Type 2 Diabetes Report 2016

Transcription

1 NEW Chronic Disease Disability Claims Data Business Group on Health TBGH Business Group on Health Type 2 Diabetes Report 2016 Featuring Demographic, Utilization, Charge, and Pharmacotherapy Data With a Special Focus on With Cardiovascular Disease 11th Edition SINCE 1987 MANAGED CARE DIGEST SERIES

2 TEXAS TYPE 2 DIABETES REPORT 2016 Introduction Sanofi U.S. (Sanofi), Regeneron, and the Business Group on Health (TBGH) are pleased to present the 11th edition of the Type 2 Diabetes Report for 2016, an overview of demographic, financial, utilization, and pharmacotherapy measures for Type 2 diabetes patients in key local markets across the state of. The Report, intended to help providers and employers better identify opportunities to serve the needs of their patients, organizes Type 2 diabetes and lipid disorders benchmarks into 10 local markets and as a whole. All chronic disease patient claims and discharge data are drawn from the Managed Care Digest Series. Chronic disease disability claims data are provided by the Integrated Benefits Institute. Sanofi, as sponsor of this report, maintains an arm s-length relationship with the organizations that prepare this report and carry out the research. The desire of Sanofi is that the information in this report be completely independent and objective. The Type 2 Diabetes Report helps TBGH fulfill its mission of helping employers play an active and enthusiastic role in collaboration with health plans, providers, and purchasers, and be a catalyst in promoting cost- effective delivery of quality health care to the benefit of the community. This 11th edition features examples of the kinds of patient-level, disease-specific data on Type 2 diabetes and lipid disorders that can be provided by TBGH using the Managed Care Digest Series as a resource. Its focus on locales allows for heightened scrutiny of community progress with these patient populations. Most of the data (covering 2013 through 2015) were gathered by IMS Health, Parsippany, NJ, a leading provider of innovative health care data products and analytic services. The data provide employers with independent, third-party information against which they can benchmark their own data. Please see the back page for information on the data methodology. contents TBGH Members: Baptist Health System City of Frisco City of Plano Northside ISD Southwest Airlines Whataburger DFW Business Group on Health (161 Members) contacts Marianne Fazen, Ph.D. President & CEO Business Group on Health fazen@dfwbgh.org Glenn Beers Senior Employer Account Executive US Market Access glenn.beers@sanofi.com Mary Lynne Yeager Regional Account Executive US Market Access marylynne.yeager@sanofi.com SINCE 1987 MANAGED CARE DIGEST SERIES Provided by Sanofi U.S., Bridgewater, NJ Regeneron, Tarrytown, NY Developed and produced by Forte Information Resources, LLC, Denver, CO Data provided by IMS Health, Parsippany, NJ Introduction and Patient Count... 2 and Nation: Diabetes MSA Comparisons: A1c Levels... 5 MSA Comparisons: Charges... 6 : Diabetes Therapy Persistency... 7 MSAs: Diabetes Number of Type 2 Diabetes in Sample Austin Bryan/College Station Dallas El Paso , ,000 70,000 35, ,663 Austin 3,156 Bryan/ College Station 121,125 26,297 58,792 Ft. Worth/Arlington Galveston Houston Lubbock San Antonio Tyler MSA Comparisons: Lipid Disorders Disability Claims Position Statement/Methodology A1: TOTAL NUMBER OF TYPE 2 DIABETES PATIENTS TRACKED IN THIS REPORT, BY MARKET, , ,690 8,123 51,289 Dallas El Paso Ft. Worth/ Galveston Houston Lubbock San Arlington Antonio : 659,907 Nation: 9,103,288 NOTE: Throughout this report, the Austin market includes San Marcos, and the Galveston market includes City. 12,407 Tyler 2 TEXAS TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

