Behavioral Profiles report
What are Healthcare Utilization Profiles?
A person's needs, lifestyle, risks, preferences, and behaviors drive how (and how much) they utilize care services within the healthcare system. In response, Pivotal Analytics has developed proprietary Healthcare Utilization Profiles(TM) to help Pivotal users to gain a deeper understanding of a defined market’s distribution of healthcare utilizers and how that is likely to impact the mix, volume, cost, and location of care needed within that particular market, now and over the next 5-10 years.
These Profiles segment the population of a specific market into nine major healthcare utilization categories, each based upon an analytical methodology that uniquely integrates demographic, social/lifestyle, and clinical risk data.
Data Sources
We have partnered with UniteUs who combine consumer and clinical claims data to identify the characteristics that differentiate consumers with and without the risk, such as presence of a diagnosis. The specific attributes that are statistically significant and highly correlated are then used to predict presence of health behaviors and health outcomes based on consumer socio-economic and behavioral profile. The following sources were used to derive the insights:
Consumer data of 265 Million U.S. adults
Clinical claims across 400 million records
Public data of 1000+ health indicators
National plan market data of 8 years
Proprietary geo-spatial data of 125 million households
Survey responses of 1.3 million surveys
Nation-wide activity and investment data
Model Definitions
The two models used to create 9 behavioral profiles are:
High Cost - The likelihood of having high total cost of care in the next 12 months;
High Engagement - The likelihood to visit healthcare providers based on claims and clinical data set.
Utilization segments
Using the two models, the following utilization segments were built based on the US population and clinical claims data:
High Cost = Consumers in top 3 deciles (Top 30%) of likelihood to have a high total cost of care in the next 12 months
Medium Cost = Consumers in the middle 4 deciles (Middle 40%) of likelihood to have a high total cost of care in the next 12 months
Low Cost = Consumers in the bottom 3 deciles (Lowest 30%) of likelihood to have a high total cost of care in the next 12 months
High Engagement = Consumers in the top 3 deciles (Top 30%) of likelihood to visit healthcare providers
Medium Engagement = Consumers in the middle 4 deciles (Middle 40%) of likelihood to visit healthcare providers
Low Engagement = Consumers in the bottom 3 deciles (Lowest 30%) of likelihood to visit healthcare providers
Profile Segments
The following healthcare utilization segments were defined based on the methodology described above.
High Cost, High Engagement - Busy and Independent Super-Utilizers: Predominant age ranges between 50-54, this segment represents those who are in the middle of their career – with the thought of retirement in the future. This profile has the highest social need score of 58.2 due to their higher-than-average social barriers of food insecurity, housing instability, and loneliness. Despite their barriers, this segment makes sure to visit their Primary Care Provider regularly -as they are struggling with multiple conditions such as Asthma, Depression, and Pulmonary Issues. People in this segment are 41% more likely to use the Emergency Department for their healthcare needs. In Case of Inpatient Care, they are 36% more likely to get readmitted. They often have Medicaid Insurance.
High Cost, Low Engagement - Active, Healthcare Inattentive Retirees: Predominant age ranges between 70-79, this segment represents active retirees with a higher-than-average household income. People in this segment make up to 18% of the US population. Their financial stability makes fewer social barriers for this cohort- resulting in an SRG score of 34.7. However, due to age, most are living with a range of chronic conditions – such as Diabetes, Hyperlipidemia, Cardiovascular, Hypertension, and pulmonary disease. Despite this, the segment tends to not engage with their health care providers regularly. Lack of engagement places this segment into the highest category for in-patient and re-admission risk with 34% and 29% overutilization.
High Cost, Medium Engagement - Sunsetting Workforce: Predominant age ranges between 55-64, this segment represents those who are winding down in their career. A quarter of the population in this segment is in an ethnic minority and often insured through their employer or use Medicare Advantage. While they are thinking of retirement, many suffer from multiple chromobodies such as Diabetes, Cardiovascular Disease, and high cholesterol issues that may give them pause to exit the workforce. Their Social Risk Score is 46.9, slightly above the national average. Several social barriers such as transportation and food insecurity prevent this segment from visiting their healthcare providers as much as they should – which may result in costly trips to the hospital. This segment is 20% more likely than average to be admitted into an in-patient facility – and 35% more likely to be re-admitted within 60 days.
