Worksite clinics providing intensive lifestyle interventions are good business for some forward-thinking employers. They lead to measurable improvement in the health status of employees with chronic conditions, and — in the case of Cummins, Inc., according to CMO for Global Health & Wellness, Dr. Dexter Shurney — some of the key interventions tend to pay for themselves within six months.
The health status improvement also tends to not be limited to the chronic disease that is the subject of the intervention. Diabetes interventions lead to improvements in diabetes (some people with diabetes going off insulin entirely), but also to improvements in controlling hypertension, cholesterol and other conditions.
Come hear Dr. Shurney discuss his experiences in implementing these interventions at Diabetes Innovation 2013.
Dr. Shurney used the metaphor of a vegetable garden in our conversation: If you have a healthy plant, it’s because: “The roots are healthy. The stem is healthy. The leaves are healthy and it bears good fruit.” Changing the overall environment, through the heavy lifting done in the primary care medical homes at the Cummins worksite clinics, yields improvement across multiple conditions.
(Listen to our conversation, and read a transcript, after the jump.)
I asked him about incentives offered to employees to motivate them to participate in behavior modification efforts. His response: ” If I have to pay you money not to stick a pin in your eye . . . .” It has been his experience that information presented in an engaging manner will reach the target audience and promote behavior change without direct financial incentives. For example, a program to reduce consumption of processed meats engaged two-thirds of the patient population as a result of the educational efforts. Grocery store discount cards were offered to program participants, making compliance with changes in diet easier to implement, but the key was the information presented.
From what we learned about the work being done at Cummins, it is clear that knowledge is power — power to change one’s health care status and outlook.
Press the “play” button below to hear our entire twenty-minute conversation.
Here is the full transcript of our conversation:
Diabetes Innovation Interview with Dexter Shurney, MD, CMO lobal Health & Wellness, Cummins, Inc.
David Harlow: This is David Harlow with Diabetes Innovation, and I’m speaking today with Dexter Shurney. Shurney is the Chief Medical Officer for Global Health and Wellness at Cummins Incorporated. Thank you for joining us today Dr. Shurney.
Dexter Shurney: It’s good to be here David.
David Harlow: So, I am interested in understanding — what is your role as Chief Medical Officer for Global Health and Wellness at Cummins?
Dexter Shurney: Sure. Well it’s a lot of different things that I do there. So, one of the nice things about it is that because it’s so many different things that gives me all of the different leverage points to sort of make things happen. So for one thing, benefits, the entire healthcare benefits program reports through me, and that includes the wellness and those kinds of activities as well, and what we choose to do — disease management, case management, who the carriers are, so really all of those interrelationships go through my office.
David Harlow: And we should say — if I can interrupt you for just a sec, could you describe Cummins, let us know where are you located, how many employees?
Dexter Shurney: Sure. We’re about 50,000 employees. We’re located in Columbus Indiana, but we’re truly a global organization so about 50% of our employees are actually in places other than the United States. But we’re a manufacturer. About 50% of our business is actually dealing with engine manufacturing, diesel engines, large and small, light duty and heavy duty as well as marine diesels as well. And then we also have other businesses such as a distribution business and a filtration business, and also the power generation business too. So, that’s basically our business.
David Harlow: Okay and you were starting to say that you oversee employee benefits and that includes wellness programs?
Dexter Shurney: That’s exactly right, and so I oversee that. Now, we also are moving towards onsite medical centers as well, patient center medical home model that we will have onsite and next to our plants and office buildings, and so I’m overseeing that, that development as well.
David Harlow: Excellent and do you — I imagine you see the opportunity there for better primary care management, employee health as well avoidance of some downstream costs?
Dexter Shurney: That’s exactly right. And so really what we’re doing — we’re sort of approaching that from a 360 aspect, so if we’re providing or helping to provide some degree of primary care services through these onsite clinics, we also have incentives that we can provide the employees through benefit design and other kinds of incentives. Then you can — we also have the opportunity to educate employees through wellness programs some other things that we have online.
So, if you think about it, it’s really a 360 approach. We have also some influence on the built environment. So, if you think about the cafeteria, if you think about work-life balance issues, we can attack some of these things as well, so really from every aspect we will be looking at — probably in a nutshell — how care is delivered as well as a lot of the lifestyle aspect that we know drive a lot of the demand.
David Harlow: So, for the purposes of our conversation today I’m focused on diabetes, and I’m wondering how much of a focus your programs have on chronic diseases that are a driver of a large proportion of cost?