3 TEXAS AND NATION: DIABETES B1: DEMOGRAPHICS: AGE AND GENDER, Percentage of Type 2 Diabetes Nation AGE GROUP % 0.5% 0.8% 0.4% 0.5% 1.0% GENDER Male 45.6% 45.9% 45.9% 46.7% 46.8% 46.9% Female B2: DEMOGRAPHICS: COMORBIDITIES AND COMPLICATIONS, ,3 Percentage of Type 2 Diabetes Nation ACTUAL COMORBIDITIES Depression 8.6% 8.6% 9.9% 10.4% Hyperlipidemia Hypertension Obesity ACTUAL COMPLICATIONS Cardiovascular Disease 49.6% 46.4% 51.5% 48.8% Hypoglycemia Nephropathy Neuropathy PAD Average Length of Stay (Days) B3: AVERAGE LENGTH OF STAY PER INPATIENT DIABETES MELLITUS CASE, $3,200 $2,400 $1,600 $800 $0 4.4 B5: PROFESSIONAL CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, COMMERCIAL INSURANCE PAYERS, ,7 $2,952 $3,078 Inpatient Nation $1,338 $1,242 Outpatient $58,000 $51,000 $44,000 $37,000 $30,000 $2,455 $2,401 Ambulatory Surgery B4: CHARGES PER INPATIENT DIABETES MELLITUS CASE, ,5 $49,045 $1,769 $53,753 $1,283 Emergency Room 2013 $41,107 $1,950 Nation Office/ Clinic $43,935 1 On all pages, the percentages are representative of the universe of Type 2 diabetes patients on whom claims data have been collected in a given year. 2 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, congestive heart failure, dysmetabolic syndrome, hyperlipidemia, hypertension, and obesity. 3 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, peripheral artery disease (PAD), and retinopathy. 4 Average length of stay (ALOS) and hospital inpatient charge data come from IMS Health s Procedure/Diagnosis (HPD) database and are current as of end-of-year. 5 Charge data are per-case averages for inpatients with a particular diagnosis of interest. Charges may be for treatment related to other diagnoses. Data reflect the total charges billed by the hospital for the entire episode of care, and may include accommodation, pharmacy, laboratory, radiology, and other charges not billed by the physician. Data do not necessarily indicate final amounts paid. 6 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 7 Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. Nation $1,885 TX TYPE 2 DIABETES PTS. ARE MORE APT TO HAVE CERTAIN COMPLICATIONS VS. NATION Type 2 diabetes patients were more likely to be diagnosed with a complication of hypoglycemia, nephropathy, neuropathy, or peripheral artery disease (PAD) than were their counterparts nationally in Furthermore, the shares of such patients who were diagnosed with any one of these four complications increased from to CHARGES PER IP DIABETES MELLITUS CASE IN TEXAS SURPASS THOSE OF U.S. In both 2013 ($49,045) and ($53,753), average charges per inpatient (IP) diabetes mellitus case in exceeded the corresponding national benchmarks ($41,107 and $43,935, respectively). Additionally, such charges in grew at a faster pace than did those nationwide during this period: 9.6% versus 6.9%. MANAGED CARE DIGEST SERIES TEXAS TYPE 2 DIABETES REPORT

