Innovation at Insigne Health

9 -1 1 8 -0 4 2
REV: NOVEMBER 9, 2018
SRIKANT M. DATAR
LINDA A. CYR
CAITLIN N. BOWLER
Innovation at Insigne Health

It was mid-January 2017 and Elizabeth Quinby was preparing to lead her team’s first meeting
following two weeks of field research on behalf of Insigne Health (Insigne), a for-profit, integrated
health insurer/healthcare provider. Quinby was a partner at Hamilton Strategic Design (HSD), an
innovation strategy and design consultancy that worked with clients in the health and consumer
products sectors to develop and bring to market comprehensive digital and service experiences.
Caroline Hodgman, Insigne’s Vice President of Member Engagement, had hired Quinby’s team to
help her better understand Insigne’s member base and to create opportunities for Insigne to more
effectively engage their members in their own health and well-being. Quinby and her multi-
disciplinary team were now tasked with making sense of the data it had collected via various
qualitative and quantitative methods so they could make recommendations.
Doubling Down on Prevention

Insigne Health had operated in the mid-Atlantic for nearly 20 years and was recognized as an
innovator in the notoriously risk-averse and highly regulated insurance industry. It had grown from a
small experiment in community-based insurance and care into a regional player. After passage of the
Affordable Care Act (ACA) in 2010, Insigne focused on growth, acquiring new members and
expanding its provider network. For a variety of reasons Insigne was now shifting its focus to achieving
savings through operational excellence and increasing the overall well-being of its member base.
In its position as both payer and care provider for a large and diverse network of members,
prevention had always been a natural strategic objective for Insigne. However, in response to the
ACA’s requirements for coverage of preventative services, 1 Insigne modified its insurance plans to
eliminate co-pays for most screenings, increase reimbursements for clinicians who engaged in
prevention-related coaching, and promoted adoption of a preventative mindset among both patients
and providers. In the six years since, Insigne had registered a significant increase in preventative
screenings and treatments across its entire clinical practice.
HBS Professor Srikant M. Datar, Professor Linda A. Cyr (Harvard T.H. Chan School of Public Health), and Research Associate Caitlin N. Bowler
prepared this case. This case is not based on a single individual or company but is a composite based on the author’s general knowledge and
experience. Funding for the development of this case was provided by Harvard Business School. HBS cases are developed solely as the basis for
class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective management.
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This document is authorized for use only in Prof. Gitanjali Saksena's Design Thinking_09/06/2023 at SOIL School of Business Design from Sep 2023 to Mar 2024.
118-042 Innovation at Insigne Health
Focusing on Well-Being
Insigne positioned the insurance change as part of a larger effort to expand the conversation about
health and to shift members’ associations of health insurance from one of “sickness” to “well-being.”
Definitions of health tended to focus on individuals’ physical well-being, whereas definitions of well-
being were more expansive, taking into account other important facets of people’s lives. Insigne’s
leadership believed that by shifting members’ focus to well-being it could increase the overall health
of its insured population and decrease the resources it spent each year on delivering care (e.g., fewer
office visits, fewer drug prescriptions, tests, etc.).
The company used the Gallup-Healthways Well-Being Index (WBI) as a framework for defining
well-being. Built from decades of data, the index measured on a scale of zero to one hundred (0-100)
“Americans’ perceptions of their lives and their daily experiences through five interrelated elements: sense of
purpose, social relationships, financial security, relationship to community, and physical health.” 2 The model’s
structure accounted for the full context of an individual’s well-being of which physical health was just
one element. The components were interrelated and interdependent. Table 1 provides further
definition of each element of well-being.
Table 1 Gallup-Healthways Framework Component Definitions
Component Definition
Purpose Liking what you do each day. Motivated to achieve goals.
Social Having supportive relationships in your life.
Financial Managing your economic life to reduce stress and increase security.
Community Liking where you live. Feeling safe in your community.
Physical Having good health and enough energy to manage daily tasks.
Source: Gallup, “How Does the Gallup-Healthways Well-Being Index Work?,” Gallup Website,
http://www.gallup.com/185471/gallup-healthways-index-work.aspx, accessed February 13, 2017.
Launching a Mobile App