Medium Cost, High Engagement - Socially Vulnerable and Engaged: Predominant age ranges between 40-44, this segment represents busy full-time professionals who are moving along in their career. More than a quarter of the population is represented by ethnic minorities. Top Clinical Risks of this segment is Anxiety due to ongoing stresses, which may lead to a higher cost of care in the future. There is an elevated risk of financial insecurity and unemployment, which contributes to their high Social Risk score of 39.2. Elevated scoring may indicate future adverse health outcomes, which may lead to higher cost of care in the future. This segment is 12% more likely than average to use telehealth – although they also contribute to overutilization of an emergency department. This group has a high likelihood of being uninsured.
Medium Cost, Medium Engagement - Small Families Nearing Retirement: Predominant in the age range between 50-59, this population represents those who are starting to wind down in their career. As many are getting ready to send their kids to college and become empty nesters, they are looking forward to a more leisured lifestyle. With 34% of the population represented by ethnic minorities, people in this segment represent average risk across all categories. Their social risk score of 47.3 places them slightly higher risks of unemployment, food insecurity, and health literacy. Their healthcare engagement is primarily with their family PCP – with a possibility for occasional ED visits for an injury. Top predicted risks are HIV, Anxiety, Asthma, and Depression. Health Literacy risks may contribute to a higher-than-average re-admission risk.
Medium Cost, Low Engagement - Healthy and Active Empty Nesters: Predominant age ranging from 60-74, this segment represents those who are looking forward to their approaching retirement or have recently retired. They lead an active lifestyle, utilizing their free time by spending time with their loved ones or practicing hobbies. This segment has the lowest overall social risk score across all cohorts of 39.2. Despite their free time, they are not engaged with their health, elevating their risks in their future. Top Clinical risks for this group is Diabetes. They are prone to comorbidities –including an elevated risk of Hypertension and High Cholesterol. Lack of engagement on risks may lead to cardiovascular disease down the line and elevated admission risks in the future.
Low Cost, High Engagement - Young Professionals: Predominant age ranging between 25-34 years old, population in this profile is in the earliest stages of their career. They prefer spending their free time socializing, exercising, and improving skill sets to advance professional development. Their Social Risk Score of 50.3 is heavily influenced by this cohort's age and tenure in the workforce. They have many social barriers, such as financial insecurity and housing instability, running 36% higher risk of being uninsured. Being healthier than other segments due to age they are less likely to visit their healthcare provider. When they decide to see a doctor, they are more inclined to utilize telehealth for their healthcare needs than most other segments. The top clinical risks for this segment are Asthma and mental health disorders such as Anxiety and Depression, which may result in higher healthcare engagement over time.
Low Cost, Medium Engagement - Aspiring, Risky Professionals: Predominant age ranging between 25-34 years old, population in this profile is in the earliest stages of their career. They prefer spending their free time socializing, exercising, and improving skill sets to advance professional development. Their Social Risk Score of 50.3 is heavily influenced by this cohort's age and tenure in the workforce. They have many social barriers, such as financial insecurity and housing instability, running 36% higher risk of being uninsured. Being healthier than other segments due to age they are less likely to visit their healthcare provider. When they decide to see a doctor, they are more inclined to utilize telehealth for their healthcare needs than most other segments. The top clinical risks for this segment are Asthma and mental health disorders such as Anxiety and Depression, which may result in higher healthcare engagement over time.
Low Cost, Low Engagement - Steady Under-Utilizers: Predominant age ranging between 50-60 years old, this segment represents those who prioritize their lifestyle, jobs, and hobbies over healthcare needs. With 22%, this segment has the largest Hispanic representation. The low socioeconomic status is the top social risk for this profile. Their Social Risk Group score of 50.3 is heavily influenced by de-prioritization of healthcare engagement. The population in this segment has few predicted clinical conditions, resulting in deprioritizing seeing their healthcare provider on a regular basis. Lack of engagement may lead to an elevated risk over time.
Please note that the segment age ranges represent the highest concentration of ages within each segment, although each segment contains consumers of all ages.