4 TEXAS AND NATION: DIABETES TESTING RATES FOR TX TYPE 2 DIABETES PATIENTS ARE LOWER THAN U.S. MEANS In 2015, Type 2 diabetes patients in were less apt to receive any of the six profiled tests than were such patients across the nation. For instance, 69.5 Type 2 diabetes patients received an A1c test that year versus 74.0% of similar patients nationwide. SHARE OF TYPE 2 DIABETES PTS. IN TX USING THREE NON-INSULINS INCREASES The portion of Type 2 diabetes patients who filled prescriptions for three non-insulin antidiabetic products expanded from (7.9%) to 2015 (8.8%), and topped the U.S. benchmark in both years. 1 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 2 who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. 3 Figures reflect the per-patient yearly payments for Type 2 diabetes patients receiving a particular type of therapy. These are the actual amounts paid by the insurer and patient for such prescriptions. mainly include copayments, but can also include tax, deductibles, and cost differentials where applicable. Percentage of Percentage of 90% 80% 70% 60% 50% 20% 15% 10% 5% 0% B6: UTILIZATION: PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY SERVICE, % A1c Test 1 B7: PHARMACOTHERAPY: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING COMBINATION THERAPIES, % 74.0% 7.9% 84.0% 86.6% 80.1% Blood Glucose Test 18.7% Serum Cholesterol Test Use of 2 Non- Use of 3 Non- 8.8% 84.3% 76.4% Glucose Test 18.9% 83.8% 63.0% Microalbumin Test 7.2% 71.3% Use of 2 Non Use of 3 Non Nation 18.7% B8: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, % Ophthalmologic Examination Long-Acting Rapid-Acting Short-Acting Mixed 35.0% 20.5% 8.0% 10.4% 5.9% 10.4% 7.5% 2.8% 3.2% NATION 34.0% 19.1% 8.9% 10.7% 7.1% 10.7% 8.4% 2.3% 2.4% B9: AVERAGE ANNUAL PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, ,3 Long-Acting Rapid-Acting Short-Acting Mixed $3,648 $2,464 $2,330 $2,250 $2,427 $2,250 $2,250 $3,319 $2,122 NATION $3,792 $2,440 $2,445 $2,290 $2,556 $2,290 $2,512 $3,372 $2, % Nation 69.4% B10: PERCENTAGE OF AND AVERAGE ANNUAL PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING NON-INSULIN THERAPIES, ,3 Non- Antidiabetic Product Biguanides DPP-4 Inhibitors GLP-1 Long-Acting Sensitizing Agents Sulfonylureas SGLT-2 Inhibitors 86.3% $1, % $ % $2, % $2, % $ % $63 9.2% $2,111 NATION 85.8% $1, % $ % $2, % $2, % $ % $75 6.8% $2,165 Biguanides Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibitors Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. Sensitizing Agents Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting replacement product with a long duration of action. Mixed replacement product combining a short-acting and an intermediate-acting insulin product. Rapid-Acting replacement product with a rapid onset and shorter duration of action than short-acting insulin. Short-Acting replacement product with a short onset of action and duration. Sodium/Glucose Cotransporter 2 (SGLT-2) Inhibitors Lower blood glucose concentration so that glucose is excreted instead of reabsorbed. Sulfonylureas Stimulate the release of insulin in the pancreas. 4 TEXAS TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

5 TEXAS MSA COMPARISONS: A1c LEVELS Percentage of Percentage of 60% 45% 30% 15% 0% 60% 45% 30% 15% 0% C1: PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY A1c LEVEL RANGE, % 47.4% 20.7% 20.4% 16.2% Austin 13.3% 18.9% C2: PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY A1c LEVEL RANGE FOR COMMERCIAL PAYERS, ,2 17.6% 51.8% C3: PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY A1c LEVEL RANGE FOR COMMERCIAL PAYERS, ,2 39.3% 7.0% % % >9.0% MARKET Austin 43.8% 44.6% 19.4% 20.4% 14.8% 15.8% 21.9% 19.2% Bryan/College Station Dallas El Paso Ft. Worth/Arlington Galveston Houston Lubbock San Antonio Tyler NATION 47.2% 48.3% 21.5% 21.4% 14.1% 13.7% 17.2% 16.6% 16.5% Bryan/ College Station 20.4% 11.8% 19.9% 20.0% 20.4% 48.1% 42.8% 21.1% Dallas El Paso Ft. Worth/ Arlington 23.3% 13.7% 16.7% 17.0% 17.3% 7.0% % % >9.0% 44.0% 7.0% % % >9.0% 49.6% 21.9% 18.9% 16.9% 12.9% 17.2% 18.6% 50.5% 46.1% 21.8% 21.5% 12.7% 14.6% 15.0% 17.8% 48.0% 47.7% 18.9% Galveston 21.7% Houston Lubbock San Antonio Tyler Nation 12.4% 13.9% 20.7% 16.7% PORTION OF TEXAS TYPE 2 DIABETES PATIENTS WITH AN A1c LEVEL >9.0% IS HIGH The percentage of Type 2 diabetes patients in (17.3%) with an A1c level greater than 9.0% on their latest test surpassed that of the nation (16.6%) in Seven of the 10 local markets profiled had higher shares of such patients than that of the nation; Lubbock (23.5%) recorded the largest portion of such patients among the profiled markets that year, followed by Galveston (20.5%). TX TYPE 2 DIABETES PTS. WITH COMM. INS. ARE MORE LIKELY TO HAVE AN A1c >9.0% VS. U.S. In 10 of the 11 markets profiled, the shares of Type 2 diabetes patients covered by commercial insurers with an A1c level above 9.0% topped the corresponding national benchmark (16.7%) in Furthermore, in Bryan/ College Station, Galveston, and Lubbock, at least one in five Type 2 diabetes patients with commercial insurance recorded a poorly controlled A1c level on their most recent test. Meanwhile, Ft. Worth/ Arlington (15.0%) was the only profiled market in which this percentage fell below the U.S. mean. 1 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentages of Type 2 diabetes patients who have had at least one A1c test in a given year. 2 Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. NOTE: Some data were unavailable for Bryan/College Station. MANAGED CARE DIGEST SERIES TEXAS TYPE 2 DIABETES REPORT