As head of member engagement, Hodgman knew that increases in individual well-being (WBI)
scores were associated with lower healthcare costs for those members. One study had shown that “for
every 1-point increase on a 100-point scale, individuals were 2.2% less likely to have a hospital admission, 1.7%
less likely to have an emergency room visit, 1% less likely to incur any healthcare costs and, if they did, incurred
1% fewer costs.” 3 An initiative for which Hodgman had won support from leadership was to launch a
mobile app—HealthTips.
When it first developed the HealthTips app, Hodgman’s team had looked closely at the work of
Nicholas A. Christakis and James H. Fowler on social networks and the spread of obesity. Christakis’
and Fowler’s research revealed how a non-contagious condition like obesity could spread through
diffuse social networks, even across indirect links (i.e., A knows B, B knows C, but A doesn’t know C),
where social ties were the mechanism of “transmission.” 4, 5 Hodgman and her team had hypothesized
that it could leverage the power of social connections to encourage healthy behaviors among Insigne’s
members.
From Hodgman’s perspective, the launch was partly successful; many members had engaged with
the app in a sustained way and reported (through the app) increases in well-being. However, uptake
had not been what she had hoped and she suspected that many of those who had engaged with
Innovation at Insigne Health 118-042
HealthTips thus far were actually the members Insigne was least concerned about from a future costs
perspective. She suspected that these members were somehow primed to engage with the app.
Hodgman tasked an internal team to gather data to test this hypothesis. A survey of current
HealthTips users and subsequent follow-up interviews with a subset of respondents revealed three
distinct user types:
• The first subset of users was healthy. Users in this group already monitored their health closely
and jumped at a free app that helped them do this.
• The second subset of users was also relatively healthy. Users in this group had previously not
paid too much attention to their health, but had recently decided to start paying closer attention.
• The third subset of users were not well. Users in this group had been actively managing chronic
diseases on their own. They adopted the app believing it would help them manage their
diseases more effectively and reduce complications.
Common to all these users was some level of intrinsic motivation to monitor their health, a
willingness to engage with a tool to do this, and comfort with smartphone technology. Based on these
data and further review of the usage patterns of the HealthTips app, it was clear the app was picking
up members who were on the extreme ends of the spectrum; at one end were the vibrantly healthy (i.e.,
the fit, athletic set), while at the other end were those managing chronic diseases or the more acutely
sick (i.e., unwell). In short, it captured the approximately 20% of Insigne’s members who could be
labeled “well” and the approximately 10% of members who Insigne had already identified as having
chronic diseases and was actively managing. Hodgman concluded that the app was not addressing a
wide swath of Insigne’s current membership.
Engaging the “Silent Middle”

Hodgman and Insigne’s leadership were especially worried about the 70% of members who were
“neither sick nor well,” but who might be quietly developing conditions that would eventually develop
into costly chronic diseases. This was the “silent middle.” According to recent estimates, people in this
group drove more than half of organizational healthcare costs, 6 so engaging them was critical to
Insigne’s long-term viability. One challenge was that many of these members rarely interacted with
their care providers.
Another challenge was that this population did not fall into a well-defined demographic bucket.
Individuals in the silent middle included men and women of all races and ethnicities, aged early 20s
through late 60s. They may have shared some physical characteristics (e.g., excess weight) or behaviors
(e.g., inadequate exercise), but not necessarily others. Some had never been concerned with their health,
while for others health had taken a backseat to other concerns, such as work or family, over time. Some
were interested in being more active and had time, but were socially isolated and resisted online
connections. For others, knowledge of the need for change was there, but the motivation required was
intermittent. When Quinby conducted research, she would seek to identify patterns by which to
segment Insigne’s silent middle according to their shared pain points, what they valued and what drove
their behaviors (i.e., motivators).
Addressing Modifiable Behaviors to Avoid Chronic Disease

