F Y 1 9 U T I L I Z A T I O N R E V I E W 7/1/2018 TO 9/30/2018 L O C K T O N C O M P A N I E S

Transcription

1 UNIVERSITY OF ALASKA F Y 1 9 U T I L I Z A T I O N R E V I E W 7/1/2018 TO 9/30/2018 L O C K T O N C O M P A N I E S

2 Premera- Medical L O C K T O N C O M P A N I E S

3 Medical Utilization % Change Norm FY18 FY19 Utilization Category over FY18 Inpatient Paid Claims Per Member Per Month $94 $102 9% $85 Admissions Per 1000 Members % 46 Days Per 1000 Members % 211 Average Length of Stay % 4.6 Paid Claims Per Admission $27,124 $24,881-8% $22,298 Outpatient Paid Claims Per Member Per Month $105 $127 21% $111 Visits Per 1000 Members 1,024 1,081 5% 982 Paid Claims Per Visit $1,226 $1,412 15% $1,359 Services Per 1000 Members 4,125 4,120 0% 3,889 Services Per Visit % 4.0 Paid Claims Per Service $305 $370 22% $343 ER Utilization: Paid Claims PMPM $27 $26-3% $27 ER Utilization: Visits Per 1000 Members % 183 ER Utilization: Paid Claims Per Visit $2,159 $2,065-4% $1,771 Professional Provider Paid Claims Per Member Per Month $196 $202 3% $188 Services Per 1000 Members 16,508 17,024 3% 15,788 Paid Claims Per Service $142 $142 0% $143 Norm is based on Premera s Alaska large group book of business 2

4 Premera Medical Emergency Room The number of ER visits increased slightly but paid claims per visit decreased. Outpatient Services The number of services decreased while the cost per visit/service increased slightly. Large Claims The number of large claimants & total paid claims increased from Q1 FY18 compared to Q1 FY19 however average claim amount decreased 16 large claimants over $100k for FY19 (Q1) 3 Large claimants are over $200,000 Claimant 2 terminated from the plan on 10/31 however additional claims to be paid through October $2,481,717 total paid in claims over $100,000 Average claimant over $100,000 is $155,107 6 large claimants over $100k for FY18 (Q1) Largest claimant (Liveborn Infant + Mother) was $879,965 $1,892,334 total paid in claims over $100,000 Average claimant over $100,000 is $315,389 Norm is based on Premera s Alaska large group book of business 3

5 Large Claims Analysis FY18 vs. FY19 FY18 FY19 Medical & Rx Plan Spend $11,829,901 $10,445,552 Average Monthly Employees 3,284 3,197 PEPM Cost $1,201 $1,089 % Change % -9.3% % Total Paid for Large Claimants (Over $100k) $1,892,334 $2,481,717 # of Large Claimants (Over $100k) 6 16 Average Large Claimant $315,389 $155,107 Average Large Claimant % Change -50.8% Without large claims $9,937,568 $7,963,835 PEPM Cost $1,009 $830 % Change Over Previous Yr -17.7% 16.0% 23.8% 84.00% 76.24% Large Claims above $100k as a percentage of Total Medical & Rx Claims FY18 FY % 23.8% 4

6 Top 20 Claimants FY19 (July 2018 to September 2018) Paid Claims Period: July 1, 2018 through September 30, 2018 Claimant Status Diagnosis YTD Claims 1 Active Spondylosis $234,820 2 Inactive Traumatic Brain Injury $216,130 3 Active Ovarian Cancer $216,114 4 Active Abdominal and Pelvic Pain $199,955 5 Active Lung Cancer $197,407 6 Active Back Pain $182,937 7 Active Heart Disease $167,018 8 Active Brain Cancer $143,813 9 Active Breast Cancer $132, Active Irregular Heartbeat $120, Active Blood Clot $118, Active Premature Rupture of Membranes (Pregnancy) $114, Active Epilepsy and Recurrent Seizures $111, Active Heart Attack $111, Active Attention-deficit Hyperactivity Disorders $107, Active Pulmonary Embolism $105, Active Back Pain $99, Active Intracranial Injury $90, Active Spondylosis $89, Active Intervertebral Disc Disorders $86,704 Total $2,847, Large Claimants with claims over $100,000 Total Claims over $100,000 was $2,481,717 5

