Know your trends. Drive your results Annual Review for City of Los Angeles

Transcription

1 Know your trends. Drive your results Annual Review for City of Los Angeles

2 HMO/PPO COMPARISON HMO PPO Anthem National Total Members (Employees + Dependents) 18,405 4,354 N/A Average Age (Employee) Average Age (Member) Total Paid $38,782,902 $36,543,251 N/A 2017 Paid PMPM $ $ $ Paid PMPM (Prior Plan) $ $773 $ Health Risk Index Average Contract Size* Top 5 Health Conditions by Paid Amount Behavioral Health, Circulatory System, Digestive System, Injury & Poisoning, Musculoskeletal System Neoplasms Malignant, Musculoskeletal System, Aftercare, Digestive System, Health Status N/A Top 5 Lifestyle Conditions by Paid Amount High Cost Claimants > $50k # of members/% of members High Cost Claimants > $50k as a % of plan costs Inpatient Facility Acute Admissions/1,000 CAD, Chronic Kidney Disease, Substance Abuse/Drug Addiction, Stress/Anxiety/Depression Cancer Skin, Osteoarthritis, Cancer Breast, Overweight/Obese, Substance Abuse/Drug Addiction 133/0.7% 144/3.3% 1.2% 38.7% 53.9% 41.6% Formulary Compliance Rate 97.0% 94.0% 97.4% Generic Fill Rate 84.3% 80.1% 85.7% N/A Specialty Drug % of Plan Cost 39.3% 41.1% 37.9% *Average contract size = Average number of enrolled members per contract (employee plus dependents)

3 KEY FINDINGS SUMMARY CATEGORY METRIC RELEVANCE RECOMMENDATIONS HMO plan costs The City s paid per member per month (PMPM) claim costs increased 3.28% from the 2016 plan year with the prior plan. Low PMPM cost increases are associated with strong utilization management, care coordination and network contracting. Anthem s HMO medical group partners have been effectively managing utilization and associated costs for the City s members. Continue to promote Vivity, which allows members to utilize high quality providers such as UCLA and Cedars Sinai while maintaining plan affordability. PPO plan costs The City s paid PMPM claim costs decreased 9.6% from the 2016 plan year with the prior plan. Reduced PMPM claim costs are associated with strong utilization management, and network contracting. In network utilization is also a key driver of lower PMPM costs, and 94.2% of the City s PPO plan spend was paid to in-network providers. Continued efforts around PPO member engagement, including promotion of Anthem clinical programs via available channels, including Mobile Health Consumer. High Cost Claimants - PPO A total of 144 members (3.3% of membership) drove 53.9% of all costs. High cost claimants totaled $22,226,218 in 2017, compared to $19,590,840 in the 2016 plan year. A total of 13 claimants exceeded $300k in claim costs The City s PPO plan continues to struggle with significant high dollar claim activity, resulting from an aging population with a higher illness burden and risk than Anthem s benchmark. Continued efforts around PPO member engagement, including promotion of Anthem clinical programs via available channels, including Mobile Health Consumer. Continue promotion of services such as Heal and LiveHealth Online, which allow PPO members the flexibility to receive treatment for nonemergency conditions after hours and from the convenience of home. Early detection of many conditions can prevent them from resulting in high cost claims. Prescription Drug Utilization The City s formulary compliance and generic fill utilization rates are below Anthem benchmarks. While below benchmarks, the City s formulary compliance and generic fill rates were impacted by the grandfathering of non-formulary drugs and brand name drugs from the prior plan. Increased member education regarding effectiveness of generic drugs, and promotion of savings opportunities that result from adhering to the formulary.

4 KEY FINDINGS SUMMARY (cont.) CATEGORY METRIC RELEVANCE RECOMMENDATIONS Lifestyle Conditions HMO and PPO Combined Claims attributed to specific Lifestyle conditions make up 27.1% of the total dollars spent Coronary Artery Disease represents the primary Lifestyle Related Condition by paid amount and is 4.2% of the total paid claims amount in the current period. Improving lifestyle choices and behavior change will plays an important role in preventing many chronic diseases. Align key City wellness monthly/seasonal wellness topics with lifestyle conditions identified in the City s Anthem utilization. Mental Health & Substance Abuse HMO and PPO Combined Depression and Pervasive Development Disorder (Autism) prevalence is significantly higher than Anthem s benchmark. Mental Health/Substance Abuse PMPM of is 45.2% higher than Anthem. Professional outpatient behavioral health utilization is 39.3% higher than Anthem The City s Depression and Pervasive Developmental Disorder prevalence are key factors in the City s professional mental health utilization being significantly higher than Anthem s benchmark. Increased promotion of 24/7 Anthem s Behavioral Health Resource and LiveHealth Online Psychology and Psychiatry for web-based visits. Emergency Room Utilization HMO and PPO Combined The City s Emergency Room utilization (visits per 1,000 members) is -33.4% below Anthem s benchmark. However, over 50% of Emergency Room visits were considered low intensity and possibly avoidable. Avoidable emergency room visits are defined as visits due to diagnoses that can be treated in an alternative setting such as an urgent care facility. Low Emergency Room utilization is associated with strong condition management at the primary care physician level, care coordination at the medical group level and member awareness of available alternatives. Continued promotion of alternatives to the emergency room, such as urgent care clinics, retail health clinics (PPO only) and LiveHealth Online.