Hodgman’s goal was to keep those in the silent middle from developing chronic diseases such as
heart disease or diabetes that accounted for over 85% of the nation’s healthcare costs. 7 Chronic diseases
were those that lasted three months or more and could neither be prevented by vaccines nor “cured”
by medication. Once present, a chronic disease did not just resolve itself, but required effective
management to reduce future complications associated with those diseases.
Many of those in the silent middle were on a trajectory to develop a chronic disease if they did not
make significant lifestyle changes. A growing body of research showed that chronic diseases stem from
a set of unhealthy behaviors—including lack of exercise, poor diet, and alcohol and tobacco use—that
are largely modifiable. These modifiable behaviors cause much of the illness, disability and premature
death associated with chronic disease:
• More than half of adults in the U.S failed to meet minimum recommendations for aerobic
physical activity with almost 40% engaging in little or no physical activity. 8
• Almost 40% of adults said they ate fruit less than once a day and over 20% said they ate
vegetables less than once a day. At the same time, over 70% of the population exceeded
recommended daily intakes of added sugars, saturated fats and sodium. 9
• Excessive alcohol use was also a major factor. About 38 million US adults reported binge
drinking an average of 4 times a month, and had an average of 8 drinks per binge yet most
binge drinkers were not alcohol dependent. 10
• Although far fewer Americans used tobacco than in the past, about one in five Americans (42
million) still smoked as of 2014. On average, a smoker cost an employer an additional $5,000
per year in healthcare costs and lost productivity, and nationwide, smoking was responsible for
nearly 9% of healthcare costs. 11
Hodgman was also concerned about increases in obesity within Insigne’s membership. These
increases reflected national averages. The National Center for Health Statistics found that about one
third of Americans meets the criteria for obesity 12 and, as of 2010, the Journal of the American Medical
Association reported that 16% of children aged 2 to 19 were obese. 13 Because obesity impacted the
prevalence and severity of many chronic diseases, these numbers had grave implications for the
nation’s future health—and healthcare spending.
The opportunity within these grim statistics was that, to some extent, individuals could change their
relationships to any of these activities.
Hiring Specialists and Framing the Consulting Engagement

While Hodgman believed she had a firm understanding of Insigne’s membership, she also
recognized that there was tremendous value in bringing in outside perspectives and capabilities. She
had worked with Elizabeth Quinby in the past and was always impressed with her thoroughness and
ability to design research that would lead to deep understanding of user needs and values, which in
turn led to actionable insights. On that basis, she hired Quinby and her team to help her understand
the silent middle within Insigne’s membership base.
Based on her work with other insurers and providers, Quinby encouraged Hodgman to broaden
the scope of the research to include Insigne’s providers as well. Specifically, she thought it was
important to understand the differences between what clinicians understood health and well-being to
be and what their patients in the silent middle might believe.
Mainstream conceptions of health traditionally focused on the absence of disease. Consequently,

healthcare providers focused on a well-defined set of physical characteristics that could be measured
and tracked over time, such as blood pressure, cholesterol, and weight.
Even as concepts of health became more holistic, evolving to account for mental and social health,
for the primary care physician a patient’s physical health was the primary focus. Tensions between
doctor and patient could, therefore, be expected. A physician could believe in a patient’s right to self-
determination and still feel strongly that the patient should lose fifteen pounds, improve his diet, and
get his blood pressure down. Quinby wanted Hodgman to understand when and how physicians’
perspectives might deviate from the patient’s desires, needs, and values.
Hodgman agreed with Quinby that it would be helpful to better understand providers and their
potential influence on the behaviors of the silent middle. In fact, she hoped that they might provide some
insight into why certain members did not take advantage of the generous preventative services Insigne
offered. With Hodgman on board, Quinby and her team designed a research strategy that would
involve first interviewing providers and then seeking to understand the silent middle through
interviews and generative exercises.
Interviewing providers In interviews with providers across the care spectrum, from primary
care physicians and nurse practitioners to specialists treating patients with complications from their
chronic diseases, Quinby’s research team heard a common complaint: Why did so few patients take action
to prevent the onset of chronic disease? (See Exhibit 1 for excerpts from provider interviews.) Seeing how
physically and emotionally difficult chronic diseases were for patients, providers struggled to
understand why a patient would not do more to prevent these diseases, even after being told exactly
where the patient was headed if they did not begin attending to their own health.
To gain a greater appreciation of the emotional intensity many of the clinicians spoke of in interviews,
Quinby asked her team to conduct secondary research that would give them a clearer picture of the
functional and emotional implications for patients of living with a chronic disease such as coronary artery
disease or diabetes. The team quickly recognized the significant burden effective “disease management”
put on both patients and providers. People with multiple chronic conditions were faced with managing
multiple prescriptions, carefully monitoring condition indicators (e.g., blood pressure, glucose levels),
and scheduling regular appointments with various providers. These required regimens were often
complex and led to patients feeling overwhelmed and stressed. In addition to the direct personal toll, this
also imposed burdens on their relationships with families and friends. Once Quinby’s team understood
this, the content of the provider interviews made much more sense.
Seeking to understand the silent middle Quinby’s team was especially interested in
understanding how those in the silent middle viewed and managed their own health and well-being.
What motivated them to engage in healthy behaviors? What hindered them from doing so? What did
well-being mean to them? To explore this broad set of questions, Quinby and her team developed a
research strategy that combined interactive interviews with a series of generative exercises (e.g.,
journaling, future-self) that challenged respondents to reflect more deeply on their current levels of well-
being, their aspirations for the future and barriers they faced in making positive change.
Quinby’s team conducted in-depth, interactive interviews with over thirty Insigne members in the
silent middle. Most of the interviews took place in members’ homes enabling Quinby’s team to observe
and interact with interview respondents in their natural environments. In addition, they video
recorded each interview, which allowed them to review the interviews for subtleties that they may
have initially missed.
They complemented the interviews with generative exercises that provided respondents the time
to reflect more deeply than they might in an interview setting. In the week prior to the interviews,
Quinby asked that respondents keep journals in which they made note of and reflected on day-to-day
experiences that affected their well-being. Another exercise that Quinby often found quite informative
was called future-self in which each participant first drew images and symbols that represented his life
and conception of well-being today, followed by a set of images that represented where he wanted to
be five years into the future. These hands-on, generative exercises enabled participants to express
feelings and aspirations in writing and visually that often revealed latent needs and unlocked
important insights regarding what motivated them and what they most valued. (See Exhibit 2 for
excerpts from the interviews and journaling exercises, and see Exhibit 3 for two participants’ drawings
of their future selves.)
Quinby and her team pored through the hundreds of pages of interview transcripts, respondent
journals and future-self drawings looking for insights that would help them develop design principles
and guide their ideation phase. As a first step in structuring their thinking, they clustered key quotes
according to components of well-being (e.g., activity, cooking & diet, etc). During this initial review,
they also sought to identify respondents who seemed to share similar pain points and to face similar
challenges in maintaining healthy behaviors. Although they had yet to develop full-fledged personas,
two distinct segments seemed to emerge which they labeled Segment A and Segment B. (Again, these
can be found in Exhibit 2).
Choosing a Framework of Behavior Change

