A Q&A With Elizabeth Colyer: COVID-19-Related Effects on National, State Level Well-Being

The American Journal of Managed Care^® discussed nationwide, state level takeaways of Sharecare's Flatten the Curve survey with Elizabeth Colyer, senior vice president of Community Well-Being Index at Sharecare.

AJMC^®: Can you tell us a little bit about yourself and what is the Flatten the Curve survey?

Colyer: Absolutely, thank you so much for having me! I'm Elizabeth Colyer, I run the Community Well-Being Index at Sharecare and our Flatten the Curve survey was really about deploying a question set, as well as feedback to our respondents around really 3 or 4 core categories. One was around—based off their habits and behaviors if they were doing their part leaning in to really flatten the curve, and that was everything from whether or not individuals were being compliant to hand washing to staying at home, work from home policies, and various other mandates that we know were coming from the public’s health, as well as government sphere. So, that was 1 major category that we wanted to address.

Another was making sure that we were continuing to understand COVID-19 transmission, symptoms and rates, as well as habits that individuals were taking when they were experiencing symptoms. Everything from whether or not they were still exposing themselves to others if they were physically distancing, and how they were accessing care at that time. The last 1 core category as a foundational part to our philosophy, and really Jeff Arnold's philosophy around community driven care, we wanted to make sure that we had a pulse on individual's well-being or potential well-being changes that we're seeing. So, everything from impacts on mental well-being to financial and physical resilience, all the way through to issues, potential issues with health care and food access. So, that was really the goal of this. We will always—Sharecare is a highly data driven company that is community driven, care is a big piece of that and we always start our blueprint for change process by understanding the data, and more importantly, aligning interventions that are relevant to what we see in the data.

So, just a few examples of that—so, again, we never just want data for data sake, we always want to be able to apply that to an intervention. So, just to give a few examples of that, when we saw in the survey that 9 of 10 individuals were experiencing some form of worry regarding COVID-19, 66% or 2 of 3 respondents indicated that they were seeing or feeling some sort of financial worry regarding their retirement funds in the market overall. We worked with our partner, which is now actually a company that's part of the Sharecare family, MindSciences, to deploy their Unwinding Anxiety^® program for free for consumers starting in Arizona for 90 days. Again, just making sure that we're relating what we're seeing in the data to actually an intervention that will improve individuals access to care and well-being.

Another example of that was we saw that 60% of respondents indicated that they would prefer to seek care with their primary care physician. So, a lot of the telemedicine offerings that were out there were with providers that somebody doesn't already know and doesn't already trust, and we know that trust is a huge part of the health care system. So, we deployed a telehealth solution that really encouraged getting providers on the platform and to ensure that more providers were using digital means to be able to connect with individuals. Then, again, I think I could just continue to go on and on with sort of the results and how we tried to align protocols to that, but that's really our goal with Flatten the Curve was to understand what were the core needs, were people doing their part, what symptoms are they experiencing to ensure that we could align those to interventions that exist within the Sharecare ecosystem, as well as deploying new capabilities for consumers and for our enterprise partners.

AJMC^®: Can you tell us about the Sharecare Well-Being Index, the partnership with Boston University School of Public Health, and the purpose of the Flatten the Curve Survey?

Colyer: Yeah, absolutely. So, well-being is foundational to everything that we do at Sharecare, and where that started really was in 2007. Actually a company we acquired, Healthways, commissioned a study with Gallup to really move beyond analyzing just physical factors of well-being and really understand the non-physical factors most critical when it comes to major health outcomes that we know both individuals and our clients care about. What manifested from that study was the 5 elements of well-being. So, that's physical well-being, financial well-being, social, community, and purpose. So, over the course of 10 years we studied well-being, we have longitudinal data that's representative of 95% of the United States population, and truly the ability to contextualize individual risk factors and perceptions; but what we noted, what Jeff Arnold noted was that there was a missing component to that, and so we partnered with the Boston University, Dr. Sandro Galea is the head of their School of Public Health, partnered with them to create a next generation index.

So, we've spent about 9 months with their Biostatistics and Epidemiology Data Analytics Center collecting over 600 elements of social determinants of health data, to not only be able to contextualize what we've been able to achieve through well-being, which is a true understanding of those individual risk factors and perceptions that are critical to our overarching health and ability to achieve health, but really, to combine that with the circumstances that we know are so critical to whether or not an individual has access to live a healthy life to begin with. That's really what that social determinants component is about.