5 DEMOGRAPHICS Summary: Employees consume 57.8% of total plan costs There are 6,109 total unique members who have not filed a claim during the time period represented on this report Metric Total HMO PPO * Demographics: Employees 10,172 7,591 2,581 N/A Membership 22,790 18,406 4,354 N/A Contract Size Average Age of Member Average Age of Employee PMPM Costs by Relationship HMO PPO Combined Employee $ $ $ Spouse $ $ $ Child $66.10 $ $ Plan Select (Narrow) HMO Traditional (Full) HMO Enrollment by Plan Average Subscribers Average Members 6,696 16, Vivity HMO 796 1,990 PPO 2,581 4,354 Total 10,172 22,790 Membership By Gender Female 11,291 49% Male 11,805 51% Membership and Paid Amount by Relationship Percent of Membership Percent of Paid Amount 58% 45% 36% 19% 21% 21% Employee Spouse Child * : Anthem Book of Business 5

6 COST AND MEMBERSHIP Total Expenditures: Plan paid medical claims = $75,326,153 PPO total PMPM (medical + Rx expenses) = $ HMO total PMPM (medical + capitation + Rx expenses) = $ % of paid claims were paid in-network Network discounts totaled 62.3% Total PMPM $ $ $ HMO PPO Health Risk Index: Plan Health Risk Index Variance to Commercial HMO % PPO % PPO Average Contract HMO Average Contract Combined (HMO and PPO) Average Contract Size by Plan * HCC threshold determined by the member s total cost, medical plus pharmacy 6

7 Rx PATIENT STRATIFICATION HMO and PPO COMBINED Patient Care Needs Well Smoking Cessation, Allergies, Constipation/Anti diarrheals, Topical Antifungal / Anti-bacterial infection treatment Acute Colds & Flu, Strep Throat, Ear Infection, Headache, Sprains Chronic 70% 60% 50% 40% 30% 20% 10% 0% 35% 19% 39% % of Total Members Current 8% 1% 3% 44% 52% % of Total Plan Cost Heart Disease, Diabetes, Arthritis, High Blood Pressure, High Cholesterol, Dementia, Back Pain Complex Multiple Chronic Conditions such as Heart Failure & Diabetes, Cancer, AIDS, Multiple Sclerosis, Metabolic Syndrome Well Acute Chronic Complex Members 7,927 4,253 9,013 1,722 22,915 Members % 34.6% 18.6% 39.3% 7.5% 100.0% Plan Cost $338,764 $958,304 $12,332,136 $14,630,554 $28,259,758 Plan Cost % 1.2% 3.4% 43.6% 51.8% 100.0% Member Age (Avg.) Copay $25,807 $94,515 $1,181,008 $516,399 $1,817,729 Copay/Member $3 $22 $131 $300 $79 Plan Spend/Member $43 $225 $1,368 $8,496 $1,233 Days of Therapy/Member , GFR % 85.3% 90.9% 84.8% 78.8% 83.3% Home Delivery Utilization 3.4% 2.2% 8.1% 13.9% 9.9% Total GFR % calculated with Unadjusted Rxs

8 HIGH COST CLAIMANT (HCC) DETAIL: HMO Summary*: Medical Paid: $9,804,486 RX Paid: $5,202,920 Medical and RX: $15,007,406 A total of 133 members (0.7% of membership) drove 38.7% of all costs The was 1.2% of members driving 38.2% of all costs 92.5% of members with claims paid greater than $50,000 are in an Active status in the plan Employees are responsible for 46.5% of HCC cost $400 $300 $200 $100 $0 $95.69 $78.32 Current HMO Claimants $50K (Medical PMPM) ADJ PMPM HCC PMPM $ $ Top Ten High Cost Claimants ($50,000) Case Diagnosis Paid Amount Relationship 1 ACUTE MYOCARDIAL INFARCTION $640,658 Employee Yes 2 OTHER IMMUNODEFICIENCIES $548,059 Child Yes 3 COMP ARTFICL OPENINGS DIGESTIVE SYS $487,543 Child Yes 4 OTHER IMMUNODEFICIENCIES $468,275 Spouse Yes 5 ACUTE MYOCARDIAL INFARCTION $379,785 Spouse Yes 6 CHRONIC VIRAL HEPATITIS $373,068 Employee Yes 7 MALIGNANT NEOPLASM OF PANCREAS $353,438 Employee No 8 ACUTE MYOCARDIAL INFARCTION $333,525 Spouse Yes 9 OTH DISEASES UP RESPIRATORY TRACT $275,458 Employee Yes 10 OTHER SEPSIS $255,951 Employee Yes Active Plan Status HCC threshold determined by the member s total cost, medical plus pharmacy 8

9 HIGH COST CLAIMANT (HCC) DETAIL: PPO Summary*: Medical Paid: $16,452,391 RX Paid: $3,261,100 Medical and RX: $19,713,491 A total of 144 members (3.3% of membership) drove 53.9% of all costs The was 1.2% of members driving 38.2% of all costs 92.4% of members with claims paid greater than $50,000 are in an Active status in the plan Employees are responsible for 64.9% of HCC cost PPO High Cost Claimants $50K (Medical PMPM) $ $ ADJ PMPM HCC PMPM $ $ Current Top Ten High Cost Claimants ($50,000) Case Diagnosis Paid Amount Relationship 1 MALIGNANT MELANOMA OF SKIN $2,168,029 Employee Yes 2 LIVEBRN INFNT ACCRD PLACE BRTH&TYPE $791,358 Child Yes 3 ENCOUNTER FOR OTHER AFTERCARE $507,251 Employee Yes 4 MALIGNANT NEOPLASM OF BRAIN $501,414 Spouse Yes 5 ENCOUNTER FOR OTHER AFTERCARE $461,595 Spouse Yes 6 MALIGNANT NEOPLASM ACCESSRY SINUSES $367,941 Spouse No 7 ENCOUNTER FOR OTHER AFTERCARE $344,643 Employee Yes 8 SEC & UNS MAL NEOPLASM LYMPH NODES $343,995 Employee Yes 9 KYPHOSIS AND LORDOSIS $343,470 Employee Yes 10 COMP OTH INTRL PROSTH DEVC IMPL GFT $334,743 Child Yes Active Plan Status HCC threshold determined by the member s total cost, medical plus pharmacy 9