Ultimately, Quinby’s team had to provide recommendations for how Insigne could engage the silent
middle. For many members, engagement would mean initiating behavior change around one or more
of the modifiable behaviors that drove chronic disease: inadequate physical activity, poor diet, tobacco
use, alcohol use and excess weight (a frequent by-product of these behaviors).
There was no shortage of models to explain and predict the process for individual behavior change
and seemingly little consensus as to whether one model could even capture the process. Each model
conceptualized behavior change somewhat differently; many shared causal factors, but emphasized them
in different ways. At one end of the continuum was a set of models focused narrowly on the individual’s
role in behavior change (e.g., BJ Fogg’s Behavior Model 14) while at the other were those that took a
broader scope that encompassed how multiple factors (e.g., social, environmental, and technological
contexts) interacted to shape individual behavior (e.g., Michie’s Behavior Change Wheel 15).
Researchers and practitioners constantly grappled with the tradeoff between a simpler model that
might not account for the full set of significant causal factors and a more comprehensive model whose
complexity made it difficult to apply. Quinby favored BJ Fogg’s Behavior Model. She found it to be
simple enough to readily explain to clients and yet robust enough so as to be actionable.
Fogg developed his model based on years of research conducted at his Persuasive Technology Lab
at Stanford University. He tested the efficacy of behavior change interventions derived from different
models and synthesized elements from each based on outcomes to arrive at his own model. Fogg
argued that three factors had to converge at the same moment for an individual to engage in a new
behavior: 1) motivation, 2) ability, and 3) a trigger. If a particular intervention did not lead to a behavior
change, Fogg’s Behavior Model suggested that one of these three conditions had not yet been met. 16
Figure 1 provides an adapted illustration of Fogg’s Behavior Model including several sub-
components that are critical to each factor. The model implies that motivation and ability can be viewed
as trade-offs represented by the action line. While it is desirable to push the action line to the right,
even if both motivation and ability are high, a behavior will not occur without an effective trigger. In
addition, the subcomponents play key roles in determining the levels of motivation and ability and
appropriateness of the trigger:
• Fogg identified three two-sided core motivators that are central to the human experience and
play a role in determining motivation levels: sensation (pleasure/pain), anticipation (hope/
fear) and belonging (social acceptance/rejection).
• Fogg often referred to ability and simplicity interchangeably and contended that ability is
enhanced when a behavior is easier to do. Several simplicity factors (e.g., time, money, physical
effort) play a role in making behaviors either easier or more difficult and therefore enhancing
or limiting ability. A key insight was that “simplicity is a function of a person’s scarcest resource at
the moment a behavior is triggered.” 17 For example, if one is extremely pressed for time, taking
even a 10-minute walk may become difficult. Similarly, what may seem like an easy amount of
money to spend for one (e.g., $20) may be prohibitive for another.
• Finally, triggers tell an individual to perform the behavior now. Sparks motivate behavior when
there is high ability but low motivation. Facilitators make behavior easier when ability is low
but motivation is high. Signals serve as reminders when both ability and motivation are high.
Figure 1 Adapted Fogg Behavior Model
Source: Adapted from: BJ Fogg, “A behavior model for persuasive design,” Persuasive ‘09, April 26–29, 2009.
https://www.bjfogg.com/
Determining Next Steps

