparave'Physiology'282,'1536J1539.'

11. 11
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.

12. 12
Marshmallow+
Experiment
Given%a%choice%
between%a%small%
reward%now%and%a%
larger%reward%in%a%
later,%people%
typically%opt%for%the%
small%reward.

13. 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.

14. 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?

15. 15
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
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
ibit 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

16. SINCE+IT’S+HARD+TO+CHANGE+OUR+BIOLOGICAL+
(INSTINCTUAL)+BEHAVIOR,+WE+NEED+TO+THINK+ABOUT+
CHANGING+OUR+APPROACH.
BUT+WHAT+CAN+WE+IMPACT?

17. 17
Policy%
Making
Social%
Factors
Health%
Services
Individual%
Behavior
Biology%&%
Genetics
DETERMINANTS+OF+HEALTH

18. 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

19. 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

20. Behavior+Change+Can+Succeed:
MemberICentric+Paradigm

21. PRINCIPLES

22. Increasing+Burden+of+Illness
22

23. TAKE+A+HOLISTIC+
APPROACH+TO+A+
MEMBERS+NEEDS

24. Contributions+to+Health+Status
24
Other+
12%
Genekc+
13%
Medical+Care+
34%
Behavior+
41%
Source:'Kaplan,'Sallis'&'Patterson,'1991'Health'and'Human'Behavior

25. ADDRESS+BARRIERS+TO+THE+DESIRED+BEHAVIOR+CHANGE

26. INTERVENTIONS+THAT+TARGET+MULTIPLE+
DETERMINANTS+OF+HEALTH+ARE+MOST+LIKELY+TO+BE+
EFFECTIVE.

27. Communication
27
Care%doesn’t%stop%when%members%
leave%the%doctor’s%office.%
Communication%becomes%a%lot%
more%important.

28. FREQUENT+FEEDBACK+AND+COMMUNICATION+
ENCOURAGES+BEHAVIOR+CHANGE+
++
COMMUNICATION+MUST+BE+TWOIWAY++
!
RIGHT+MESSAGES+AT+THE+RIGHT+TIME+AND+FREQUENCY
ACTIVE+COMMUNICATION

29. PROVIDE+CLEAR+ADVICE+ON+THE+BEHAVIOR+TO+CHANGE+

30. EVOKE+SELFIEFFICACY+(YOU+CAN+DO+IT)+TO+
ENHANCE+CONFIDENCE

31. MEMBERS+MUST+FEEL+THAT+THERE+IS+HOPE+AND+BENEFIT+
IN+DOING+A+GOOD+JOB+

32. EXPRESS+EMPATHY+TO+MOBILIZE+CHANGE

33. BehaviorIBased+Segmentation
+Organized+&+Intelligent+
Outreach++
%Create%behavioral%
segments%by%stratifying%
members%by%selected%
predictors%
%Match%or%provide%the%
right%intervention%to%the%
right%member
33

34. 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)
34

35. UTILIZE+DIFFERENT+CHANNELS+OF+COMMUNICATION

36. ENSURE+COMMUNICATION+IS+PERSONALIZED

37. BEHAVIORALLY+BASED+INCENTIVES+CAN+BE+USED+TO+
ENCOURAGE+CHANGE

38. 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

39. If+this+sounds+like+something+you+need…
Check$Out:$$
!
+SMART+Connect+
+SMART+Appointment+Scheduling+
+COMMUNITY+Link
39

40. AltegraHealth.com
THANK%YOU.%
OMID.TOLOUI@ALTEGRA.COM%
310.243.6643%