10 CLINICAL COST DRIVERS Summary: The Employee was responsible for 57.8% of spend; the Spouse was responsible for 21.3% and the Child 20.9% Depression prevalence for HMO and PPO plan participants is at or above Anthem s benchmark. Target Program Conditions Employees account for 64.4% of total paid claims HMO and PPO PMPM costs are at or above benchmarks Percent Of Spend By Relationship and Health Condition HMO & PPO Employee Spouse Child Neoplasms - Malignant 72.9% 26.7% Behavioral Health 32.1% 11.8% 56.1% Circulatory System 74.4% 23.1% 0.4% 2.5% Musculoskeletal System 71.7% 22.3% 6.0% Digestive System 54.5% 20.9% 24.6% Utilization by Setting HMO PPO Inpatient Facility Inpatient Paid Amount $9,913,952 $8,961,004 Inpatient Paid Amount PMPM $44.89 $ $96.21 Outpatient Facility Total Outpatient Paid Amount $5,670,631 $10,634,001 Total Outpatient PMPM $25.67 $ $ Professional Total Professional Paid Amount $4,494,143 $8,073,744 Total Professional PMPM $20.35 $ $99.93 Total Paid Amount $20,078,726 $27,668,752 Total Medical PMPM $90.91 $ $ Coronary Artery Disease Congestive Heart Failure Target HMO Program Conditions By Prevalence/1000 Depression Cancer Maternity Current Coronary Artery Disease Target PPO Program Conditions By Prevalence/1000 Low Back Pain Depression Cancer Maternity Current

11 LIFESTYLE CONDITIONS Summary: Claims attributed to specific Lifestyle conditions make up 27.1% of the total dollars spent (HMO and PPO combined) Coronary Artery Disease represents the primary Lifestyle Related Condition by paid amount and is 4.2% of the total paid claims amount in the current period. Hypertension represents the highest Lifestyle Related Condition per 1,000 and is 9.8% below the. Top Five HMO Lifestyle Conditions by Paid Amount Paid Amount Unique Members Current Period PMPM PMPM Variance to Coronary Artery Disease $1,689, $7.65 $ % Chronic Kidney Disease $563, $2.55 $ % Substance Abuse/Drug Addiction $341, $1.55 $ % Stress/Anxiety/Depression $256, $1.16 $ % Cancer Gallbladder Pancreas $229,117 7 $1.04 $ % Top Five PPO Lifestyle Conditions by Paid Amount Paid Amount Unique Members Current Period PMPM PMPM Variance to Cancer Skin $1,553, $29.34 $ % Osteoarthritis Except Low Back $702, $13.45 $ % Cancer Breast $605, $11.59 $ % Overweight/Obese $360, $6.91 $ % Substance Abuse/Drug Addiction $332, $6.36 $ % 11

12 MENTAL HEALTH AND SUBSTANCE ABUSE HMO and PPO COMBINED Summary: Behavioral Health expenses on a PMPM basis for the HMO and PPO plans combined is 45.2% higher than Anthem s benchmark. Professional outpatient behavioral health utilization is 39.3% higher than Anthem Behavioral Health: Employees represents 32.1% of the of spend for this category Behavioral Health PMPM $12.49 $18.14 $0.00 $5.00 $10.00 $15.00 $20.00 Current Service Behavioral Health Behavioral Health Utilization Commercial Claimants/1,000 Variance to Commercial Substance Abuse Commercial Variance to Commercial Inpatient Acute % % Residential Treatment % % Visits/1,000 Partial Hospital Program % % Professional Inpatient % % Professional Outpatient % % $5.00 $0.00 $4.29 $0.82 PERVASIVE DEVELOPMENTAL DISORDERS $2.45 MAJOR DEPRESSIVE DISORDER RECURRENT Top Five Behavioral Health Diagnoses By PMPM Current $1.68 $1.98 $1.69 $1.62 $1.16 $1.37 $0.88 ALCOHOL RELATED DISORDERS OPIOID RELATED DISORDERS MAJOR DEPRESSIVE DISORDER SINGLE EPISODE 12

13 EMERGENCY ROOM SUMMARY HMO and PPO COMBINED Emergency Room Summary: Emergency Room (ER) facility paid amount was 6.5% of the total medical plan paid amount for the HMO and PPO plans combined Average paid per ER facility visit was $1,647, compared to the of $1,404 ER visits utilization per 1,000 members was compared to Anthem s of Despite the City s below average ER visits per 1,000 members, 53.4% of ER visits were potentially low intensity Top 5 ER Avoidable Visits By Diagnosis DORSALGIA (Back Pain) 4.8% HEADACHE 3.9% NAUSEA AND VOMITING 3.3% OTHER & UNSPECIFIED INJURIES HEAD 3.3% OPEN WOUND OF WRIST HAND & FINGERS 2.7% 0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% 3.5% 4.0% 4.5% 5.0% 13

14 PHARMACY TOP LINE METRICS HMO and PPO COMBINED Plan Cost PMPM is $ Specialty Plan Cost PMPM is $40.97 Generic Fill Rate (GFR) is 83.3%, 2.4 percentage points lower than benchmark City of Los Angeles - HMO and PPO Combined Description 2017 Avg Subscribers per Month 10,266 Avg Members per Month 22,915 Number of Unique Patients 16,214 Pct Members Utilizing Benefit 70.8% Total Plan Cost $28,259,758 Total Days 7,484,347 Total Rxs 231, Average Member Age Plan Cost PMPM $ $ Plan Cost/Day $3.78 $3.22 Plan Cost per Rx $ $ Nbr Rxs PMPM Generic Fill Rate 83.3% 85.7% Retail 90 Conversion Rate 26.5% 11.7% Home Delivery Utilization 9.9% 40.7% Member Cost % 6.0% 10.7% Specialty Percent of Plan Cost 39.9% 37.9% Specialty Plan Cost PMPM $40.97 $45.32 Formulary Compliance Rate 96.2% 97.4%

15 TOP PHARMACY INDICATIONS HMO and PPO COMBINED Drugs for Top 10 indications represent 58.4% of the City s total pharmacy costs Diabetes represents $4.2M, or 15.0% of the City s total pharmacy costs Generic Fill Rate (GFR) in Asthma lags your peer by 5 points Top Indications by Plan Cost Available Clinical Edits Rank Peer Rank Indication Rxs Patients Plan Cost Generic Fill Rate Peer Generic Fill Rate Plan Cost PMPM PA/ST/DQM 1 2 DIABETES 18,190 1,525 $4,244, % 50.5% $15.44 PA/ST/DQM 2 1 INFLAMMATORY CONDITIONS 1, $3,189, % 44.4% $11.60 N/A 3 7 HIV 1, $2,222, % 4.6% $8.08 PA/DQM 4 3 CANCER 1, $1,284, % 80.8% $4.67 PA/ST/DQM 5 6 ASTHMA 9,685 2,745 $1,234, % 40.8% $4.49 PA/ST/DQM 6 4 MULTIPLE SCLEROSIS $1,203, % 4.9% $4.38 PA/DQM 7 63 HEREDITARY ANGIOEDEMA 32 2 $1,009, % 0.0% $3.67 PA/ST/DQM 8 5 PAIN/INFLAMMATION 18,847 5,689 $752, % 94.6% $2.74 PA 9 26 GROWTH DEFICIENCY $685, % 0.0% $2.49 PA/ST/DQM MENTAL/NEURO DISORDERS 2, $675, % 86.6% $2.46 Total Top 10: 52,714 $16,502, % $60.01