As Quinby headed into her meeting with her team, she was confident they had gathered a lot of
valuable data that would help them develop recommendations that Hodgman and the Insigne team
could use to develop effective strategies for engaging the silent middle more effectively in their health
and well-being. That said, she recognized that her meeting with Hodgman was only three days away
and there was still a lot to do. A flurry of questions raced through Quinby’s mind:
• Who are the relevant stakeholders?
• How might the two member segments (i.e., Segments A and B identified in Exhibit 2) be
characterized as personas a?
• What pain points does each stakeholder and persona experience? How are the pain points
similar or different for each group?
• What key insights emerged from the design research?
• What design principles might these insights suggest to guide ideation?
• How does Fogg’s Behavior Model inform each of these questions?
• How else might the team gain a deeper understanding of the problem to instigate behavior change?
a Personas are a way to model, summarize and communicate research about users (e.g., patients) who have been observed. They
represent behavior and activity profiles that are context-dependent and enable the designer to focus on a manageable and
memorable set of characters. Source: “Innovating for People,” Pittsburgh: LUMA Institute, 2012, p. 34.
Exhibit 1 Excerpts from Provider Interviews
Primary Care Physicians, Nurse Practitioners, Physician’s Assistants, Nurses
Why did so few patients MD(1): Of course there is variation, but for the most part the patients I see are
act sooner to prevent aware that there are activities and behaviors that would help them feel
the onset of chronic better and have better health. Quitting smoking. Exercising. Eating
disease? healthier foods and controlling portions. Drinking less. Etcetera. They
may not be aware of just how harmful these behaviors can be, but they
get the big idea.
But change is hard. It’s frustrating for me as a clinician when patients

I care about don’t make changes that would help them, but I feel for a
lot of them. Change is especially hard when someone wants to change
and he’s surrounded by people who don’t share that aspiration. And
look, a lot of my patients are really stressed. Stress can make it harder
to consistently make better decisions about behaviors.
PA: It’s always been a bit shocking to me how little patients know about
some of these widespread conditions beyond the very, very basics. The
classic is diabetes. Most people understand that diabetes occurs when
the body can’t properly regulate sugar levels, that obesity is a big
factor, that sugar is bad, and that insulin is a treatment. But for most
people, knowledge does not go deeper than that. Even fewer have any
concept of how the disease progresses.
So unfortunately, some of our patients are really surprised when they

