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

• 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

• 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

• 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

• 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

• 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

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
7

4.00
3.10
3.00
2.96
2.00
1.00
0.00
Compliance
Rx Occurrence
Financial
Treatment Gap
Medication Compliance
Evidence Based Medicine
Utilization
Total
Risk Profile As of 04/2007
(Incurred thru 12/2006)
0.94
0.32
0.01
0.09
0.55
0.20
1.00
3.10
Risk Profile As of 10/2007
(Incurred thru 06/2007)
0.89
0.31
0.00
0.09
0.51
0.21
0.95
2.96
2.85
F-500
0.66
0.33
0.01
0.23
0.44
0.22
0.96
2.85
Proprietary risk index creates a member specific score to identify, measure, and manage the health of members with chronic conditions.
8

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

• 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 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
ACE
Rx
Total Members with:
ARB
Rx
Both ACE and ARB
% of Total
Receiving Rx
Treatment
Diabetics with
Hypertension 1,139 525 239 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

• 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
Lack of Advice on Specific Medication Health Plan Design
Side Effects Cost of
Medication
Physician does not
Prescribe
Medication
Non-Compliance
13

• 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

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
600
500
400
300
200
100
0 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”
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.
15

No statistical difference found in compliance based on plans for
2007 or 2008
Compliance and Non-Compliance by Benefit Plan
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.”
Compliant
Cummins Inc., Confidential & Proprietary
Non-Compliant
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

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

No statistical evidence of salary impact on compliance over the period analyzed.
Distribution of Compliance by Annual Salary, 2008
(Excludes 3sd outliers, i.e., salaries above $125,857)
Compliant Non-Compliant
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 50000 100000 1500000 50000
2008 Salary (Dotted line shows mean salary of $49,195)
100000
Percent normal Salary
Cummins Inc., Confidential & Proprietary
150000
18

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.
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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
20

• Define 1:1 interactions between members and health professional
• Offer relevant incentives to enroll in the SHPS programs
21

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