16 Appendix 2017 Annual Review for City of Los Angeles

17 TOP HEALTH CONDITIONS - HMO Summary: The top five health condition categories accounted for 52.4% of claims paid for the total plan HMO costs do not include capitation Employees drove 43.9% of the expense in the top five health condition categories, spouses drove 22.7% Health Condition Unique Claimants Inpatient Outpatient Professional Total % of Total Paid Amount per Unique Claimant Behavioral Health 1,592 $756,285 $477,984 $2,143,049 $3,377, % $3,183 Circulatory System 2,056 $2,497,432 $189,152 $56,711 $2,743, % $20,783 Digestive System 1,736 $932,452 $537,407 $142,684 $1,612, % $5,907 Injury & Poisoning 2,273 $734,293 $602,820 $178,852 $1,515, % $3,680 Musculoskeletal System 4,053 $552,175 $463,792 $253,951 $1,269, % $2,662 $40.00 $35.00 $30.00 $25.00 $20.00 $15.00 $10.00 $5.00 $0.00 Top Five Health Conditions By PMPM Current $33.13 $33.03 $26.97 $22.72 $21.84 $15.22 $12.49 $12.36 $7.26 Behavioral Health Circulatory System Digestive System Injury & Poisoning Musculoskeletal System $

18 TOP HEALTH CONDITIONS - PPO Summary: The top five health condition categories accounted for 45.6% of claims paid for the total plan Nine of the ten top conditions have PMPMs higher than the Employees drove 68.3% of the expense in the top five health condition categories, the spouses drove 25.8% Health Condition Unique Claimants Inpatient Outpatient Professional Total % of Total Paid Amount per Unique Claimant Neoplasms - Malignant 196 $604,376 $3,288,504 $456,822 $4,349, % $22,192 Musculoskeletal System 1,377 $944,710 $616,940 $1,185,727 $2,747, % $1,995 Aftercare 118 $259,881 $1,654,590 $124,343 $2,038, % $17,278 Digestive System 564 $963,017 $402,765 $370,810 $1,736, % $3,079 Health Status 2,679 $0 $707,911 $1,023,381 $1,731, % $646 $90.00 $80.00 $70.00 $60.00 $50.00 $40.00 $30.00 $20.00 $10.00 $0.00 $82.98 $52.41 $23.63 Top Five Health Conditions By PMPM Current $37.62 $38.89 $33.13 $22.72 $33.03 $24.69 $10.51 Neoplasms - Malignant Musculoskeletal System Aftercare Digestive System Health Status 18

19 TOP THREE HEALTH CONDITIONS WITH TOP THREE DIAGNOSES HMO and PPO COMBINED Summary: The top five health conditions with the top three diagnoses represent $22.0M of total costs and affects 50.1% of unique claimants Health Conditions with Top Three Diagnoses Diagnoses Total Unique Claimants Neoplasms - Malignant % of Total Claimants % of Total Claimants MALIGNANT MELANOMA OF SKIN $1,474, % 0.1% MALIGNANT NEOPLASM OF BREAST $733, % 0.5% MALIGNANT NEOPLASM OF BRAIN $602, % 0.0% $6.00 $5.00 $4.00 $3.00 $2.00 $1.00 $0.00 $5.00 $4.00 $3.00 $2.00 $1.00 $0.00 $5.37 $4.29 $2.45 $1.68 $1.98 $1.69 $0.82 $0.00 $0.00 $0.00 PERVASIVE DEVELOPMENTAL DISORDERS $2.67 Behavioral Health MAJOR DEPRESSIVE DISORDER RECURRENT $2.20 $0.46 $0.00 $0.00 $0.00 MALIGNANT MELANOMA OF SKIN Neoplasms - Malignant $4.36 MALIGNANT NEOPLASM OF BREAST $0.96 MALIGNANT NEOPLASM OF BRAIN ALCOHOL RELATED DISORDERS PERVASIVE DEVELOPMENTAL DISORDERS MAJOR DEPRESSIVE DISORDER RECURRENT Behavioral Health $1,175, % 0.2% $673, % 1.8% ALCOHOL RELATED DISORDERS $543, % 0.4% Circulatory System ACUTE MYOCARDIAL INFARCTION $1,416, % 0.2% CHRONIC ISCHEMIC HEART DISEASE $454, % 1.3% $6.00 $5.00 $4.00 $3.00 $2.00 $1.00 $0.00 $5.16 $3.18 $4.39 $1.66 $1.38 $0.00 $0.00 $0.00 ACUTE MYOCARDIAL INFARCTION Circulatory System CHRONIC ISCHEMIC HEART DISEASE $1.32 CEREBRAL INFARCTION CEREBRAL INFARCTION $380, % 0.2% * This value is not shown due to small numbers. Current 19

