The authors used health care claims and survey data to identify a strategy that might promote life satisfaction while advancing equity in an insured population.
Objectives: To develop a strategy to promote life satisfaction with equity for a diverse insured population.
Study Design: Cross-sectional survey and claims analysis.
Methods: We conduct an ongoing survey of a stratified random sample of adult plan members. Among other questions, the survey asks about adequacy of physical activity, healthy eating, abstinence from tobacco, limited alcohol consumption, adequate sleep, and whether the respondent takes time to think about the good things that happen to them (hereafter referred to as “healthy thinking”). We assessed the association of demographic characteristics and the 6 behaviors with life satisfaction.
Results: We found that although all 6 behaviors were positively associated with life satisfaction, healthy thinking was the behavior associated with the greatest difference in life satisfaction between individuals who did and those who did not practice the behavior. We also found that although members insured through Medicaid or who had a psychosocial diagnosis tended to report significantly lower levels of life satisfaction, two-thirds of the opportunity to improve life satisfaction across the member population was among individuals with neither of these attributes.
Conclusions: The most effective strategy to promote both overall life satisfaction and equity will address social determinants for members with unmet social needs, provide the behavioral and mental health services that benefit members with these needs, and promote healthy lifestyles with an emphasis on healthy thinking for the entire population.
Am J Manag Care. 2020;26(10):e305-e311. https://doi.org/10.37765/ajmc.2020.88496
Examining our claims and member survey data, we found that taking time to think about the good things that happen is the behavior most strongly associated with life satisfaction. However, adults living in poverty, as indicated by Medicaid enrollment, and members with claims for psychosocial conditions have particularly low levels of life satisfaction. We conclude that the strategy with the greatest apparent potential to promote overall life satisfaction and equity in health plans similar to ours will:
Like many Americans,1 the majority of the individuals insured by HealthPartners are experiencing less-than-ideal levels of life satisfaction.2 Although individuals who are experiencing social conditions that burden health—like poverty, housing instability, and food insecurity—and psychosocial conditions—such as anxiety and depression—are particularly likely to report low levels of life satisfaction,3-5 we have found that individuals who are not experiencing these conditions can also suffer from low levels of life satisfaction.2 Promoting life satisfaction as a component of well-being is important to us because we share Atul Gawande’s perspective that “well-being is about the reasons one wishes to be alive.”6
To identify the optimal strategy to increase life satisfaction for the adults covered by our health insurance plan, we used HealthPartners summary measures of health and well-being data2,7,8 to address 3 questions: (1) Which health-promoting behaviors are associated with the largest differences in life satisfaction? (2) In addition to members experiencing poverty and psychosocial conditions, are there groups of members with particular medical conditions that would benefit from programs to improve their life satisfaction? (3) What strategy appears most likely to promote both health equity and overall life satisfaction for our membership? The answer to the first question is important because it guides the focus of our health promotion programs. The answer to the second question is important because it identifies members whose needs might not immediately come to mind. The answer to the third question will guide our overall strategy to increase life satisfaction for each individual member and across the entire member population.
MATERIALS AND METHODS
We conducted the analyses as part of our accountable care organization program to promote our mission “to improve health and well-being in partnership with our members, patients, and community.” The HealthPartners Institutional Review Board (IRB) reviewed the project and agreed that the intent is quality improvement, not human subjects research, and the project is thus not subject to further IRB review.
Population and Setting
Founded in 1957, HealthPartners is the largest consumer-governed nonprofit health care organization in the nation. HealthPartners provides a full range of health services including insurance, care delivery for medical and dental conditions, and health and well-being programs for 1.8 million members nationwide. The current analysis applies to health plan members who meet the following criteria: (1) continuously enrolled for a full year, with allowance for a 30-day gap in insurance coverage or discontinuance of enrollment due to death; (2) enrolled during 2015, 2016, and/or 2017; and (3) aged 18 years or older without upper limit. Among the members meeting these criteria, we excluded the following: (1) members known to prefer a language that is not English (less than 2% of our adult member population); (2) members having an address of a correctional facility, nursing home, or hospice (less than 0.002% of our members); and (3) members having their name on our health plan, research, or related do-not-contact lists (less than 1% of our members).
