F Y 1 8 U T I L I Z A T I O N R E V I E W 7/1/2017 TO 3/31/2018 L O C K T O N C O M P A N I E S

Transcription

1 UNIVERSITY OF ALASKA F Y 1 8 U T I L I Z A T I O N R E V I E W 7/1/2017 TO 3/31/2018 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 FY17 (Q3) FY18 (Q3) Utilization Category over FY17 (Q3) Inpatient Paid Claims Per Member Per Month $86 $85-1% $88 Admissions Per 1000 Members % 48 Days Per 1000 Members % 227 Average Length of Stay % 4.8 Paid Claims Per Admission $27,845 $27,015-3% $22,147 Outpatient Paid Claims Per Member Per Month $104 $110 6% $104 Visits Per 1000 Members 1,035 1,092 5% 1,008 Paid Claims Per Visit $1,205 $1,212 1% $1,244 Services Per 1000 Members 4,023 4,143 3% 3,843 Services Per Visit % 3.8 Paid Claims Per Service $310 $319 3% $326 ER Utilization: Paid Claims PMPM $20 $23 16% $26 ER Utilization: Visits Per 1000 Members % 191 ER Utilization: Paid Claims Per Visit $1,795 $1,956 9% $1,665 Professional Provider Paid Claims Per Member Per Month $210 $219 4% $203 Services Per 1000 Members 16,987 17,220 1% 16,178 Paid Claims Per Service $148 $152 3% $151 Norm is based on Premera s Alaska large group book of business 2

4 Premera Medical Emergency Room The number of ER visits increased compared to FY17 Q3 and the cost per visit decreased minimally but continues to be above the Premera norm. Lower number of visits coupled with higher cost per visit can indicate appropriate ER utilization. Outpatient Services The number of services and the cost per visit/service increased moderately. Large Claims The number of large claimants decreased; however, the severity of the claimants and total dollars paid increased in Q3 FY18 compared to Q3 FY Large Claimants over $100k for FY18 (Q3) o Largest claimant $1,659,215 (Liveborn Infant with Respiratory Issues) o Two claimants had over $400k each in claims (Facial Fracture & Wilson s Disease-Pharmacy) o $9,273,707 total paid claims over $100,000 o Average claimant over $100,000 was $197, large claimants over $100k for FY17 (Q3) o One claimant was over $400k with Myeloid Leukemia at $454,980 o $9,180,674 total paid in claims over $100,000 o Average claimant over $100,000 was $170,012 3

5 Large Claims Analysis FY17 vs. FY18 University of Alaska Large Claimants Over $100,000 FY17 (Q3) FY18 (Q3) Medical & Rx Plan Spend $36,309,962 $35,966,123 Average Monthly Employees 3,423 3,276 PEPM Cost $1,179 $1,220 % Change % 3.5% % Total Paid for Large Claimants (Over $100k) $9,180,674 $9,273,707 # of Large Claimants (Over $100k) Average Large Claimant $170,012 $197,313 Average Large Claimant % Change 16.1% Without large claims $27,129,288 $26,692,415 PEPM Cost $881 $905 % Change Over Previous Yr 2.8% 25.3% 25.8% 74.72% 74.22% Large Claims above $100k as a percentage of Total Medical & Rx Claims FY17 FY % 25.8% 4

6 Top 20 Claimants Paid Claims Period: July 1, 2017 through March 31, 2018 Claimant Status Diagnosis YTD Claims 1 Active Respiratory Conditions Originating in the Perinatal Period $1,659,215 2 Active Fracture of Skull & Facial Bones $466,539 3 Active Wilson's Disease (Pharmacy) $400,089 4 Inactive Lung Cancer $365,213 5 Active Leukemia $340,579 6 Inactive Spondylosis $265,003 7 Inactive Pyogenic Arthritis $239,812 8 Active Intracranial Injury/Intracranial Hemorrhage $229,129 9 Active Breast Cancer $201, Inactive Colon Cancer $189, Active Gallstones $189, Active Fracture of Cervical Vertebra and Other Parts of Neck $186, Active Upper Back Pain $176, Active Heart Disease $175, Active Scoliosis $172, Active Lung Cancer $167, Active Prostate Cancer $164, Active Multiple Myeloma - Pharmacy (Blood/Bone Cancer) $163, Active Scoliosis $159, Active Spondylosis $144,316 Total $6,057, Large Claimants with claims over $100,000 Total Claims over $100,000 was $9,273,707 5