come in and find out that they are pre-diabetic. For instance, we had a
patient new to the practice who’d been a little overweight for many
years, and who, to her credit, had been trying to lose that weight for
years. When we saw her the first time we told her she was pre-diabetic
and that she had to make some changes or this thing would progress.
She was shocked. And I was shocked—that someone could be in the
system and be so unaware of the specifics of her current trajectory.
RN: I try to do as much education as I can with patients, wherever they are
on the continuum, from “at risk” or “pre-diagnostic” to somewhere in
the early stages of a condition. But wherever they are there’s a lot of
information to take in and it can be overwhelming for patients.
MD(2): I know it’s hard for people to make changes, but at the same time it’s
health—it’s really, really important. Chronic diseases can sound
boring and they can be hard to conceptualize because they can develop
so slowly, but these are really serious diseases. With life changing
impacts on people. I wish I could get more of my patients to
understand that.
Source: Casewriter.
Exhibit 2 Excerpts from Member Interviews and Journaling Exercises
Segment A
What is well- Well-being is happiness. It’s also about being fit and eating good food.
being?
My kids are at the center of my well-being. They influence me, and I influence them too.
Money is a big source of tension in our family, because it stresses my relationship with
my husband. The kids can feel that stress.
Some people at work treat well-being as something only self-centered people care about. I
believe the opposite. If I’m feeling calm and content, I’m a better husband, a better parent,
and much more effective at work.
Ultimately I had to choose between my work and my well-being. The culture at the office was
really awful and I did a lot of stress eating. I put on 30 pounds in three years. It took
almost a year to save enough to feel okay about leaving my job, but in the long run it was
the right choice.
Nutrition, fitness, and emotional happiness—that’s my personal definition of well-being.
Not being sick is a good place to start. And that goes for me, my kids, and my partner.
When any one of us is under the weather stress levels go up.
When I feel stretched, but not torn or frazzled, then we’re doing well.
I aspire to be a well-oiled machine so I can manage the family as well as possible. If I have an
achievable action plan, with enough flexibility to adapt to the unexpected, I feel okay.
Activity The kids love soccer and so do I, but my playing days are over. Physically I could probably
do it, but the last thing I need is a sprained ankle or torn ACL.
I walk around the neighborhood, but it’s hard not to think: Is this actually helping me at all? I
mean, I rowed in college. Walking for exercise feels like it just can’t be enough. I used to go
to the gym three to four times a week, but that not possible any more. My responsibilities
are to my family and work.
When I was a kid my parents came to as many of my games as they could. We didn’t have a
lot of money, but we knew we had their support. I’m the same way with my sons. I go to
all their hockey games—for four months a year hockey structures my life. If I miss their
stuff I feel really guilty.
I stopped going to the gym when I had my second child. I was able to get back to it pretty
quickly with one, but the second made it impossible. I just rejoined, because of the daycare
option. It was awesome to be moving and to see people I’d known from before.
The social aspect of the gym is great. Once I make time, I go and really enjoy it. The logistics
of getting there can be hard.
I finally got my bike out of the basement and tuned up. It was great to out for a ride. Now that
it’s done, I couldn’t tell you exactly why it took me more than two years to take care of.
10
Between the commute and the cost of membership, I finally ended my gym membership. I
just didn’t go enough to justify it.
Segment A (continued)
Cooking & I love going to the farmers’ market to get fresh produce. Almost every time I go I learn about
Diet some new vegetable from our region and the sellers are really friendly about sharing easy
recipes.
I’m like the creature of best intentions. Cooking healthy is always on my list of things to do
next week. Then next week comes and nothing changes.
I like to think we eat pretty healthy. Pizza, processed foods, butter are not typical at our house.
But beyond the most basic, I’m not sure I know what healthy cooking really looks like. I
could probably do better, but it’s got to be easy! If I’ve got 15 extra minutes I don’t want
to be reading a recipe.
Stress & My life is very full, but it can be chaotic. Kids, work, errands, the house, the dog, soccer
Sleep practice…you get the idea.
We run a tight ship in terms of time and money. It’s hard for me to justify a lot of the activities
I used to do to stay in shape. Convenience is actually pretty expensive.
Work is really weighing down my wife right now. She’s usually very upbeat, but with the
economy still slow everyone at the company is worried. Our relationship has suffered,
even though I really appreciate her situation.
Life has been stressful lately. I wish I could take more time for myself. Sitting with my sister
while the kids play is something that helps. It would be great to do more.
My kids are awesome, but they’re a lot of work! Work is a lot of work too. Now that the kids
are a little older I hope to have some time each week to do my own thing.
Life is tradeoffs. I love my family and I love to spend time with them. I just don’t do as much
of the stuff that helped me blow off steam a few years ago. That’s okay. You have to just
allow that to happen.
Sometimes I’ll leave my phone at home when we go away for the weekend. It sounds
counterintuitive, but after a few hours of feeling acutely disconnected, I end up feeling
better.
Sometimes I feel really overwhelmed at work. I cut back working out in September because I
didn’t have time, but not working out makes me stressed. My body gets really cranky.
I know I’m too busy when I’m rushing the kids.
My stress causes me stress.
Unhealthy Quitting smoking is definitely the hardest thing I’ve done. My family asked me to do it—
Behaviors actually, my daughter asked me to do it for her birthday. My whole family has really
supported me, including brothers in law and my sister’s older kids. It makes it easier to
be with the family knowing they want to help me succeed.
11
My husband and I generally don’t drink too much, but I know that the weekend beers can
add up.
Segment A (continued)
Social Life Most of my social life is built around the kids. I have a son and daughter and I go to their
soccer and basketball games.
My daughter is nine and she’s really active. She’s really fun to be around, so we do a lot on
weekends. We try to walk whenever we can.
Saturdays are game days for the kids. The games are fun and just competitive enough. For
the most part the parents have a good time on the sidelines.
I see my kids’ friends all the time. I wish their parents were my friends. That would make
things a lot easier socially.
Segment B
