The social determinants of health include behavioral issues that add to utilization and cost

Behavioral health is as much a part of the social determinants as where and how consumers live.

Behavioral issues, which reflect a person's mental well-being, can cause otherwise healthy, employed consumers to visit their physician numerous times or to see multiple doctors, without any apparent results, according to Eric Hamborg, co-founder and chief commercial officer for MOBE, a company that offers guidance to these heavy utilizers through their health plans.

"They're bouncing in and out of doctors' offices," Hamborg said. "The biggest surprise to me is how much these people are using the healthcare system and they're not getting any better."

MOBE works with high utilizer beneficiaries who are covered under their employer's insurance. These commercial plan members represent 5% of the population and spend 20% of the healthcare dollars, according to Hamborg.

This is compared to the population as a whole, in which 5% have complex or chronic health conditions that reportedly account for half of the annual healthcare spend.

"This is the commercial population," Hamborg said. "They have a good job and good health insurance. The social determinants affect those people too."

For example, one woman in her 20s went to see her physician because her hair kept falling out, he said. Providers ran a bunch of tests and found nothing wrong. Her physician began asking about her eating habits and she finally admitted she had an eating disorder.

"She wasn't willing to share that," he said.

They often have conditions that are not easily addressed but which can put them in a downward health spiral. Symptoms can include stress, not sleeping well and taking multiple medications. One person was found to be taking at least 15 drugs prescribed by 10 different providers.

But substance use disorder is a small part of what MOBE sees, according to Hamborg.

Not feeling good about themselves is a more common concern, but this type of complaint is a real challenge for health professionals.

WHY THIS MATTERS

High commercial utilizers can make up between 15 and 20 percent of the healthcare spend for insurers, according to Hamborg.

MOBE works with insurers to identify the population through claims and pharmacy data and then provides the identified individuals with one-on-one health coaching as an added benefit to their insurance plan.

MOBE takes full risk in contracts with insurers, such as with Blue Cross Blue Shield plans across the country. The company writes a reinsurance policy against the population.

"We fully guarantee we will save money," he said. "We provide guaranteed savings through a reinsurance policy. Essentially, large health plans pay us a reinsurance premium. If they don't see savings we would return up to 100 percent of the dollars."

This approach of combining behavioral modification with medical care is having a significant impact on outcomes and savings, according to Hamborg who claims MOBE has delivered over $50 million in savings since 2016.

SELF-RESPONSIBILITY

"There's a big portion that is patient responsibility, driven by the choices we make as individuals," Hamborg said. "It's a heated topic, there's a lot of talk around self-responsibility."

To get individuals to start making changes for their own benefit, the best method is to let them come to conclusions on their own.

"It's best when it's your idea and not our idea," Hamborg said. "We spend 20- to 25-minutes with people. We do story-telling."

These connections are done through the telephone and digitally, through an app.

"People prefer a digital platform and chat function," he said. "I believe we will expand that over time."

Often, the changes can be small, such as the realization that drinking more water, getting up from the desk and taking a walk - "sitting is the new smoking," said Hamborg - really do matter to health.

"It's small behavioral changes," he said. "We help people help themselves. We teach self-management skills. The core principles are how the mind and body work together. Be healthy, be more holistic, eat, sleep, move, smile. We share with them how to take responsibility for their own care and to stop running to the ER."

THE LARGER TREND

Health systems have long been aware of the cost incurred from what Health Affairs called "super utilizers."

Many super-utilizer program models seek to address common reasons for persistently high and avoidable use among individuals with multiple comorbid chronic conditions, such as medication nonadherence, poor health literacy, housing instability, substance abuse or narcotic seeking behaviors and mental health comorbidities, according to the Health Affairs study.

The study found that 82% of the super-utilizers had multiple chronic conditions; 41% had a serious mental health diagnosis; and 30% reported homelessness. However, the study also found that 18% of super-utilizers did not fit this common program profile.

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com