7 Major Diagnostic Category Medical Only Major Diagnosis Category 7/1/16-3/31/17 7/1/17-3/31/18 Paid PMPM Total Paid Percentage of Total Paid Percentage of Paid PMPM Claims Overall Total Claims Overall Total Health Status & Services $58.73 $4,031, % $84.76 $5,550, % Musculoskeletal System $78.54 $5,390, % $72.50 $4,747, % Injury and Poisoning $26.35 $1,808, % $36.54 $2,393, % Ill-Defined Conditions $33.57 $2,304, % $34.50 $2,259, % Neoplasms $47.16 $3,237, % $32.86 $2,151, % Mental Disorders $28.10 $1,928, % $28.02 $1,834, % Digestive System $20.32 $1,395, % $27.50 $1,801, % Circulatory System $33.93 $2,328, % $26.67 $1,746, % Nervous System $24.14 $1,656, % $21.28 $1,393, % Pregnancy and Related $15.36 $1,054, % $18.09 $1,184, % Genitourinary System $17.16 $1,177, % $16.49 $1,079, % Endocrine, Metabolic and Immunity $14.65 $1,005, % $14.93 $977, % Respiratory System $12.16 $834, % $14.18 $928, % Eye Disorders $1.92 $166, % $7.70 $504, % Skin and Tissue $5.33 $438, % $5.16 $337, % Perinatal $0.56 $63, % $3.39 $221, % Blood $2.43 $168, % $2.69 $175, % Ear Disorders $0.01 $6, % $2.16 $141, % Congenital Anomalies $0.93 $131, % $2.14 $139, % Infectious and Parasitic $2.46 $365, % $1.57 $102, % Injury and Poisoning External Causes $0.09 $38, % $0.00 $ % Other $0.00 $0 0.00% $0.00 $0 0.0% Total $ $29,534, % $ $29,674, % 6

8 Member Responsibility FY 18 (Q3) Allowed Charges $49,373,873 Subrogation, COB, Etc. $1,743,690 Employee Out of Pocket Deductible $3,980,562 Copays $469,344 Coinsurance $4,123,861 Member Responsibility $8,573,766 Member Cost Share (% of Allowed Charges) 17.4% FY 17 (Q3) Allowed Charges $50,450,261 Subrogation, COB, Etc. $1,633,097 Employee Out of Pocket Deductible $4,033,764 Copays $498,951 Coinsurance $4,680,629 Member Responsibility $9,213,344 Member Cost Share (% of Allowed Charges) 18.3% 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 FY17 to FY18 Comparison Cost FY17 Q3 FY18 Q3 % Change Total Gross Cost $6,775,876 $6,292, % Total Net Cost $6,089,602 $5,642, % Drug Mix % Single Source Brands 17.3% 16.5% -4.7% % Multi Source Brands 1.8% 1.5% -14.9% Generic Dispensing Rate 80.9% 82.0% 1.3% Utilization Total Prescriptions 41,707 39, % % Retail Prescriptions 83.4% 84.2% 0.9% % Mail Prescriptions 16.6% 15.8% -4.7% Average # of Scripts per Member % Specialty Specialty Total Gross Cost $2,223,315 $2,470, % Specialty % of Total Gross Cost 32.8% 39.3% 19.7% The average number of members decreased from 7,630 FY17 to 7,276 FY18. 9