What is Well-being is low or manageable stress levels. You enjoy day-to-day activities. The good
well-being? outweighs the bad. You feel healthy and optimistic. I left my job because it was impacting
my well-being.
I think I am in okay health for my age. I want to stay where I am. That may not sound so
ambitious, but when the natural trajectory is decline it’s a reasonable objective. I don’t
want to become a burden.
I don’t really think of online communities as being a source of well-being. You have to spend
time with real people.
Having energy and feeling connected are the biggest pieces to well-being. Everyone gets there
a little bit differently.
No disease and minimal pain—also, fitting into my current wardrobe!
Feeling part of a community is important to me. I don’t do much online, because I don’t get
much satisfaction from it. But seeing friends in real life? That feels wonderful.
Activity It can be hard for me to stick to something. Challenges come up and it gets easier to stop than
to keep going. I definitely make excuses to myself. I wish I could change.
I know I have to find a way to get to the gym. I’ve tried Zumba and kickboxing and muscle
conditioning. But then Christmas came and I got too busy. I have trouble being consistent.
I get all fired up and then I lose steam. Whatever it is, I want to be consistent.
My dog is the only reason I exercise. He’s got to walk every day. I actually really like doing
it, but I know myself well enough to know that the gym isn’t for me.
My grandfather’s line was: “The road to hell is paved with good intentions.” If you replace
“hell” with “gym” you have me covered.
12
I’ve had a routine for years and it just hasn’t included exercise.
Segment B (continued)
I have a habit, I admit, of putting things off. Especially when something really interesting
comes along…and the alternative doesn’t require sweat.
In the past I’ve found gyms overwhelming. I definitely felt out of my league. I haven’t really
“worked out” since high school, so I guess it’s not that surprising.
I like doing things with people—friends. If I could find a friend who was committed and at
my speed, that would be amazing.
Some friends are much more intentionally active. They probably wouldn’t mind if I joined, but
there’s no way I could keep up.
Cooking & Weight watchers worked for me. People who knew I was doing it could be supportive without
Diet getting into the details.
High cholesterol and high blood pressure run in our family. My brother really watches his
diet to keep both in check. I have mine checked, of course, and I’m borderline on both
counts. I know I need to make a change. If I don’t start eating better, this will become a big
problem.
I love to cook and to entertain. My friends come over all the time. After a recent episode a
friend started a very low sodium diet. I want to do right by him, but I’m struggling to
adapt my cooking (which everyone loves) to his needs.
Last time I was at my doctor’s he recommended a heart healthy diet and gave me some
handouts, but I never really followed up. There was a lot to keep track of.
For some reason, the idea of revising all my recipes to be healthier is just not exciting. I know
I should, but I don’t want to change that much.
Stress & Life is both a lot of work and a lot of luck. I try not to sweat the small stuff and keep a positive
Sleep attitude.
Look, life can be frustrating. Sometimes it gets to me. Keeping stress in check takes effort, but
it’s important that I try.
Now that my kids are out of the house my stress levels have definitely gone down. Big time.
But I still try to manage them and do yoga in my living room a few times a week. That
really helps.
Unhealthy My husband loves beer. Ten years ago that was not an issue. But now when we visit our nieces
Behaviors and nephews they bring us to local breweries. This doesn’t seem like such a big deal, but
I’m uncomfortable with the role that alcohol now plays in our social life—and our diets.
I know I should go to the doctor, but I just can’t quite get myself there. I don’t think there’s
anything really going on with me.
13
To us, wine signals freedom. We have a glass of wine when everything else is taken care of. I
don’t think we drink too much, but I don’t know. I’ve certainly never thought to discuss it
with my doctor.
Segment B (continued)
I smoked for ten years. It was really, really hard for me to quit. I could definitely stand to eat
a little bit healthier, and to lose a few pounds, but I figure if I never smoke again then I’m
ahead of the game.
Social Life When I have more energy, I feel more optimistic and feel better. Seeing people and meeting
people, that gives me energy.
I see friends dealing with issues that are more and more serious. The last time I was at the
doctor, she said my blood pressure was high – that doesn’t sound good, but I’m not ready
to deal just yet and she didn’t push it.
Feeling part of a community is important to me. I don’t do much online, because I don’t get
much satisfaction from it. But seeing friends in real life? That feels wonderful.
Since the kids left home I’ve made a lot of new friends and acquaintances. I see people all the
time around town. It makes life fun.
Source: Casewriter.
14
Exhibit 3 Example Output from Future-Self Exercise
Source: Casewriter.
15
Endnotes
1 The Kaiser Family Foundation, “Preventive Services Covered by Private Health Plans under the Affordable Care
Act,”(August 2015), http://kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/, accessed
February 2017.
2 Gallup, “How Does the Gallup-Healthways Well-Being Index Work?,” http://www.gallup.com/185471/gallup-healthways-
index-work.aspx, accessed February 13, 2017.
3 Patricia L. Harrison et al., “Evaluation of the relationship between individual well-being and future health care utilization
and cost,” Population health management, 15, 6 (2012), 325-330,
http://online.liebertpub.com/doi/pdfplus/10.1089/pop.2011.0089, accessed February 2017.
4 Scott Stossel, “You and your friend’s friend’s friends,” New York Times, October, 4, 2009,
http://www.nytimes.com/2009/10/04/books/review/Stossel-t.html?_r=1, accessed March 2017.
5 Nicholas A. Christakis and James H. Fowler, “The spread of obesity in a large social network over 32 years,” New England
Journal of Medicine, 357, 4 (2007): 370-379.
6 Peter Goldbach, Hospitals & Health Networks, “3 Strategies for Reaching the 'Silent Middle' in Population Health,” February
16 (2017), http://www.hhnmag.com/articles/8059-reaching-the-silent-middle-for-population-health-success, accessed
February 2017.
7 Center for Disease Control, “Chronic Disease Overview,” https://www.cdc.gov/chronicdisease/overview/#ref10, accessed
February 10, 2017.
8 Center for Disease Control, “Chronic Disease Overview.”
9 Office of Disease Prevention and Health Promotion, “Chapter 2: Shifts Needed To Align With Healthy Eating Patterns,”
https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/current-eating-patterns-in-the-united-states/, retrieved
March 23, 2017.
10 Centers for Disease Control and Prevention, “Chronic Disease Overview.”
11 National Association of Health Underwriters “Healthcare Cost Drivers,” June, 2015.
12 Centers for Disease Control and Prevention, “NCHS Obesity Data,”