20 TOP FACILITIES HMO and PPO COMBINED Inpatient Facility Name / Location Unique Claimants Paid Amount In-Network Paid Amount Per Claimant Percent of Total In-Network Cedars Sinai Medical Center - West Hollywood, CA 66 $3,208,528 $49, % Ronald Reagan UCLA Medical Center - Los Angeles, CA 26 $1,565,686 $74, % Keck Hospital of USC - Los Angeles, CA 10 $1,262,706 $126, % Northridge Hospital Medical Center - Northridge, CA 22 $968,275 $80, % Providence Little Company of Mary Med Ctr - Torrance, CA 31 $953,466 $39, % Total Inpatient Facility In-Network ,698,634 $36, % * Facility had less than 5 unique claimants Outpatient Facility Name / Location Unique Claimants Visits Paid Amount In-Network Paid Amount Per Claimant Percent of Total In-Network Cedars Sinai Medical Center West Hollywood, CA 497 1,795 $3,116,116 $7, % City of Hope National Medical Center Duarte, CA $2,779,068 $95, % Ronald Reagan UCLA Medical Center Los Angeles, CA $994,505 $4, % Torrance Memorial Medical Center Torrance, CA 531 1,244 $385,435 $1, % Keck Hospital of USC Los Angeles, CA $374,851 $3, % Total Outpatient Facility In-Network 5,075 17,580 $15,451,252 $4, % * Facility had less than 5 unique claimants 20

21 TOP HEALTH CONDITIONS BY RELATIONSHIP AND PMPM HMO and PPO COMBINED Summary: The Employee is responsible for 57.8% of spend; the Spouse is responsible for 21.3% and the Child 20.9% Neoplasms - Malignant: Employee represents 72.9% of the spend for this category Behavioral Health: Employee represents 32.1% of the spend for this category Employee Spouse Child Total Total Paid PMPM Paid PMPM Paid PMPM Paid Amount PMPM Neoplasms - Malignant $3,997,124 $32.56 $1,462,664 $27.58 $20,177 $0.20 $5,479,965 $19.97 Behavioral Health $1,598,875 $13.02 $586,300 $11.06 $2,791,380 $28.32 $4,976,555 $18.14 Circulatory System $3,081,225 $25.10 $955,041 $18.01 $104,786 $1.06 $4,141,052 $15.09 Musculoskeletal System $2,881,583 $23.47 $896,081 $16.90 $239,630 $2.43 $4,017,295 $14.64 Digestive System $1,826,355 $14.88 $698,690 $13.18 $824,089 $8.36 $3,349,135 $12.21 Injury & Poisoning $1,737,906 $14.15 $411,751 $7.76 $1,061,424 $10.77 $3,211,081 $11.70 Ill-Defined Conditions $1,597,340 $13.01 $646,795 $12.20 $475,116 $4.82 $2,719,252 $9.91 Health Status $1,286,323 $10.48 $508,591 $9.59 $644,311 $6.54 $2,439,224 $8.89 Aftercare $1,393,551 $11.35 $899,014 $16.95 $22,376 $0.23 $2,314,940 $8.44 Genitourinary System $1,283,467 $10.45 $647,060 $12.20 $186,969 $1.90 $2,117,495 $7.72 Subtotal $20,683,750 $ $7,711,987 $ $6,370,257 $64.62 $34,765,995 $ All Other $6,919,869 $56.36 $2,452,119 $46.24 $3,609,496 $36.62 $12,981,484 $47.31 Total $27,603,619 $ $10,164,106 $ $9,979,753 $ $47,747,478 $

22 TOP FIVE TARGETED HEALTH CONDITIONS - HMO Summary: For the top five target program conditions listed below, employees account for 61.4% of total paid claims. Depression Target Program Conditions By Prevalence/ Cancer Maternity Coronary Artery Disease Congestive Heart Failure Type Number of Claimants Paid Amount Inpatient Facility Outpatient Facility Professional Prevalence per 1,000 Prevalence per 1,000 Coronary Artery Disease 164 $1,374,572 $1,320,240 $42,579 $11, Cancer 301 $1,086,899 $561,473 $348,479 $176, Maternity 245 $828,033 $718,574 $87,416 $22, Depression 513 $645,275 $148,516 $110,034 $386, Congestive Heart Failure 41 $302,854 $291,952 $6,386 $4,

23 TOP FIVE TARGETED HEALTH CONDITIONS PPO Summary: For the top five target program conditions listed below, employees account for 66.4% of total paid claims. Prevalence of Low Back Pain, Depression, Cancer, and Coronary Artery Disease exceeded Low Back Pain Depression Target Program Conditions By Prevalence/1000 Current Cancer Coronary Artery Disease Maternity Type Number of Claimants Paid Amount Inpatient Facility Outpatient Facility Professional Prevalence per 1,000 Prevalence per 1,000 Cancer 165 $4,981,216 $823,946 $3,716,399 $440, Maternity 53 $514,084 $274,706 $51,950 $187, Depression 205 $246,433 $31,614 $41,987 $172, Low Back Pain 313 $242,149 $23,628 $103,112 $115, Coronary Artery Disease 65 $197,557 $125,960 $32,212 $39,

24 INPATIENT FACILITY METRICS - HMO Inpatient Facility Current Percent Variance Paid Amount $9,913,952 Paid Amount PMPM $44.67 $ % Acute Admissions Per % Annual Acute Days Per % Average Length Of Stay - Acute % Paid Amount Per Acute Admission $23,701 $21, % Inpatient Service Category Average LOS Admits/ 1000 Days/ 1000 Paid Amount Current PMPM Percent Variance Surgical $4,144,573 $18.67 $ % Medical $3,885,754 $17.51 $ % Maternity $883,391 $3.98 $ % Mental Health/Substance Abuse $756,285 $3.41 $ % Skilled Nursing $177,169 $0.80 $ % Rehabilitation * $66,780 $0.30 $ % Other $0 $0.00 -$ % Well New Born $0 $0.00 $ % Total * $9,913,952 $44.67 $ % * This value is not shown due to small numbers. 24

25 INPATIENT FACILITY METRICS PPO Inpatient Facility Current Percent Variance Paid Amount $8,961,007 Paid Amount PMPM $ $ % Acute Admissions Per % Annual Acute Days Per % Average Length Of Stay - Acute % Paid Amount Per Acute Admission $32,509 $21, % Inpatient Service Category Average LOS Admits/ 1000 Days/ 1000 Paid Amount Current PMPM Percent Variance Medical $4,417,287 $84.27 $ % Surgical $3,759,143 $71.71 $ % Maternity $495,712 $9.46 $ % Mental Health/Substance Abuse $235,420 $4.49 $ % Skilled Nursing $53,445 $1.02 $ % Other $0 $0.00 -$ % Rehabilitation $0 $0.00 $ % Well New Born $0 $0.00 $ % Total $8,961,007 $ $ % * This value is not shown due to small numbers. 25