Dexter Shurney: Right. So David, you hit the nail right on the head. Our whole emphasis will be around chronic conditions. When we look at our spend, and we’re probably not that much different than others, a lot of that spend is with those chronic diseases, and the other thing we realize is that most of those chronic diseases are preventable. So, we’re really, you know – our thought is why are we paying so much for things that we should be able to prevent to some degree, and so we’re really going to focus on how do we do that. And basically for us it’s what we call back to basics and the basics is really lifestyle.
So, we actually in our patient centered medical homes, we’re actually pushing towards a lifestyle approach to care. In our high performance networks that we will build around those centers there also will be an emphasis towards a lifestyle approach to care. Our disease management vendor, our case management vendor, our coaches, everyone that touches our patients will need to have this lifestyle approach to care. And our education programs will be a little different than the traditional diabetic training programs or education programs or traditional stop smoking or what have you, because they will truly have a slightly different approach to them as well, really focusing more on the lifestyle than, say, medication adherence — and that’s not to say that we will do away with it, but we’ll approach it from the basics.
David Harlow: Right, well, as you say you’re looking to touching employees’ and patients’ lives and I think that’s really the key to success here, sort of a high touch approach. I imagine you’re familiar with the RAND report on wellness programs that came out a couple of months back that was really, at a high level, questioning the whole approach and looking at wellness programs with a critical eye and questioning whether there is a return on the investment in a direct way and really questioning whether the money spent on wellness really leads to reduced costs in healthcare. I think that for many employers there’s a perceived need to offer wellness programs because that’s what the employee market demands, if you will, and I guess the question for you is whether you’ve seen some evidence of the sorts of wellness programs you’re running or looking to implement in the future actually having an effect on employee health and on cost of care.
Dexter Shurney: Yeah. That’s a good question. All wellness programs are not the same. And what I have found is that if they really focus on – again, going back to basics — if they really focus on some of the lifestyle aspects that we’re trying to do at Cummins then I believe that they can probably save quite a bit. In fact, prior to coming to Cummins I was at Vanderbilt University and I had a role there on faculty in the medical school, but I also had a similar job with benefits for employees. And we ran a lifestyle program for diabetics and we saw a tremendous return on that investment. Now we had to create our own. And being at a large academic medical center we had the resources to do that.
We really didn’t find a program that really met our needs out in the marketplace, so we had to create based on our evidence, looking in the literature, looking at the evidence in terms of what works and what doesn’t work. We put together, we cobbled together our program, and it worked quite well for us, but again it’s a lifestyle approach. So, now that I’m at Cummins, I’m doing some very similar things there not only for our diabetics, but folks that have other chronic conditions as well. And actually although we use vendors, actually trying to nudge those vendors closer to these things that we know work.
David Harlow: And it sounds like you’re looking to customize an offering from a vendor that will meet the needs of your particular population as well as approaching the philosophical approach that you’re articulating as well.
Dexter Shurney: That’s correct David.
David Harlow: And do you find that there’s openness to doing that in the community of vendors in this space?
Dexter Shurney: I think so — at least all of our vendors seem to be willing to make that move. Let me just sort of give you an example. There’s a lot of evidence and a lot of research around the impact of sleep deprivation, or not getting enough sleep, and its effect on diabetes and obesity. You will find very few — and I could be wrong, maybe people are changing — but there are very few programs that really tackle that in the vendor world, and so we want to have a very robust program that deals with how to get better sleep, sleep hygiene, what are the things that people need to do versus just kind of grab an Ambien or some medication to put them to sleep.
So, really more of a lifestyle approach to that, and what other things would people need to incorporate into their lives so they can actually get a better night’s sleep. And that can have tremendous effect not only on obesity and diabetes, but imagine the effect that it also has on stress and some other things as well.
David Harlow: Are there — that’s interesting and to me a little surprising; maybe it shouldn’t be surprising. But are there other kinds of interventions or issues that you’re dealing with that might be surprising in terms of the effect they have in chronic disease?
Dexter Shurney: Absolutely — so one of the things that we did at Vanderbilt and that program is that we have a lot of education for the people in the program around processed meat, so there’s literature out there that that shows that if you have a two ounces of red processed meat a day that you increase your rate of diabetes by 60% and very few programs that I’m aware of that really even talk to patients about that. So, basically in our program we had challenges to get people to say for the next month I’m going to cut down on the number of hotdogs that I eat, the number of pepperoni, some of the belly meats that I eat and we sort of challenged them to say, “Give that a try and see what happens.”
And amazingly it started to improve and very simple things. Now, that’s not to say they can never have a hot dog, but obviously if somebody is eating a lot of this everyday and every week then that can really affect their ability to manage their diabetes. Its not just prevention, but it’s also management.
David Harlow: Sure. Now, have you found the need to include external incentives in order to motivate people to adopt behavior changes?