Definitions and Recommended Uses
Social Risk Factors and Predictors | Definition | Recommended Use |
|---|---|---|
Social Risk Grouper (Score) | The Social Risk Grouper is UniteUs' proprietary framework to measure and address SDoH in population and identify vulnerabilities in your specific market.
| Total level of social and economic risk a consumer is exposed to, scored from 0 (low) to 99 (high). The SRG score is an early indicator of future adverse health outcomes. Social Risk Grouper national average is 46. A 10-point increase in SRG results in 13% change in total cost of care. The SRG score can be used to rank your market segments and prioritize developing strategies for the ones in the High risk category. The individual factors below contributing to the overall SRG score should be considered when developing specific strategies and tactics. |
Low Socioeconomic Status Risk | Measures a relative economic and sociological view of an individual’s work experience and family position based on household income, education and occupation. | Prioritize consumers most likely to be low socioeconomic status for financial wellness support and education on how to get most of their benefits. Measure the impact of low socioeconomic status on care compliance, missed appointments, and lack of engagement in preventative services. |
Food Insecurity Risk | Inability or difficulty in accessing health food or enough food, frequently as a result of limited funds or residence in a food desert. | Prioritize consumers most likely to have food access or affordability challenges for discounted fresh food or nutrition programs. Measure the impact of food insecurity on care compliance, ED utilization, and hospital use. |
Housing Instability Risk | Lack of permanent housing, inability to pay utility bills, or presence of housing quality risks (e.g. lead paint, mold, inadequate cooling or heating, high radon levels). | Prioritize consumers most likely to have unstable housing or temporary housing, rent support, or bill support programs. Measure impact of housing instability on care compliance, missed appointments, ED Utilization, and hospital use. |
Loneliness Risk | A subjective feeling of social distress, encompassing lack of companionship and a sense of not belonging; not adequately captured by quantitative measures of social isolation. | Prioritize lonely consumers - particularly seniors - most likely to be experiencing loneliness for social support and connection programs. Measure the impact of loneliness on hospital admissions, hospital readmissions, and ED utilization. |
Uninsured | Lacking consistent health insurance over the last 2 years, including those likely to voluntarily opt-out of insurance. | Prioritize consumers most likely to be uninsured or at risk of becoming uninsured for health insurance enrollment support and education. Measure the impact of being uninsured on care compliance, missed appointments, and lack of engagement in preventative services. |
Health Literacy | Degree to which individuals have the capacity to obtain, process, and understand health information, skills, and services needed to make informed health decisions and take informed actions. | Prioritize consumers most likely to have health literacy challenges for health benefits and health finances education and coaching. Measure the impact of health literacy on primary care engagement, proper insurance coverage, medication adherence, and ED utilization. |
Financial Insecurity | Lack of confidence in ability to manage financial matters, ineffective finance management. | Prioritize consumers most likely to be insecure financially for financial wellness or legal support services. Measure the impact of financial insecurity on primary care engagement, proper insurance coverage, and care compliance. |
Discord at home | Existence of issues in the home caused by co-residents, such as presence of smoking, drinking, drug-use, and violence. | Prioritize consumers most likely to have discord at home for children and family social service support. Measure the impact of discord at home on primary care engagement, care compliance, and ED utilization. |
Unemployed | Measures how likely an individual is to lose employment, by taking into consideration fear of losing job and relationships with co-workers; and likelihood of not currently have a job. | Prioritize consumers who are most likely to lose employment or not currently having a job. Measure the impact of unemployment risk on primary care engagement, care compliance, and ED utilization. |
Transportation | Lack of reliable transportation or the lack of easy public transportation to satisfy non-emergency transportation needs. | Prioritize consumers most likely to have transportation needs to help them get to the doctor, the grocery store, or other important locations. Measure the impact of transportation needs on primary are engagement, emergency department utilization, missed appointments, and care compliance. |
Unacculturated | Degree to which an individual of Latino-descent immerses in an Anglo-American lifestyle, representing activities of 4th generation Americans. | Prioritize consumers most likely to be unaccultured to US culture and lifestyle for tailored health services that align with preferred healthcare service consumption and in the preferred language. Measure the impact of unacculturation on health program and service engagement, system utilization, and consumer experience. |
Profile Descriptors | Definitions |
|---|---|
ED Super-Utilization | Predicting likelihood of being an Emergency Department super-utilizer (4+ visits) in the next 12 months |
Inpatient Readmission | Predicting the likelihood of hospital inpatient readmission in the next 12 months |
Likelihood to engage in telehealth | Identify consumer likelihood to use virtual medicine services |
Diseases | Predicting likelihood of consumers to have specific clinical diagnosis |