Transcript Six Sigma Green Belt Training

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
1
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
2
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
3
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
4
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
5
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
6
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
Net Savings
– Care plans structured with individual member as focal point
7
SHPS Health Risk Index
4.00
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
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
3.00
2.00
1.00
0.00
Proprietary risk index creates a member specific score
to identify, measure, and manage the health of
members with chronic conditions.
8
Cummins Health Risk and Opportunity
Risk
• Cummins risk score is 15%
higher than SHPS’ client
norms
• Highest risk factors:
– Cardiovascular conditions
– Diabetes
Opportunity
• 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.
9
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 comorbidities are at least 2.3 times higher
– As compared to a non-diabetic patient of the same age-sex stratum
10
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.
11
Baseline Information on Members with Diabetes
and Hypertension
Cummins Population FY2006
Total Members with:
Total Members
Diabetics with
Hypertension
1,139
ACE
Rx
ARB
Rx
Both ACE
and ARB
% of Total
Receiving Rx
Treatment
525
239
57
62.07%
• 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
12
Measure Phase
• Cause/Effect Diagram
→ Identified four possible
causes
Lack of Advice
on Specific Medication
Health Plan Design
•FMEA
→ Confirmed first four causes
and added one
Fishbone Diagrams
→ Funnel down to likely root
causes for data selection
Medication
Non-Compliance
Side Effects
Cost of
Medication
Physician does not
Prescribe
13
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%
14
Hypothesis One:
Lack of Advice on Specific Medication
Statistically higher compliance for
those who are enrolled in the SHPS
programs, p<0.05
600
500
400
Slightly higher compliance by those
who have visited the Cummins
Health Center
Population
Compliant
Non-Compliant
300
200
100
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
Enrolled
Not Enrolled
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.
15
Hypothesis Two: Plan Design
“I find it difficult to refill my
medications due to my insurance
plan.”
600
400
200
Non-Compliant
UNKNOWN
HealthSpan Consumer PPO/Rx
HealthSpan Consumer HSA/Rx
HealthSpan Consumer 400/Rx
HealthSpan Consumer 1000/Rx
Survey results:
99% of those responding and on an
ACEI or ARB either strongly
disagreed or disagreed with the
statement:
Compliance and Non-Compliance by Benefit Plan
0
Count of unique IDs
No statistical difference found in
compliance based on plans for
2007 or 2008
Compliant
Cummins Inc., Confidential & Proprietary
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
16
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
17
Hypothesis Four: Cost of Medication
“I find the cost of this
medication a major reason I do
not take this medication.”
(Excludes 3sd outliers, i.e., salaries above $125,857)
Non-Compliant
10
15
Compliant
5
Survey results:
90% of those responding and
on an ACEI or ARB disagreed
with the statement:
Distribution of Compliance by Annual Salary, 2008
0
Percent Complaint/Non-Compliant
No statistical evidence of salary
impact on compliance over the
period analyzed.
0
50000
100000
1500000
50000
100000
2008 Salary (Dotted line shows mean salary of $49,195)
150000
Percent
normal Salary
Cummins Inc., Confidential & Proprietary
18
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.
Prescribing Behavior
47%
53%
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.
19
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
20
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
21
Q&A
22