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

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

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

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

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

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

SHPS Engagement Model Data-driven approach to health risk management 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

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

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

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

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.

Baseline Information on Members with Diabetes and Hypertension Total Members with: Total Members ACE Rx ARB Both ACE and ARB % of Total Receiving Rx Treatment Diabetics with Hypertension 1,139 525 239 57 62.07% 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 1.8σ

Measure Phase Cause/Effect Diagram FMEA Fishbone Diagrams Identified four possible causes FMEA Confirmed first four causes and added one Fishbone Diagrams Funnel down to likely root causes for data selection

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%

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” 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.

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

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

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.”

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.

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 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

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

Q & A