So, this summer, we'll be deploying a combined index that capitalizes on that intellectual property that we've generated through well-being, again, tons of peer-reviewed publications and understanding around well-being significance when it comes to everything from health care utilization to macroeconomic indicators like the S&P 500, combining that with our social determinants index to create a single variable and a single ranking in community well-being. Again, contextualizing somebody's individual well-being plus the circumstances of where they live, work, and play.

So, when we think about that, relative to what I just described around the Flatten the Curve survey, again, this is something that we're working towards this summer not only to understand what it was like pre-COVID-19, what was the state of our well-being at that time, but how have we seen that trend from October to date, October of last year to date, anticipating some declines, which we'll talk about why, but flatten the curve was really an interim approach as we move towards that ranking’s release to in very short order understand the needs of individuals and respondents across the country so that we can deploy those interventions. Again, as we prepare for a much broader release that will truly contextualize our pre-COVID-19 well-being status, as well as sort of how we've trended based off of the COVID-19 pandemic to date.

AJMC^®: What are the top takeaways of the Flatten the Curve results from a nationwide perspective?

Colyer: So, the first thing I say as a quasi statistician, mostly analyst is that we recognize these are not representative results. Our Community Well-Being index is representative, but we did have a very, very large respondent pool. Over 115,000 people have taken the survey to date so we do feel very strongly that we saw a sample size that was significant in at least contextualizing some of what our country's experiencing. I think there was probably 3 core things that I would call out, while there was a ton of things that came out of this survey, there's probably 3 that I would call out specifically.

One, I mentioned already, which was the mental well-being component of this, it cannot be discounted. Nine of 10 respondents, indicated they're experiencing some form of worry regarding COVID-19, and the 2 of 3 or the 66% is the percentage of individuals experiencing some form of financial worry regarding their retirement funds in the market overall. So, that's huge, right? That amount of worry, in particular, and again, it's not a 1 to 1 comparison, but in particular, when you look at our most recent Community Well-Being Index released where 38% of the United States’ population typically experiences some form of worry—that's a huge increase. That's something, even if it's estimated.

So, that's something that was hugely profound when it came to these results. Relevant to that, and looking at the connection between health and wealth, we saw that about a third of respondents were experiencing 1 of 3 financial stressors that we analyzed. So, beyond just broad financial worry, which I've just mentioned, there's sort of 3 financial stressors that are within contingency with Boston University that we dug into a little bit deeper. Those were issues with paying your bills, decreases in pay, and likelihood to lose your job, and about a third of people exhibited at least 1 of those, our respondents exhibited 1 of those financial stressors. What was pretty amazing was that of the people, any of those financial stressors created a much higher likelihood of also having a negative health behavior change. What we mean by that is that if you were experiencing—you had a decrease in pay, you lost your job already or you thought it was likely to lose your job, or you thought you're going to have issues with paying bills–that you either were eating less healthy, that you are sleeping less, that you are exercising less, that you are drinking more, or that you are smoking and vaping more. So, again, that incredible connection between health and wealth, I think was a major finding, again that we explored in contingency or in concert with Boston University.

Then I'd say that the last thing was really around access. I think it was pretty profound to see individuals indicating their likelihood of wanting to go see a PCP. Seeing that 67% of people were still going to the grocery store, to restaurants to get takeout. Again, these necessary things that were still keeping us moving in leaving the house and that we knew was still significant when it comes to the risk of COVID-19 transmission and social distancing. Again, we can't totally social distance just because of a lot of these necessary sort of components. So, I'd say those were sort of 3 major themes that stuck out to us. Those again, were a lot of what drove us to put an anxiety program that's free for consumers in concert with Blue Cross Blue Shield of Arizona to spin up a telehealth platform, and also to really think a lot harder about expanding and augmenting against our financial well-being suite of offerings.

AJMC^®: The ShareCare Well-Being Index has always taken snapshots at the state level. What are some state-level findings that stand out?

Colyer: So, I'll give you 2, and again, not that we can say that these are representative of the entire state, but we had about 2000, on average about 2000 respondents plus per state. So, we felt good again, that a lot of this was covering a population for which these results would be significant. I think 1 was really in Hawaii, just an incredible amount of financial worry that we were seeing there. Really even seeing Hawaii top the charts when it comes to declines in physical behaviors like exercise was also incredibly surprising to us. Hawaii is our star from a well-being standpoint and always has been. They rank first in the country and have ranked first in the country or very close to it in many years, as well as in financial well-being, they also ranked number 1.

