1 Applying Six Sigma Principles to Drive Healthcare Behavior Change: Presented by: Todd Prewitt, Director of Clinical Operations/Medical Director, SHPS,

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Applying Six Sigma Principles to Drive Healthcare Behavior Change:

Presented by:

Todd Prewitt, Director of Clinical Operations/Medical Director, SHPS, Inc.

Louisville, KY

Jill D. Olds, Director, Global Benefit Strategy, Cummins Inc., Columbus, IN

Using Medication Compliance to Improve Healthcare Outcomes

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Objectives

• Introduce Cummins & SHPS

• Understand the Cummins/SHPS partnership

• Understand the importance of medication compliance and its effect on health outcomes and medical spend

• Share how the team used the DMAIC Six Sigma approach to address medication compliance

• Share the results of the project to date

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• Global company with over 36,000 employees (13,500 US) • Design, manufacture, distribute and service engines and

related technologies– Including: fuel systems, controls, air handling, filtration, emission

solutions and electrical power generation systems

• $13 billion in sales in 2007 – the role of Six Sigma

Cummins, Inc.

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• Healthcare strategy approach– Aggressive plan management

• Account-based plans

– Encourage a responsible partnership between Cummins and employees concerning benefit use and expense

– Address root cause of medical expense• Health status

• 2007 healthcare spend -- $176 million

Cummins, Inc.

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Cummins / SHPS Partnership

• Began: January 1, 2007• Annual Spend: $176 million• Cummins’ primary strategy: reduce short and long term risk

to the business and the employee • Medication compliance is an area specifically identified to

improve employee health

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SHPS

• Privately held firm with more than 600 clinical professionals and 2,200 employees

• Provides population health management services to large, self-funded employers– Utilization review– Case management– Disease management– Advocacy– Wellness services

• Serves 8.1 million employees• 78 Fortune 500 clients

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SHPS Engagement Model

Risk Analysis and Needs Identification

Enrollment and Engagement

Behavioral Change

Improved Health Outcome

Reduced Health Risk Index

Reduced Health Utilization

Net Savings

• Data-driven approach to health risk management

• Clinical, financial and lifestyle risk profiles for each member

• Holistic approach to health improvement

– Integrated stratification across clinical and lifestyle programs

– Care plans structured with individual member as focal point

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SHPS Health Risk Index

Proprietary risk index creates a member specific score to identify, measure, and manage the health of

members with chronic conditions.

2.963.102.85

0.00

1.00

2.00

3.00

4.00

Compliance 0.94 0.89 0.66

Rx Occurrence 0.32 0.31 0.33

Financial 0.01 0.00 0.01

Treatment Gap 0.09 0.09 0.23

Medication Compliance 0.55 0.51 0.44

Evidence Based Medicine 0.20 0.21 0.22

Utilization 1.00 0.95 0.96

Total 3.10 2.96 2.85

Risk Profile As of 04/2007 (Incurred thru 12/2006)

Risk Profile As of 10/2007 (Incurred thru 06/2007)

F-500

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Cummins Health Risk and Opportunity

• Cummins risk score is 15% higher than SHPS’ client norms

• Highest risk factors:

– Cardiovascular conditions

– Diabetes

• Outcomes for cardiovascular conditions and diabetes can be improved through disease management programs, personal health coaching, and medication compliance

Risk Opportunity

Reducing Cummins risk profile to typical SHPS client norms will contribute $6.2 million in annualized gross savings.

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• 2007 estimated U.S. cost of diabetes:– Direct medical: $116 billion– Total direct and indirect: $174 billion

• 2005 estimated direct costs of hypertension: $54 billion• Approximately 3.5% to 10% of the population have

confirmed diagnoses of type one or type two diabetes– Depending upon the demographic mix of patients

• Healthcare costs for a diabetic patient without co-morbidities are at least 2.3 times higher – As compared to a non-diabetic patient of the same age-sex stratum

The Six Sigma Project

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• The combination of diabetes and hypertension were selected based on the following criteria: – Member sample was statistically significant – Medication protocol was well-defined

• Research literature indicates intensive hypertension control reduces the costs of complications an average of $4,836 over the patient's lifetime. – Deducting $4,060 in intervention and treatment costs, the incremental

savings is $776 per person or $1,132,184 for the Cummins sample

• Meta-analysis research into the economic value of glycemic control indicates per member per year cost-savings between $672 PMPY to $2,647 PMPY. – Potentially, this translates into an annual compliance-based cost savings

between $980,448 and $3,832,793.