11 Top 25 Drugs by Gross Cost Rank Drug Name Specialty Drug Chapter Members Plan Cost Cost Per Member 1 HUMIRA PEN Yes Rheumatoid Arthritis 15 $491,846 $32,790 2 TECFIDERA Yes Neurological Therapy 7 $388,907 $55,558 3 ENBREL Yes Rheumatoid Arthritis 11 $289,839 $26,349 4 NOVOLOG No Insulin Therapy 32 $117,759 $3,680 5 SYPRINE No Wilson's Disease 1 $111,727 $111,727 6 JADENU Yes Chronic Iron Overload 1 $103,841 $103,841 7 COPAXONE Yes Neurological Therapy 3 $100,238 $33,413 8 XTANDI Yes Prostate Cancer 1 $94,637 $94,637 9 HARVONI Yes Hepatitis C 2 $92,518 $46, LANTUS SOLOSTAR No Insulin Therapy 40 $83,532 $2, ENBREL SURECLICK Yes Rheumatoid Arthritis 7 $83,483 $11, NOVOLOG FLEXPEN No Insulin Therapy 31 $81,602 $2, VICTOZA 3-PAK No Non-Insulin Hypoglycemic Agents 22 $74,739 $3, OTEZLA Yes Rheumatoid Arthritis 3 $73,911 $24, ARANESP Yes Anemia 1 $65,392 $65, REBIF Yes Interferons 1 $59,309 $59, POMALYST Yes Multiple Myeloma 1 $58,916 $58, ADVAIR DISKUS No Pulmonary Agents 50 $56,576 $1, TARCEVA Yes Chemotherapy 1 $54,538 $54, LATUDA No Antipsychotics 7 $51,779 $7, SYMBICORT No Pulmonary Agents 39 $50,578 $1, GILENYA Yes Neurological Therapy 1 $48,883 $48, RESTASIS No Eye Drops 33 $47,799 $1, JANUVIA No Non-Insulin Hypoglycemic Agents 19 $46,760 $2, CIMZIA Yes Anti-Inflammatory 2 $45,374 $22,687 $2,774,483 $876,396 Specialty Drugs make up 15 of the top 25 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 DEXTROAMPHETAMINE-AMPH N Generic $26,307 $ METOPROLOL SUCCINATE N Generic $13,334 $ BUPROPION XL N Generic $19,308 $ ESCITALOPRAM OXALATE N Generic $11,896 $71.23 ATORVASTATIN CALCIUM N Generic $20,140 $65.60 GABAPENTIN N Generic $6,201 $54.87 PROAIR HFA N Brand $14,364 $50.94 VENLAFAXINE HCL ER N Generic $4,372 $47.01 LISINOPRIL N Generic $13,182 $40.68 LOSARTAN POTASSIUM N Generic $5,676 $39.42 METFORMIN HCL N Generic $5,527 $37.85 LEVOTHYROXINE SODIUM N Generic $10,770 $34.30 AMLODIPINE BESYLATE N Generic $4,161 $32.76 VALACYCLOVIR N Generic $5,905 $32.62 MONTELUKAST SODIUM N Generic $4,975 $28.76 SERTRALINE HCL N Generic $3,980 $27.26 HYDROCHLOROTHIAZIDE N Generic $2,919 $20.56 OXYCODONE-ACETAMINOPHE N Generic $3,959 $17.75 SYNTHROID N Brand $1,500 $16.67 HYDROCODONE-ACETAMINOP N Generic $3,423 $9.33 AMOXICILLIN-CLAVULANAT N Generic $2,515 $9.01 ALPRAZOLAM N Generic $1,116 $7.11 OMEPRAZOLE N Generic $831 $4.59 AZITHROMYCIN N Generic $815 $2.55 AMOXICILLIN N Generic $407 $1.20 Total 10,982 4,962 $187,585 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