Dexter Shurney: We will. But before I get to that, let me just say that two ounces — a lot of people say well it’s about portion control. Well to some degree it is, but two ounces isn’t very much. There’s not a whole lot of portion control that you can do around that, so people really have to understand that and again not to force anybody to do anything, but you know what we found is that when we started the program at Vanderbilt is that about a third of people just got so excited about this new information that they just pretty much did all that we asked them to do.
Another third didn’t do very much of anything, another one-third made some changes. So, we had two-thirds of the population making some dramatic changes such as giving up some of this processed food that they were eating. And showing them exactly how to do it, and we saw a dramatic result even in as little as six months we saw the results. People actually coming off of their insulin.
David Harlow: That’s terrific.
Dexter Shurney: Yeah, diabetics who had been on insulin for ten years now being able to come off their insulin completely just by controlling their diet, exercise and sleep.
David Harlow: Well, that’s a very impressive result, I have to say. And so the other question I was asking is whether — so it sounds like you did not necessarily see the need to introduce external incentives; that seems to be the secret sauce that people are looking for as we talk to these days about gamification of healthcare and developing incentives for people that change behaviors. It sounds like you were able to find through a high-touch program, by simply sharing the information, the health effects was enough and the tools to change behavior, the information and alternatives that that was enough to get people that are really motivated to change.
Dexter Shurney: That’s absolutely right. So, what I always say is that if I have to pay you money, not to stick a pin in your eye –
David Harlow: Yes.
Dexter Shurney: And so that’s where the way a lot of these incentives are — we’re actually paying people to do things that are really in their best interest and so what behind with these more intensive lifestyle program changes is that they start to get better right away because the change is so dramatic that it’s almost like somebody that has bariatric surgery, and they’re no longer diabetic even before they’ve lost the weight, because they made a radical change. And so some of these intensive lifestyle changes — even though they’re not starving and in fact they’re eating quite a bit they’re pretty full — but they change what they’re eating and how they eat you can get some pretty dramatic changes, and people start to feel pretty good, pretty quickly, and that really what we had found is the incentive and actually that’s what makes the program sustainable.
Now so we did give them an incentive to make sure that they kept coming back to the clinic and that kind of thing, but the incentive was in the form of a grocery card, so that they could then go buy these healthy foods that we were talking about. So, that was the only incentive, but we didn’t give them cash or lower their co-pays deductibles on their health plan. We didn’t put it into their health reimbursement accounts or anything like that. We just gave them a shopping card for groceries.
David Harlow: Okay. It sounds to me like this sort of high touch program would be more expensive than other sorts of interventions that people use around the country and I’m assuming based on your discussion that the cost is recovered by employers through employing these tools, by virtue of lower overall healthcare expenditures, lower absenteeism, other things like that.
Dexter Shurney: Yeah, just slightly more expensive initially, but to your point we did recoup the cost quite quickly — I mean within six months, we recouped the cost. And then assuming that people are sustaining these behaviors, and by all indications it seems that they are, they will continue to recover or have a positive effect, financial effect on this. And so I mentioned how many came off of their insulin. I should also mention that the total savings wasn’t just from diabetic medications, but people also could lower their doses of their cholesterol medications and their hypertension medications.
What you find is when you do intensive lifestyle interventions everything starts to get better, and the way I look at this is, well, that if you think about somebody growing vegetables in their garden and in order to have a healthy plant you need the right soil, you need the right amount of water and the right amount of sunshine, and what you then get is you get a healthy plant.
The roots are healthy. The stem is healthy. The leaves are healthy and it bears good fruit. And a human organism is very similar — so that when you start to create this proper environment not only does the diabetes gets better, but the hypertension gets better. The cholesterol gets better. All these things start to go in groups and anybody that’s treated diabetics knows, none of these people usually have a single chronic condition. They have multiple chronic conditions, and if they only have a single, its just a matter of time before they have more than one and so again all of these things go together and when you change this environment everything also tends to get better as well, together.
David Harlow: Excellent. Well this sounds like encouraging work that you’ve been doing, and I’m glad you’re able to bring it to new locations both here and elsewhere.
I am wondering what you hope to experience at the Diabetes Innovation Conference this fall.
Dexter Shurney: Well I hope to share some of the things that I’ve learned through experience as well as learn from others in terms of the good things that they’re out there doing. I know that we’re not the only ones that are being innovative and creating new things, and so I think it will just be a great gathering of us like-minded folks trying to find solutions to these issues and to get together and to share our wisdom.
David Harlow: Well, thank you very much, Dr. Shurney. I appreciate your taking the time to speak with us. This is David Harlow for Diabetes Innovation.
Dexter Shurney: My pleasure. Thank you.