So, to see the significant amount of financial worry we are estimating or assuming at this point that some of that is based off of the travel industry, some of it is based off of the culture there, but, again, that's some of those juxtapositions, these areas, Alaska and Hawaii, where we see very much being our well-being stars to see that level of stark contrast and starting to see some of the highest levels of worry and changes in physical behavior—that was very profound for us, at least again, based off of our experience.

I'd say the other thing and moving kind of to the other end of the spectrum when it comes to if Hawaii is our star, I would say states like Alabama and Mississippi haven't necessarily been stars in previous well-being index rankings, typically ranking in the last quintile, or the lowest quintile when it comes to our rankings. We saw that within states like Alabama and Mississippi that respondents in those states were the least likely to have adopted an additional negative health behavior, which was interesting, right? Because you think about ranking well into the 40s in physical well-being, seeing low levels of exercise there, high levels of obesity, and diabetes, all the things that you think coincide typically with negative lifestyle behaviors, but what we recognized in the way that we had positioned the questions was that it was about well-being change.

So, we were asking people relative to what you do or what you normally do, are you doing better or worse? So, there's a lot of theories that will unwind as we explore community well-being more specifically for the rankings released this summer, but our current theory or hypothesis around that is that many of the individuals just haven't changed their behaviors. So, it's not that they're getting—it's not that respondents in the states are behaving the healthiest, it's just that maybe they've kept some of the negative health behaviors that they were already participating in before COVID-19, and that they just really haven't therefore had a lot of change since that time.

So, again, I think those were probably the 2 things, seeing some of our stars, really, seeing some stark issues there with mental well-being and physical well-being and then kind of in the lowest areas seeing a really broad view of less negative change. So, the question is, and again, this will only unfold as the rankings release, as we start to get closer to that this summer, is are we going to see kind of states sort of coming more towards the middle, where we don't have nearly as much of a range or variability across states, because some of those states who were doing very well maybe doing worse, and the states that are doing the worst may be staying much closer to where they are.

AJMC^®: We’ve seen that COVID-19 is hitting particularly hard among people of color and shining a light on social and income disparities. How was this reflected in the survey results?

Colyer: Yeah, so we were very specific in this first iteration, being highly consumer focused and wanting individuals to feel very safe in their responses. We didn't ask specifically about income, we didn't ask specifically about race, and that was by intention. That's something that we do, do in our Community Well-Being Index because we do want to make sure that it is nationally representative, which of course requires waiting against those variables; but we did look at certain criteria to see how—as proxies for whether or not some of the social needs in potentially lower socioeconomic categories, and I think the biggest thing that came about this was when we compared respondents who had no health insurance to respondents who were on Medicaid to respondents who had private health insurance. I'll just give you a few examples of that.

One was individuals with no health insurance, were 8 times less likely to seek care during COVID-19 compared to individuals on private health insurance, which again is not surprising, but I think it reinforces the importance of having insurance and being willing to engage with the health care system, which I think has only been exacerbated during COVID-19. The other thing we looked at was Medicaid and some of those health behaviors because the broad assumption at this point across many individuals in the public health sphere is that there's going to be a higher percentage of people on Medicaid after this who are going to need support from the government to receive health insurance.

When we compared individuals on Medicaid versus individuals who have private health insurance, individuals on Medicaid were twice as likely to seek care via the emergency room (ER), and they were about half as likely to indicate that they would seek care during COVID-19 via telemedicine. So, when we think to the future, and again, as we said earlier, Sharecare’s always looking to pair data with an intervention—we're starting to engage with Medicaid across several states, and so our goal is to ensure that we're using that data to truly contextualize how do we ensure that those groups that don't necessarily engage as much with the health care system because they don't have health insurance, or moreover, because they're on Medicaid–that we're meeting that user where they are, that we're educating them on the benefits and importance of things like telehealth. In particular, if you're in a rural context or you're in a family planning situation, ensuring that that is an outlet that starts to get adopted more broadly, within every context, but in particular within the Medicaid population. Then we're also educating on things like ER utilization, which we know have been very big drains on health care expenditure at large.

AJMC^®: Can you discuss the impact that COVID-19 is having on sleep, including some of the differences at the state level?

