Applying Six Sigma Principles to Drive Healthcare Behavior Change

1
Applying Six Sigma Principles to Drive
Healthcare Behavior Change
Using Medication Compliance to Improve Healthcare
Outcomes

• 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

2
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

3
Cummins, Inc.

• 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

4
Cummins, Inc.

• 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

5
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

6
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

• 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

Net Savings
8
SHPS Health Risk Index

• Proprietary risk index creates a member specific
  score to identify, measure, and manage the health
  of members with chronic conditions.

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Cummins Health Risk and Opportunity
Risk
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

Reducing Cummins risk profile to typical SHPS
client norms will contribute 6.2 million in
annualized gross savings.
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The Six Sigma Project

• 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

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The Six Sigma Project
The Six Sigma Project

• 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.

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Baseline Information on Members with Diabetes and
Hypertension
Cummins Population FY2006

• 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 1.8s

13
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

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Analysis Phase

• 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

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Hypothesis One Lack of Advice on Specific
Medication

• Statistically higher compliance for those who are
  enrolled in the SHPS programs, plt0.05
• 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

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.
16
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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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.

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Hypothesis Five Physician Does Not Prescribe
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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Summary of Findings Against Original Hypothesis

• 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

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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 11 interactions between members and
  health professional
• Offer relevant incentives to enroll in the SHPS
  programs

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Q A