http://www.cdc.gov/nchs/data/factsheets/factsheet_obesity.htm, accessed January 20, 2017.
13 Center for Disease Control, “Nutrition, Physical Activity, & Obesity Data & Statistics,”
https://www.cdc.gov/healthyyouth/data/topics/npao.htm, accessed February 10, 2017.
14 BJ Fogg's Behavior Model, “What causes behavior change?” http://www.behaviormodel.org/, accessed March 2017.
15 Susan Michie, Maartje M. van Stralen, and Robert West, The behaviour change wheel: A new method for characterising and
designing behaviour change interventions, Implementation Science : IS, 6, 42 (2002), accessed February 2017.
16 Fogg's Behavior Model, “What causes behavior change?”
17 BJ Fogg, “A Behavior Model for Persuasive Design,” in Persuasive ’09 Conference, Claremont, CA, April 26-29, 2009.
16

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REV: NOVEMBER 9, 2018

Innovation at Insigne Health

Doubling Down on Prevention

Table 1 Gallup-Healthways Framework Component Definitions

Launching a Mobile App

Engaging the “Silent Middle”

Addressing Modifiable Behaviors to Avoid Chronic Disease

Hiring Specialists and Framing the Consulting Engagement

Mainstream conceptions of health traditionally focused on the absence of disease. Consequently,

Choosing a Framework of Behavior Change

Figure 1 Adapted Fogg Behavior Model

Determining Next Steps

Exhibit 1 Excerpts from Provider Interviews

Primary Care Physicians, Nurse Practitioners, Physician’s Assistants, Nurses

But change is hard. It’s frustrating for me as a clinician when patients

So unfortunately, some of our patients are really surprised when they

Exhibit 2 Excerpts from Member Interviews and Journaling Exercises

Nutrition, fitness, and emotional happiness—that’s my personal definition of well-being.

I know I’m too busy when I’m rushing the kids.

My stress causes me stress.

Exhibit 3 Example Output from Future-Self Exercise

11 National Association of Health Underwriters “Healthcare Cost Drivers,” June, 2015.

12 Centers for Disease Control and Prevention, “NCHS Obesity Data,”

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