Colyer: Sleep among other lifestyle behaviors was interesting. I think we anticipated really, really big changes broadly across the population when it came to lifestyle behaviors, and I think sleep, like many of the others, we saw that the majority or the vast majority of respondents indicated that they were sleeping the same. However, when we looked at the percentage who were sleeping more versus less, which we know is generally good, but can also be an indication potentially of sleeping too much—we did see that 23% of respondents were sleeping less, while 77% of respondents were either sleeping more or the same. So, again, I think that is going to certainly have an impact on well-being at large. We know sleep is incredibly critical when it comes to everything from mental well-being to co-occurrences that we see with eating and exercise; but I think broadly, seeing that 77% of people have been able to maintain or sleep more based on COVID-19, I would say is a silver lining.

AJMC^®: How about healthy eating and exercise? What are we seeing in those areas?

Colyer: So, I'd say again, and it was surprising to us that, yes, there are people who are eating less healthy, and yes, there are absolutely people who are exercising less; but broadly, the vast majority of individuals, again, similar to sleep in those categories, indicated that they were either eating the same, or they were eating more healthy than they were before. Then the same thing with exercise. So, we saw that a lot of individuals indicated that they were the same, exercising the same, or actually exercising more and I think we looked at that not only when it came to just broadly—are you achieving these healthier lifestyle behaviors? Are you able to maintain the same? But we also looked at it for groups who work from home versus groups who don't work from home.

We saw that working from home there was a significant difference in individuals who are able to work from home and being able to achieve some of these lifestyle behaviors or moreover, potentially not exhibiting some of the negative lifestyle behaviors. So I think, again, at large, there has been a change in lifestyle. There is definitely a connection between those individuals who are experiencing financial stressors and seeing negative lifestyle behavior changes, but I think we were very impressed at least throughout the month of April as we surveyed these individuals that a lot of people were able to maintain at least their same lifestyle behaviors or improve them during this pandemic.

AJMC^®: How can someone participate in the survey if they want to share what's happening to them during the pandemic?

Colyer: Yeah, so the survey is still live on Sharecare. If you go to our COVID-19 hub, you'll be able to access the Sharecare Flatten the Curve survey, and we would absolutely love that feedback and to continue to keep the momentum going, A) to ensure that we're all continuing to do our part even as states reopen, but also to make sure that we're managing our physical and mental resilience. We know coming out of this with a strong population well-being is going to be incredibly important.

AJMC^®: When should we expect to see the next round of results?

Colyer: So, as the world evolves, Sharecare is also evolving. Our thinking relative to what are the most critical questions for us to ask populations. So, while the Flatten the Curve survey is absolutely something we're still analyzing and looking at, and again, to support optimizing against our existing protocols, as well as how we can bring packages together to bring people back to work safely; but I think the next generation of results is going to be kind of 2-fold.

One is going to be, again, shifting beyond just—are we flattening the curve? Because we knew that that was incredibly important, but also understanding people's state of mind when it comes to readiness to go back to work. So, that's a huge thing that we're evaluating right now as we pulled together an employer readiness package that really helps employers to better contextualize, A) what are their employees, key fears, requests, desires as they go back and they re-enter normalcy, ‘normalcy,’ but also, what are the tools and assets. Again, replicating some of what we've done. So that's a huge next piece.

Then, as we've discussed, another major sort of suite of results beyond just evolving these surveys to understand user needs immediately is going to be our rankings released this summer, again, that will both comprise what was our 2019 state of well-being pre-COVID-19, but then also, how have we seen well-being trend throughout the year, and what will that mean for us in the future. Again, as we know, the financial ramifications continue to be real when it comes to job loss, pay decreases, and company closures. So, I think, the summer will only be the beginning of continuing to analyze the impact that COVID-19 will have on our national well-being.

AJMC^®: Lastly, is there anything else from the results you would like to add?

Colyer: I think everybody needs a good message these days. So, beyond some of the silver linings we've spoken to about the percentage of individuals who have been able to maintain healthy lifestyle behaviors or maintain/improve their lifestyle behaviors—I think something that we were very impressed by was that in spite of 40% of respondents having canceled vacations, in spite of the massive amount of stress that we were seeing, over a third of respondents indicated that they were experiencing feelings of gratitude. I think as we move out of this pandemic, the concept of community, community driven care, community well-being, and leaning in and volunteering and really contributing to the next phase of our reopening–I think those feelings of gratitude are going to go a long way, again, in people's mental well-being and contributions that we make to others and to our communities.