Assessing Covariates From Claims Data
In this analysis, we define psychosocial conditions according to the Johns Hopkins ACG System.9 The 3 most frequent psychosocial diagnoses among our members are major depression, anxiety neurosis, and tobacco use. A complete list of the ACG System psychosocial conditions is available in eAppendix A (eAppendices available at ajmc.com). We used coverage by Medicaid as a surrogate indicator of poverty.
Assessing Member Health-Promoting Behaviors With Surveys
As part of our project to track summary measures of health and well-being, each month our Center for Evaluation and Survey Research emails or mails a survey to a stratified random sample of members who meet the inclusion and exclusion criteria described previously. Table 1 presents the survey questions that are relevant to the current analysis and the definitions of meeting the behavior goals.
The Center contacts nonresponders sequentially by mail for email nonresponders and by telephone for mail nonresponders. We designed the survey sample to account for the differential nonresponse (ie, by gender, age, and type of insurance product) observed in prior iterations of the survey. We asked survey respondents to self-identify their ethnicity, race, and education. We collected the survey responses between July 1, 2015, and February 28, 2018, from the population defined previously. We weighted the annual samples to reflect the demographic and disease burden profile of the underlying member population in the year collected and then multiplied all survey weights by a constant in order to reconstruct the 2017 member population that met the inclusion criteria.
Defining Life Satisfaction With Surveys
We assessed life satisfaction with 1 question: “How satisfied are you with your life?” As in Table 1, the possible responses were anchored at 0, “not at all satisfied,” and 10, “extremely satisfied.” In order to prioritize organizational initiatives to maximize life satisfaction across the entire population, it is necessary to identify subpopulations with the lowest mean levels of life satisfaction, the size of those subpopulations, and a way to express the total burden of low life satisfaction for the subpopulations. The first 2 tasks are straightforward, but to estimate the benefit that might accrue from improving life satisfaction at both the individual and population levels, we needed to create the novel concepts of a “life satisfaction gap” and “life satisfaction points.” In this context, the life satisfaction gap is simply 10 minus the score the survey respondent has selected. For example, because the mean life satisfaction score for our reconstructed 2017 member population is 8.06 (Table 2), the mean life satisfaction gap would be 1.94. The potential life satisfaction points to be gained for a group of individuals are simply the sum, for all members in a group, of the individual life satisfaction gaps. For example, if we were interested in comparing the burden of low life satisfaction in 2 populations, one composed of 1000 individuals with an average life satisfaction score of 7.5 and a second composed of 2000 individuals with an average life satisfaction score of 8.0, the life satisfaction points lost for the first population would be 2500, which is 1000 × (10 – 7.5), and the life satisfaction points lost for the second population would be 4000, which is 2000 × (10 – 8.0).
We present descriptive statistics as means, 95% CIs, and frequencies. We limited the analysis to the 15,692 survey respondents who answered the life satisfaction question and all of the health-related behavior questions. Then, we used weighted general linear regression to model the relationship between (1) practicing or not practicing the 6 behaviors and (2) life satisfaction as a continuous variable, adjusted for the covariates that were available to us: time period, disease burden, age, gender, race and ethnicity, education, and insurance product. We subsequently dropped race and ethnicity and education from the equation because their β weights were not statistically significant (P > .05) (see eAppendix B for detailed results).
To test whether our β estimates were sensitive to the general linear regression model, we also used a tobit model to generate β estimates. Because the results were not substantively different, we do not report them. In the remaining analysis, we considered a score of 10 as “satisfied” and applied the results to the entire 2017 reconstructed member population. To estimate the potential reduction in the life satisfaction gap associated with each health-related behavior for our member population, we multiplied the parameter estimates from the general regression model described previously by the estimated number of members not meeting the particular health-related behavior in 2017. We used SAS version 9.4 (SAS Institute) to conduct the analyses.