7 Major Diagnostic Category Medical Only Major Diagnosis Category 7/1/17-9/30/17 7/1/18-9/30/18 Paid PMPM Total Paid Percentage of Total Paid Percentage of Paid PMPM Claims Overall Total Claims Overall Total Musculoskeletal System $58.32 $1,278, % $ $2,202, % Health Status & Services $98.85 $2,167, % $69.85 $1,481, % Circulatory System $20.50 $449, % $42.85 $908, % Injury and Poisoning $40.20 $881, % $35.20 $746, % Ill-Defined Conditions $31.90 $699, % $34.63 $734, % Neoplasms $41.97 $920, % $34.01 $721, % Nervous System $16.25 $356, % $32.35 $686, % Digestive System $18.74 $410, % $28.01 $594, % Pregnancy and Related $18.72 $410, % $27.33 $579, % Genitourinary System $16.94 $371, % $20.72 $439, % Mental Disorders $22.27 $488, % $18.28 $387, % Endocrine, Metabolic and Immunity $15.20 $333, % $15.16 $321, % Respiratory System $15.83 $347, % $9.53 $202, % Infectious and Parasitic $1.17 $25, % $6.03 $127, % Eye Disorders $5.72 $125, % $4.84 $102, % Skin and Tissue $5.76 $126, % $3.81 $80, % Congenital Anomalies $1.77 $38, % $2.04 $43, % Blood $3.32 $72, % $1.97 $41, % Ear Disorders $1.28 $28, % $1.01 $21, % Perinatal $8.73 $191, % $0.59 $12, % Other $0.00 $0 0.0% $0.41 $8, % Injury and Poisoning External Causes $0.01 $ % $0.00 $18 0.0% Total $ $9,723, % $ $10,445, % 6

8 Member Responsibility FY 19 (Q1) Allowed Charges $18,018,395 Subrogation, COB, Etc. $538,403 Employee Out of Pocket Deductible $2,093,187 Copays $158,971 Coinsurance $1,438,210 Member Responsibility $3,690,368 Member Cost Share (% of Allowed Charges) 20.5% FY 18 (Q1) Allowed Charges $16,965,031 Subrogation, COB, Etc. $465,422 Employee Out of Pocket Deductible $2,033,233 Copays $166,510 Coinsurance $1,381,370 Member Responsibility $3,581,113 Member Cost Share (% of Allowed Charges) 21.1% Member cost share includes Medical/Rx/Dental 7

9 Premera - Pharmacy L O C K T O N C O M P A N I E S

10 Pharmacy FY18 to FY19 Comparison Cost FY18 FY19 % Change Total Gross Cost $2,106,510 $2,198, % Total Net Cost $1,864,802 $1,947, % Drug Mix % Single Source Brands 17.2% 16.3% -5.3% % M ulti Source Brands 1.4% 1.2% -15.6% Generic Dispensing Rate 81.4% 82.5% 1.4% Utilization Total Prescriptions 13,535 12, % % Retail Prescriptions 84.4% 84.0% -0.4% % M ail Prescriptions 15.6% 16.0% 2.3% Average # of Scripts per M ember % Specialty Specialty Total Gross Cost $961,483 $863, % Specialty % of Total Gross Cost 45.6% 39.3% -13.9% The average number of members decreased from 7,309 FY18 to 7,070 FY19. 9

11 Top 25 Drugs by Gross Cost Rank Drug Name Specialty Drug Chapter Plan Cost Patients Cost Per Member 1 HUMIRA PEN Yes Rheumatoid Arthritis $229, $14,314 2 TECFIDERA Yes Neurological Therapy $146,630 7 $20,947 3 VOSEVI Yes Hepatits C $74,837 1 $74,837 4 TAGRISSO Yes Lung Cancer $42,322 1 $42,322 5 ZYTIGA Yes Chemotherapy $39,041 1 $39,041 6 ZEJULA Yes Ovarian Cancer $37,240 1 $37,240 7 ENBREL SURECLICK Yes Rheumatoid Arthritis $36,710 3 $12,237 8 VICTOZA 3-PAK No Diabetes $36, $2,151 9 SYPRINE No Wilson's Disease $33,542 1 $33, NOVOLOG FLEXPEN No Insulin Therapy $32, $1, NOVOLOG No Insulin Therapy $29, $1, LANTUS SOLOSTAR No Insulin Therapy $28, $ REBIF Yes Interferons $27,149 1 $27, CIMZIA Yes Anti-Inflammatory $26,702 2 $13, OTEZLA Yes Rheumatoid Arthritis $25,364 4 $6, ENBREL Yes Rheumatoid Arthritis $24,509 3 $8, ELIQUIS No Anticoagulants $23, $1, SAXENDA No Diabetes $22, $2, TRUVADA No HIV/AIDS Therapy $20,305 5 $4, TRESIBA FLEXTOUCH U-20 No Insulin Therapy $18,853 6 $3, KUVAN Yes Phenylketonuria $18,554 1 $18, GILENYA Yes Neurological Therapy $17,242 1 $17, DULOXETINE HCL No Anti-Depressant $16, $ ADVAIR DISKUS No Pulmonary Agents $16, $ LYRICA No Fibromyalgia $14,633 9 $1,626 TOTAL $1,038,403 $384, out of the top 25 are Specialty Drugs 10