26 OUTPATIENT FACILITY METRICS - HMO Top Five Outpatient Facility Percent of Spend By Service Category 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 36.8% 29.8% 10.0% 5.0% 0.0% 7.2% 1.4% 0.6% Emergency Room Surgery FACILITY OP - MH/SA Radiology Lab & Pathology Top Five Outpatient Service Categories Visits per 1,000 Current Paid PMPM Paid PMPM Percent Variance Emergency Room $9.41 $ % Surgery 66.7 $7.62 $ % FACILITY OP - MH/SA 67.8 $1.83 $ % Radiology 62.8 $0.35 $ % Lab & Pathology 22.3 $0.15 $ % All Outpatient $25.55 $ % 26

27 OUTPATIENT FACILITY METRICS - PPO Top Five Outpatient Facility Percent of Spend By Service Category 25.0% 20.0% 19.9% 15.0% 10.0% 9.5% 9.0% 5.0% 4.7% 4.1% 0.0% Surgery Emergency Room Radiology FACILITY OP - MH/SA Lab & Pathology Top Five Outpatient Service Categories Visits per 1,000 Current Paid PMPM Paid PMPM Percent Variance Surgery $40.28 $ % Emergency Room $19.37 $ % Radiology $18.35 $ % FACILITY OP - MH/SA $9.62 $ % Lab & Pathology $8.30 $ % All Outpatient 1,763.4 $ $ % 27

28 PROFESSIONAL METRICS HMO and PPO Professional Service Categories Visits Per 1,000 Total Paid Current PMPM Prior PMPM Trend PMPM Variance to Office/Home Visits 2,575.6 $1,716,527 $6.26 $ % $ % Mental Health / Substance Abuse $1,144,860 $4.17 $ % $ % OP Surgery $944,535 $3.44 $ % $ % Preventive Services $943,731 $3.44 $ % $ % Professional Other $902,195 $3.29 $ % $ % Medical $868,753 $3.17 $ % $ % Lab & Pathology 1,002.3 $851,706 $3.10 $ % $ % Therapeutic Injections 52.4 $846,394 $3.08 $ % $ % Radiology $749,662 $2.73 $ % $ % IP Surgery 36.0 $440,584 $1.61 $ % $ % IP Visits $416,520 $1.52 $ % $ % Maternity 15.7 $113,558 $0.41 $ % $ % Other $2,628,862 $9.58 $ % $ % Total 8,231.0 $12,567,886 $45.80 $ % $ % Online Care 2.9 $2,209 $0.01 $ % $ % $944,377 Top Five Provider Specialties by Paid Amount (Visits) $646,176 $640,454 $568,751 $515,104 Addiction Medicine (3,935) Psychologist (6,174) Clinical Laboratory (19,699) Psychiatry (3,769) Diagnostic Radiology (7,083) 28

29 REPORTING PARAMETERS Reporting Period(s) Medical Utilization Financials Paid during the following periods - Current Period - Jan Dec 2017 Medical Utilization: The is comprised of the Anthem Book of Business Members are defined as plan eligible Employees, Spouses and Child/dependents PMPM PMPM paid amount is the metric used throughout this analysis to understand paid amount trends by individual plan participants (per member) over the duration of the plan period (per month) High cost claimants (HCCs) are referenced in this analysis and are defined as those members with a cumulative total paid amount of medical claims $50,000 during the current reporting period High Cost Claimants HCC PMPM = Per Member Per Month cost of Members with paid claims $50K Adjusted PMPM = Per Member Per Month cost of Members with paid claims $50K Settings Plan expenditures and utilization are broken down into the following settings: Inpatient facility, Outpatient facility and Professional 29

30 TERMINOLOGY Adult Annual Well Visit: is the number of adult patients who received a well visit provided under medical coverage, expressed as a percentage of the average number of members for whom this test is appropriate. Candidates are members aged 21 or older with greater than 12 months of continuous enrollment, and a procedure code, or any diagnosis code equal to Well Visit. Adolescent Annual Well Visit: is the number of adolescent patients who received a well visit provided under medical coverage, expressed as a percentage of the average number of members for whom this test is appropriate. Candidates are members aged 12 to 20 with greater than 12 months of continuous enrollment, and a procedure code, or any diagnosis code equal to Well Visit. Admissions Per 1,000 (IP Admits): is the average number of admissions per 1,000 members per year. Allowed Amount: is the amount of submitted charges eligible for payment. Average Length of Stay: is the average number of days per Inpatient admission. Baby Routine Well Visits: is the average number of Outpatient professional well child visits provided to children aged 0 through 15 months under medical coverage, per 1,000 members aged 0 through 15 months with medical coverage per year. The number of visits is based on the count of unique patient, service date, and provider combinations. Cervical Cancer Screening Rate: is the number of patients who received facility or professional cervical Cancer screening services provided under medical coverage, expressed as a percentage of the average number of members for whom this test is appropriate. Candidates for cervical Cancer screening tests are defined as females aged 21 to 64 years. Child Routine Well Visits: is the average number of Outpatient professional well child visits provided to children aged 3 through 6 years under medical coverage, per 1,000 members aged 3 through 6 years with medical coverage per year. The number of visits is based on the count of unique patient, service date, and provider combinations. Childhood Immunization Services: is the average number of immunization services provided to children aged 0 through 23 months under medical coverage, per 1,000 members aged 0 through 23 months with medical coverage per year. Cholesterol Screening Rate: is the number of patients who received facility or professional cholesterol screening services provided under medical coverage, expressed as a percentage of the average number of members for whom this test is appropriate. Candidates are defined as males aged 35 years and older, and females aged 45 years and older. Claimant: A subscriber or dependent who received medical services covered under the health plan. Colon Cancer Screening Rate: is the number of patients who received facility or professional colon Cancer screening services provided under medical coverage, expressed as a percentage of the average number of members for whom this test is appropriate. Candidates for colorectal Cancer screening tests and procedures are defined as adults aged 50 to 75 years of age. 30