To answer the final 2 questions, identifying medical conditions that are associated with a particularly large life satisfaction gap and the strategy or strategies most likely to promote both health equity and overall life satisfaction, we identified and visually compared the life satisfaction gaps associated with particular demographic groups and medical diagnoses.
The overall response rate for our survey in 2015, 2016, and 2017 was 42%. With the exception of responses to the alcohol question (9.2% missing) and the physical activity questions (8.9% missing), rates of missing responses to the health behavior questions were 1.5% or less. Only 193 respondents did not respond to the life satisfaction question.
A total of 83% of the survey respondents answered the life satisfaction question and all 6 health-related behavior questions. In addition to listing the number of survey respondents by demographic category, Table 2 displays the attributes of the 2017 member population reconstructed to represent these survey respondents. It also lists the mean life satisfaction score and 95% CI for each of the demographic categories. The 50-to-64-year age group is the largest of the 5, and only 9.2% of the members are 65 years and older. The remaining members are distributed relatively evenly over the 18-to-49-year age range. Although there are only slightly more women than men, the members are predominantly non-Hispanic White. Nearly half have a college degree. Slightly more than 5% are insured through Medicaid.
The overall average life satisfaction score is 8.06. With the exception of a significantly higher life satisfaction score for members 65 years and older, there is little variation in life satisfaction with age, and there is no significant variation by gender or race and ethnicity. Individuals who report having a college degree also tend to report a higher level of life satisfaction. Individuals insured through Medicaid report a significantly lower level of life satisfaction than those insured through another product.
Prevalence of Practicing the Health-Related Behaviors
In the reconstructed 2017 member population, just over 89% of the members reported meeting the tobacco goal and 88% reported meeting the alcohol goal (Table 3). Nearly 70% of the members reported that they meet the physical activity goal, and two-thirds reported meeting the sleep goal. Somewhat more than half of the members reported meeting the healthy thinking goal, but only about a quarter reported meeting the healthy eating goal.
Association of health-related behaviors with life satisfaction at the individual level. At the individual level and with adjustment for time period, age, gender, disease burden, insurance product, and the other 5 behaviors, practicing each health-promoting behavior was associated with a statistically significant higher level of life satisfaction. Healthy thinking was associated with nearly a full point of higher life satisfaction. Meeting the physical activity goal, the sleep goal, and the tobacco goal were each associated with a higher level of life satisfaction of about one-third of a point. The associations of meeting the fruit and vegetable goal and the alcohol goal with life satisfaction were about half as large, at 0.17 point and 0.14 point, respectively. The impact of these differences between the current average level and the highest possible level of life satisfaction translate into a narrowing of the gap by nearly 50% for the healthy thinking goal to less than 10% for the alcohol goal.
Association of health-related behaviors with life satisfaction at the population level. The life satisfaction point gap for our member population is 1,435,000 points. If our entire member population were to meet the healthy thinking goal, the population might experience a decrease in the life satisfaction point gap of more than 300,000 points (Table 3). Meeting the fruit and vegetable goal might reduce the point gap by almost 100,000 points. If everyone met the physical activity and sleep goals, the point gap might be reduced by around 75,000 each, and if all smokers quit, the point gap might be reduced by 24,000. If everyone met the alcohol goal, the point gap might be reduced by about half this amount. If all members adopted all the behaviors that they did not currently practice, the life satisfaction point gap might be reduced by as much as 600,000 points.
Association of Life Satisfaction and the Life Satisfaction Gap With Medical Diagnoses
Members with a dental claim have, on average, the lowest level of life satisfaction (7.48), but because the group is small (11,747), the life satisfaction gap is also small (30,000 points) (Table 4). The combination of a fairly large number (168,079) of members having a claim for a psychosocial problem and a low mean level of life satisfaction (7.49) gives this group of members the second largest life satisfaction gap (422,000 points). Although the life satisfaction gap attributable to musculoskeletal conditions is larger (523,000 points), it is due to the large number of members with conditions in the diagnostic category; unlike members with psychosocial conditions, they do not have particularly low average levels of life satisfaction (7.95).