The Six Sigma ProjectThe Six Sigma Project

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Baseline Information on Members with Diabetes and Hypertension

• Standard protocol recommends that patients with these conditions should have either ACE Inhibitor or ARB or both medications

• Potentially 38% of patient population were not receiving these medications

• Defect rate was 1.8σ

Total Members with:

Total MembersACERx

ARB Rx

Both ACE and ARB

% of Total Receiving Rx Treatment

Diabetics with Hypertension 1,139

525 239

57 62.07%

Cummins Population FY2006

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Measure Phase

• Cause/Effect Diagram→ Identified four possible

causes •FMEA

→ Confirmed first four causes and added one

Fishbone Diagrams→ Funnel down to likely root

causes for data selection

MedicationNon-Compliance

Lack of Adviceon Specific Medication Health Plan Design

Side Effects Cost ofMedication

Physician does notPrescribe

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• Sources of data used to test hypotheses– Historical pharmacy data and demographic data

• Continuously eligible over 17 months, n = 1,459 members– Nurse call records for those members who were enrolled in SHPS

programs, n =323 members– Survey instrument sent to currently active members of the target

population, n = 910 members• Members who were both compliant and non-compliant• Purpose to support or modify the hypotheses• Survey response rate was 28%

Analysis Phase

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Hypothesis One: Lack of Advice on Specific Medication

Statistically higher compliance for those who are enrolled in the SHPS programs, p<0.05

Slightly higher compliance by those who have visited the Cummins Health Center

Survey results: 99% of those responding and on an ACEI or ARB agreed with the statement:

“I understand the reason why I was prescribed the medication”

0

100

200

300

400

500

600

Enrolled Not Enrolled

Population

Compliant

Non-Compliant

SHPS program enrolled population was 61% compliant compared to 51% of non-enrolled population.

When analyzed over period of 17 months controlling for other variables this was confirmed as statistically significant.

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Hypothesis Two: Plan Design

No statistical difference found in compliance based on plans for 2007 or 2008

Survey results:

99% of those responding and on an ACEI or ARB either strongly disagreed or disagreed with the statement:

“I find it difficult to refill my medications due to my insurance plan.”

There is no statistical difference in compliance based on plan type for the 2007 or 2008 plans.

New plans were introduced in 2008 population seems to have moved to plans that suit their needs

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Cummins Inc., Confidential & Proprietary

Compliance and Non-Compliance by Benefit Plan

Non-Compliant Compliant

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Hypothesis Three: Side Effects

No evidence of side effects as an indication for non-compliance in reviewing nurse records or in demographic population analysis

Survey results:

99% of those responding and on an ACEI or ARB disagreed with the statement:

“The medication has too many negative side effects.”

• The following summarizes the typical side-effects of ACE inhibitors and/or ARBs

– persistent dry cough

– dizziness

– GI side effects

– headaches

– rash

– fatigue

– impotence

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Hypothesis Four: Cost of Medication

No statistical evidence of salary impact on compliance over the period analyzed.

Survey results:

90% of those responding and on an ACEI or ARB disagreed with the statement:

“I find the cost of this medication a major reason I do not take this medication.” 0

510

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0 50000 100000 1500000 50000 100000 150000

Compliant Non-Compliant

Percent

normal Salary

Perc

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ompl

aint

/Non

-Com

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2008 Salary (Dotted line shows mean salary of $49,195)

Cummins Inc., Confidential & Proprietary

(Excludes 3sd outliers, i.e., salaries above $125,857)

Distribution of Compliance by Annual Salary, 2008

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Hypothesis Five: Physician Does Not Prescribe

Prescribing Behavior

47%53%

Evaluation of the nurse records of 66 enrolled members who were not compliant shows that for 47% of those reviewed found no evidence of a prescription for ACEI or an ARB.

Survey Results:Over 50% of those who responded to the survey as non-compliant indicated that they neither agreed or disagreed with the statement:

“I understand the reason I was not prescribed this medication.”

N = 66

Of the 21 responding “no” - only one person would not have been a candidate for an ACEI or an ARB.

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• Statistically significant improvement in compliance for population supported through one or more programs– Confirmed by healthcare analytics & survey results

• No statistically significant difference in plan selection– Confirmed by healthcare analytics & survey results

• No statistically significant difference due to cost of drugs to participant– Confirmed by survey results

• No statistically significant difference due to side effects– Review of nurse records and confirmed by survey results

• Possibility of cause of non-prescribing by doctors– Review of nurse records and survey results

Summary of Findings Against Original Hypothesis

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Improvements: Actions Based on Findings

• Increase awareness of the medication protocol and the benefit of the medication to members and indirectly to the physician

• Define 1:1 interactions between members and health professional

• Offer relevant incentives to enroll in the SHPS programs

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Q & A