31 TERMINOLOGY Contract Size: is the average number of family members per employee or subscriber. Cost Share: is the amount paid out-of-pocket by the member for healthcare services. This generally includes coinsurance, copayment, and deductible amounts. Days Per 1,000: is the average number of days from admissions per 1,000 members per year. Discount Savings: Savings resulted from discounts for network providers. High Cost Claimants (HCC): are individuals with $75,000 or more in claims during the analyzed period. Mammogram Screening Rate: is the number of patients who received facility or professional mammography services provided under medical coverage, expressed as a percentage of the average number of members for whom this test is appropriate. Candidates for breast Cancer screening procedures are defined as females aged 40 to 69 years. OP Facility Visits Per 1,000: is the average number of Outpatient facility visits, per 1,000 members with medical coverage per year. Out-of-Pocket (OOP): is the amount paid out-of-pocket by the member healthcare services. This generally includes coinsurance, copayment, and deductible amounts. Paid Amount: is the amount the plan paid. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted. PEPM/PEPY: Per Employee Per Month and Per Employee Per Year. PMPM/PMPY: Per Member Per Month and Per Member Per Year. Members are defined as all participants in the plan including employees, spouses, and dependents. PSA Screening Rate: is the number of patients who received facility or professional Prostate Specific Antigen (PSA) screening services provided under medical coverage, expressed as a percentage of the average number of members for whom this test is appropriate. Candidates for prostate Cancer screening tests are defined as males aged 50 to 70 years. Visits Per 1,000 ER: is the average number of emergency room facility visits per 1,000 members with medical coverage. Visits Per 1,000 OP Facility: is the average number of OP Facility visits, per 1,000 members with medical coverage per year. Visits Per 1,000 Professional Office: is the average number of Professional Office visits, per 1,000 members with medical coverage per year. 31

32 HEALTH CONDITION DESCRIPTIONS AFTERCARE (ICD-10: Z51) Definition: Encounter for other aftercare (typically cancer). Examples: Chemotherapy, radiotherapy, immunotherapy. BEHAVORIAL HEALTH DISORDERS (ICD-9: ) (ICD-10: F01-F99 excluding F49) Definition: Illness caused by psychiatric or psychological conditions. Examples: Drug and alcohol abuse, anorexia nervosa, bulimia, depression, paranoia, schizophrenia. CANCER SCREENINGS (ICD-10: Z08, Z12) Definition: Screening for cancer and cancer precursors in asymptomatic individuals so that early detection and treatment can be provided for those who test positive for disease. Examples: Colon cancer screening, breast cancer screening, prostate cancer screening. CIRCULATORY SYSTEM (ICD-9: ) (ICD-10: I00-I02, I05-I15, I20-I28, I30-I52, I60-I89, I95-I99) Definition: Illness caused by heart and blood vessel disorders. Examples: High or low blood pressure, hemorrhoids, varicose veins, heart attack, heart valve disease, stroke, aneurysm. CONGENITAL ABNORMALITIES (ICD-9: ) (ICD-10: Q00-Q07, Q10-Q18, Q20-Q28, Q30-Q45, Q50-Q56, Q60-Q99) Definition: Congenital malformations, deformations and chromosomal abnormalities. Examples: Cleft palate and/or lip, Down's syndrome, hydrocephalus, congenital cataracts, abnormal fetal development of the eyes, ears, nose, face, heart, lungs, etc. DIGESTIVE SYSTEM (ICD-9: ) (ICD-10: K00-K14, K20-K31, K35-K38, K40-K46, K50-K52, K55-K68, K70-K77, K80-K87, K90-K95) Definition: Illness caused by disorders of the teeth, mouth, jaw, salivary glands, esophagus, stomach, intestine, rectum, gallbladder, and liver. Examples: Dental cavities, ulcers, appendicitis, hernias, noninfectious colitis, anal fissure, gall stones, cirrhosis of the liver. DISEASES OF THE BLOOD (ICD-9: ) (ICD-10: D50-D53, D55-D78, D80-D89) Definition: Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism. Examples: Anemia, hemophilia, blood and spleen disorders. DISEASES OF THE EAR (ICD-10: H60-H62, H65-H75, H80-H83, H90-H95) Definition: Disease of the auditory and mastoid processes. Examples: Otitis media, hearing loss, middle ear mastoid 32

33 HEALTH CONDITION DESCRIPTIONS DISEASES OF THE EYE (ICD-10: H00-H05, H10-H11, H15-H22, H25-H28, H30-H36, H40-H44, H46-H47, H49-H57, H59) Definition: Disease of the visual sensory and adnexa processes. Examples: Retinal detachments and breaks, glaucoma, cataracts, corneal scars and opacities ENDOCRINE/METABOLIC (ICD-9: ) (ICD-10: E00-E13, E15-E16, E20-E36, E40-E46, E50-E68, E70-E89) Definition: Endocrine - illness caused by increased, decreased, or imbalanced hormones. Metabolic - illness caused by the body's inability to turn food into energy. Examples: Thyroid disease, diabetes, parathyroid disease, ovarian and testicular hormonal disease, vitamin and mineral excess or deficiency, obesity. GENITOURINARY SYSTEM (ICD-9: ) (ICD-10: N00-N08, N10-N23, N25-N53, N60-N65, N70-N77, N80-N99) Definition: Illness caused by disorders of the kidney, bladder, prostate, testes, breast, ovaries, and uterus. HEALTH STATUS (ICD-9: V01-V83) (ICD-10: Z00-Z04, Z18, Z20-Z23, Z28, Z30, Z40-Z49, Z52-Z53, Z55-Z57, Z59-Z60, Z62-Z93, Z95-Z99) Definition: Occasions when circumstances other than a disease or injury exists that are not classifiable to the other ICD-9 OR ICD-10 categories. This occurs in one of two ways: 1) when a person is not currently sick but encounters health services for some specific purpose, such as organ donation, vaccination, or to discuss a problem which itself is not an injury or disease; 2) some circumstance or problem is present which influences the persons health status but it is not a current illness or injury. Examples: General medical exam, contraceptive management, personal history of disease, post-procedural aftercare ILL-DEFINED CONDITIONS (ICD-9: ) (ICD-10: R00-R23, R25-R94, R97, R99) Definition: This classification will be utilized when 1) cases for which no more specific ICD-10 diagnosis code can be made even after all of the facts bearing on a case have been investigated; 2) signs or symptoms existing at the time of the initial visit proved to be short term, and the cause has not or could not be determined; and 3) the symptoms represent important medical problems, and the physician desired to classify the symptom and an additional ICD-10 diagnosis code. Examples: 'Symptoms' include fainting, convulsions, fever, edema, headache, shock, chest pain, nausea, etc. 'Signs' include nonspecific abnormal blood tests, urine tests, x-rays, EEG, EKG, etc. 'Ill-defined conditions' include senility, crib death, nervousness, etc. INFECTIOUS/PARASITIC (ICD-9: ) (ICD-10: A00-A09, A15-A28, A30-A99, B00-B10, B15-B20, B25-B83, B85-B97, B99) Definition: A disease caused by bacteria, germs, virus, or parasites (e.g., worms, ticks). The illness may be contagious. Examples: Infectious diarrhea, chicken pox, measles, herpes, viral hepatitis, bacterial meningitis, food poisoning, blood poisoning, tuberculosis, AIDS. INJURY & POISONING (ICD-9: ) (ICD-10: S00-S99, T07, T14-T88) Definition: Injury, poisoning and certain other consequences of external causes. Examples: Procedural complications, dislocations & sprains, fractures, open wounds. 33