The Potential Impact of Behavior Adoption on the Life Satisfaction of Selected Subpopulations
In Table 5 we present, for selected member categories, the number of members, their mean life satisfaction scores, and the life satisfaction gap associated with the member category. With a grand mean life satisfaction score of 8.06, the life satisfaction gap for our member population is nearly 1.5 million points. The subpopulation with the largest life satisfaction gap is members who neither are insured through Medicaid nor have a psychosocial condition. Their gap is nearly 1 million points. By contrast, although the mean life satisfaction score for our members covered by Medicaid or suffering from a psychosocial condition is significantly lower than average, the gap attributable to these members is about half the size of that attributable to members with neither of these attributes. Whereas the gap for members with a psychosocial condition constitutes about 30% of the total, the gap attributable to members covered by Medicaid is less than 10% of the total.
In this analysis we addressed 3 questions that are important for organizations like ours that are trying to increase the life satisfaction of their constituents while promoting equity: (1) Which health-promoting behaviors are associated with the largest differences in life satisfaction? (2) In addition to members experiencing poverty and psychosocial conditions, are there groups of members with particular medical conditions who would benefit from programs to improve their life satisfaction? (3) What strategy appears most likely to promote both health equity and overall life satisfaction for our membership?
Addressing the first question, we found that all 6 behaviors were associated with higher levels of life satisfaction when the target goals were met. However, practicing healthy thinking was far and away associated with the largest difference. Addressing the second question, we found that, aside from a small group of members with dental claims, members covered by Medicaid or having a psychosocial condition were the only ones with remarkably low average levels of life satisfaction. By contrast, we found that promoting healthy thinking skills for our members who were neither poor nor experiencing psychosocial conditions could significantly raise the level of life satisfaction across the entire membership. Based on these data, we conclude that the answer to the third question is multifactorial: We must address social determinants at a community level and social needs for members insured through Medicaid, provide special services for members with behavioral and mental health needs, and promote healthy lifestyles with an emphasis on healthy thinking for the entire population. Together, these will promote equity and an overall improvement in life satisfaction for our member population, in addition to meeting routine medical care needs.
It might not be surprising that healthy thinking—that is, often taking time to think about the good things that happen in one’s life—was the behavior with the biggest difference in life satisfaction between those who did and did not practice a behavior. However, it might be surprising to some readers that the largest opportunity to improve overall life satisfaction lies with the members who neither suffer from poverty nor from mental or behavioral health problems. This is simply due to the size of the group, not a particularly large gap on average.
Although the benefits of taking action based on this analysis are speculative, it has been clearly documented that individuals who practice health-promoting behaviors have high levels of emotional health and well-being.2,10-12 Randomized trials of interventions to increase appreciation, thanking people for even the smallest help and favors, and being kind to others have resulted in decreased symptoms of depression and increased expressions of happiness.13-15 Because healthy thinking increases life satisfaction, and life satisfaction has been found to be negatively associated with subsequent utilization of health services,16-18 we might expect that a program that promotes healthy thinking also reduces the seeking of health care. Conversely, individuals who have experienced, for example, adverse childhood experiences and historical trauma would be expected to have lower levels of life satisfaction and optimism.19,20
Any intervention directed at a broad population can, paradoxically, increase disparities. Our data demonstrate that the risk for this to occur is present for our own members. Coaching members who are suffering from the social burdens of poverty—for example, the inability to access a healthy diet or experiencing housing insecurity—to adopt healthy thinking strategies is probably unlikely to be effective and could be considered callous and insensitive. The same is true for members who are suffering from more than modest levels of anxiety and depression; they need help at a level commensurate with their burden. On the other hand, focusing on these 2 groups while ignoring the opportunity to improve life satisfaction for individuals who are not particularly suffering, but are also not thriving to the extent they might, is also not the optimal strategy because it would miss fully two-thirds of the opportunity to improve overall life satisfaction for the population.