12 Top 25 Drugs by Script Count Drug Name Specialty Drug Drug Type Rx Count Member Count Total Net Paid Cost Per Member DULOXETINE HCL N Generic $12,975 $245 DEXTROAMPHETAMINE-AMPH N Generic $12,307 $268 ATORVASTATIN CALCIUM N Generic $6,601 $32 BUPROPION XL N Generic $5,062 $56 METOPROLOL SUCCINATE N Generic $4,330 $57 LISINOPRIL N Generic $4,285 $19 PROAIR HFA N Brand $4,200 $42 LEVOTHYROXINE SODIUM N Generic $4,097 $20 LOSARTAN POTASSIUM N Generic $3,106 $26 ESCITALOPRAM OXALATE N Generic $2,728 $26 METFORMIN HCL N Generic $2,578 $26 VALACYCLOVIR N Generic $2,106 $25 GABAPENTIN N Generic $1,970 $30 VENLAFAXINE HCL ER N Generic $1,935 $33 FLUOXETINE HCL N Generic $1,802 $29 AMLODIPINE BESYLATE N Generic $1,771 $19 MONTELUKAST SODIUM N Generic $1,308 $14 SERTRALINE HCL N Generic $1,233 $15 HYDROCODONE-ACETAMINOP N Generic $1,192 $9 HYDROCHLOROTHIAZIDE N Generic $899 $11 OXYCODONE-ACETAMINOPHE N Generic $604 $10 OMEPRAZOLE N Generic $543 $6 SYNTHROID N Brand $175 $3 PREDNISONE N Generic $74 $1 AMOXICILLIN N Generic $63 $1 TOTAL 3,142 2,433 $77,944 11

13 Appendix L O C K T O N C O M P A N I E S

14 Medical Utilization Definitions Contract Months Number of enrolled employees for a 12 month period Medical Total PMPM Total medical cost on a per member per month basis Inpatient Services provided to patients who are hospitalized Outpatient Hospital based services where the employee is not admitted Professional Primary Care or Specialist Care Physician services Average Contract Size The average number of dependents (Spouse and Children) for each enrolled employee 13

15 Major Diagnostic Code Definitions Ill Defined category Other Health Status and Services The Major Diagnostic categories are aligned with the major sections of the ICD9-CM. In general, categories include the more ill-defined conditions and symptoms that point with perhaps equal suspicion to two or more diseases or to two or more systems of the body, and without the necessary study of the case to make a final diagnosis. Practically all categories in this group could be designated as "not otherwise specified," or as "unknown etiology," or as "transient." Examples: Fever, Convulsions, Chest Pain, Abdominal Pain. The Major Diagnostic categories are aligned with the major sections of the ICD9-CM. The Other category consists of claims with diagnoses that don t map to the ICD9-CM, mostly Rx and Dental claims. Excluding those benefits from the Benefit checkbox list will usually reduce Other to a negligible amount. Also known as "V-Codes" (i.e., V70.0) Usually used as a secondary diagnosis, but sometimes appears in the primary. Full details available in the ICD9 diagnosis book. General Medical Examination is common 1. Non-sick persons encountering the system (donors, family doc counseling, vaccines, etc) 2. Sick person encountering the system for treatment of a known (ongoing) disease or injury. 3. When a circumstance or problem is present that influences the patient's health, but isn't itself an illness (personal or family history health hazards, circumstances related to reproduction and development, etc) Injury & Poisoning Injury & Poisoning External Causes Factures, Wounds, Burns, Poisoning by Drugs, Medicinal and Biological Substances (DX Code ) Factures, Wounds, Burns, Poisoning by Drugs, Medicinal and Biological Substances (DX Code E800 - E999) Transport accidents (E800-E848) include accidents involving: aircraft and space craft (E840-E845) watercraft (E830-E838) motor vehicle (E810-E825) railway (E800-E807) other road vehicles (E826-E829) 14