34 HEALTH CONDITION DESCRIPTIONS INJURY & POISONING - EXTERNAL (ICD-9: V00-V99, W00-W74, W85-W99, X00-X08, X10-X19, X30-X39, X52-X58, X71-X83, X92-X99, Y00-Y09, Y21-Y33, Y35-Y38, Y62-Y84, Y90-Y99) (ICD-10: E000-E019, E029, E030, E800-E807, E810-E838, E840-E857, E860-E876, E878-E888, E890-E907, E909-E960, E962-E989, E991-E999) Definition: External causes of morbidity. Examples: Burns, falls, transportation accidents. MATERNAL COMPLICATION OF PREGNANCY (ICD-10: O10-O16, O20-O48, O60-O77, O85-O92, O94, O98, O99, O9A) Definition: Pregnancy, childbirth and the puerperium. Examples: Abnormality of pelvic region, perineal laceration during delivery, obstetric trauma. MATERNAL OUTCOME OF DELIVERY (ICD-10: O00-O08, O80-O82, Z37, Z3A) Definition: Pregnancy, childbirth and the puerperium/factors influencing health status and contact with health services. Examples: Full-term uncomplicated delivery, ectopic pregnancy, hydatidiform mole. MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUES (ICD-9: ) (ICD-10: M00-M02, M05-M19, M1A, M20-M27, M30-M36, M40-M43, M45-M51, M53-M54, M60-M63, M65-M67, M70-M96, M99) Definition: Illness caused by disorders of the joints, muscles, ligaments, and bone (excluding fractures). Examples: Arthritis, back pain, bursitis, ganglions, bunions. NEOPLASMS, BENIGN (ICD-10: D10-D36, D3A) Definition: A tumor or cell growth that does not spread beyond its origin (non-cancer). Examples: Benign neoplasm of meninges (brain), benign neoplasm of colon, leiomyoma of uterus. NEOPLASMS, MALIGNANT (ICD-10: C00-C26, C30-C41, C43-C49, C4A, C50-C58, C60-C79, C7A, C7B, C80-C96, D00-D09) Definition: A tumor or uncontrolled cell growth (Cancer). Examples: Hodgkin lymphoma, lymphoid leukemia, malignant neoplasm of breast, multiple myeloma. NEOPLASMS, UNCERTAIN/UNSPECIFIED (ICD-10: D37-D49) Definition: A tumor or uncontrolled cell growth whose behavior is unknown or not specified. NERVOUS SYSTEM (ICD-9: ) (ICD-10: G00-G14, G20-G26, G30-G32, G35-G37, G40-G47, G50-G65, G70-G73, G80-G83, G89-G99) Definition: Nervous system - illness caused by brain, spinal cord, and nerve disorders. Sense organs - illness caused by disorders of the eyes and ears. Examples: Migraine headache, meningitis, encephalitis, Alzheimer's disease, Parkinson s disease, cerebral palsy, muscular dystrophy, quadriplegia, epilepsy, cataract, retinal detachment, glaucoma, color blindness, otitis media, hearing loss. 34

35 HEALTH CONDITION DESCRIPTIONS NEWBORN INITIAL RECORD (ICD-10: Z38) Definition: Code used to designate the birth of a newborn infant. NON-CANCER RELATED SCREENING AND TESTING (ICD-10: Z09-Z11, Z13-Z17, Z32) Definition: Diagnostic codes related to the treatment of various (non-cancer) diseases and conditions. Examples: Genetic carrier testing, pregnancy testing, infectious and parasitic disease testing. PROCREATIVE MANAGEMENT (ICD-10: Z31) Definition: Services related to the treatment of infertility. RESPIRATORY SYSTEM (ICD-9: ) (ICD-10: J00-J06, J09-J18, J20-J22, J30-J47, J60-J70, J80-J86, J90-J99) Definition: Illness caused by nose, larynx, bronchus, and lung disorders. Examples: Common cold, laryngitis, tonsillitis, deviated nasal septum, viral pneumonia, emphysema, asthma, lung disease. SHORT GESTATION, LOW BIRTH WEIGHT (ICD-10: P07) Definition: Services related to the occurrence and care of a low birth weight infant. SUPERVISION OF PREGNANCY (ICD-10: O09, Z33-Z34, Z36, Z39) Definition: Services related to pregnancy and related care. Examples: Supervision of normal pregnancy, supervision of high risk pregnancy, postpartum care and examination. TRANSPLANT EXCLUDES COMPLICATIONS (ICD-10: Z94) Definition: Care related to the identification, preparation, and surgical removal of a healthy organ from one person and its transplantation into another person whose organ has failed or was injured. Examples: Heart transplant, kidney transplant, bone marrow transplant, liver transplant. 35