These findings are reassuring for our organization. Although not driven by data as explicit as those presented in this analysis, HealthPartners has already started to address the social determinants of health as a community business model.21 Experience gained with this strategy underscores the necessity of developing partnerships with community organizations—both governmental and nongovernmental—because the sectors that influence health and well-being are so diverse and the resource needs are so great. These partnerships are much easier to develop when brand promotion is set aside. Although HealthPartners already provides intensive, high-quality case and care management services to patients with mental and behavioral health challenges and promotes higher levels of well-being and life satisfaction through its health promotion programs,22 it continues to seek and develop more effective solutions by addressing both social needs and social determinants. Among these programs are a partnership with Catholic Charities to provide housing and supportive services for the chronically homeless,23 partnerships with a broad array of community stakeholders to promote optimal brain development in all infants,24 and a partnership with a broad array of stakeholders to create physical and social environments that permit and promote physical activity and healthy nutrition for all children and their families.25
There are notable limitations to the inferences that can be made from the analysis we have presented. First, caution is always advised when attributing causality to cross-sectional associations; the extent to which reverse causality is present in our data cannot be determined but could be large. The fact that individuals with high levels of life satisfaction are more likely to seek preventive services26 suggests that they may also be more likely to practice health-promoting behaviors. Basing our analysis on a single question creates obvious limitations. We would have liked to have a far richer database, but we have found that the longer survey that would be required is less acceptable to our members. Without established benchmarks to indicate how much of a life satisfaction gap could be plausibly reduced, we explored extreme scenarios in which 100% of each specified gap is closed. Partial improvements would likely yield proportionally smaller benefits. Finally, our analysis is based on the experience of members who are insured through a commercial or Medicaid product offered by a single health care organization in the Midwest United States, are predominantly non-Hispanic White, are highly educated, and prefer English as their language of choice; thus, the findings must be generalized with caution.
We found that, although practicing each of 6 health-promoting behaviors was significantly associated with a higher level of life satisfaction, increasing the number of members who practice healthy thinking appears to have far and away the greatest potential to increase life satisfaction at both the individual and the population levels. With the exception of a small group of members with dental claims, the members most likely to report low levels of life satisfaction were those living in poverty, as indicated by enrollment in Medicaid, or who have a psychosocial condition. These data suggest to us that the most effective strategy to promote both overall life satisfaction and equity for our member population will address our members’ social determinants of health and social needs: It involves striving to reduce poverty and its impacts, provide behavioral and mental health services to benefit the members who need them, and promote lifestyle interventions with an emphasis on healthy thinking for all members.
Author Affiliations: HealthPartners (TEK, ML, JOT, KDC, JMG, NPP, SMK), Minneapolis, MN; HealthPartners Institute (TEK, JYZ, MMJ, NPP), Minneapolis, MN.
Source of Funding: HealthPartners health plan.
Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (TEK, MMJ, JMG, NPP, SMK); acquisition of data (TEK, JYZ); analysis and interpretation of data (TEK, ML, JYZ, MMJ, KDC, NPP); drafting of the manuscript (TEK, MMJ, KDC); critical revision of the manuscript for important intellectual content (TEK, JOT, JYZ, NPP, SMK); statistical analysis (ML, MMJ, KDC); provision of patients or study materials (JYZ); obtaining funding (JOT, NPP); administrative, technical, or logistic support (ML, JOT, JMG, NPP, SMK); and supervision (TEK, JMG, NPP, SMK).
Address Correspondence to: Thomas E. Kottke, MD, MSPH, HealthPartners, 8170 33rd Ave S, MS 21110X, Minneapolis, MN 55425. Email: Thomas.e.kottke@HealthPartners.com.
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