6 TEXAS MSA COMPARISONS: CHARGES PROVIDER CHARGES FOR TEXAS TYPE 2 DIABETES PTS. TOP NATIONAL AVERAGES In 2015, average annual professional charges for Type 2 diabetes patients in surpassed the corresponding U.S. means in all five settings shown. Most notably, such emergency room charges for Type 2 diabetes patients ($2,295) exceeded those of the nation ($1,534) by nearly 50%. D1: PROFESSIONAL CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, Inpatient Outpatient Ambulatory Surgery Center Emergency Room Office/ Clinic MARKET Austin $2,291 $2,273 $1,050 $1,064 $3,111 $2,578 $2,054 $2,138 $1,796 $1,848 Bryan/College Station 2,199 2,429 1,368 1,202 3,445 3,327 2,297 2,613 1,011 1,195 Dallas 4,111 3,821 1,714 1,672 3,599 3,316 2,017 2,270 2,495 2,362 El Paso 2,645 2, ,096 2,493 2,637 2,074 2,719 2,166 2,214 Ft. Worth/Arlington 4,639 4,176 1,835 1,752 3,377 3,161 2,244 2,596 2,976 2,950 Galveston 4,463 4,165 1,769 1,600 3,304 2,895 2,757 2,587 1,587 1,546 Houston 4,412 4,267 1,431 1,485 3,311 2,919 2,133 2,475 2,445 2,178 Lubbock 3,494 3,075 1,514 1,497 sx3,995 2,890 1,356 1,474 1,900 1,747 San Antonio 3,166 3,052 1,551 1,497 2,820 2,602 1,696 1,904 2,073 1,919 Tyler 3,806 3,686 1,864 1,864 4,738 5,974 1,773 1,837 2,233 2,131 3,596 3,439 1,416 1,407 3,389 3,065 2,034 2,295 2,318 2,226 NATION $3,433 $3,316 $1,299 $1,291 $3,143 $2,963 $1,280 $1,534 $2,203 $2,163 D2: PROFESSIONAL OFFICE/CLINIC CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, Professional Charges $3,000 $2,250 $1,500 $750 $0 $1,796 $1,848 Austin $1,011 $1,195 Bryan/ College Station $2,362 $2,495 $2,166 $2,214 $2,976 $2,950 Dallas El Paso Ft. Worth/ Arlington $1,587 $1,546 $2,445 $2,178 $1,747 $1,900 $2,073 $1,919 Galveston Houston Lubbock San Antonio $2,131 $2,233 $2,226 $2, $2,203 $2,163 Tyler Nation D3: INPATIENT FACILITY CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, $60,000 $50,000 $40,000 $30,000 $20,000 $37,360 $39,888 $47,094 $55,238 $51,042 $42,807 $43,327 $41,761 $42,034 $40,912 Austin Bryan/ Dallas El Paso Ft. Worth/ College Station Arlington $46,420 $48,677 $44,460 $41,710 $42,155 $39,364 Galveston Houston Lubbock San Antonio $29,139 $30, $45,057 $43,183 $42,821 $41,589 Tyler Nation D4: INPATIENT FACILITY CHARGES FOR TYPE 2 DIABETES PATIENTS, OVERALL VERSUS TYPE 2 DIABETES PATIENTS WITH CARDIOVASCULAR DISEASE, ,3 $64,000 $53,000 $42,000 $31,000 $20,000 $39,888 $42,783 $47,094 Austin Bryan/ College Station $47,626 $42,807 $60,601 $55,238 Dallas El Paso Ft. Worth/ Arlington Overall $52,011 $48,326 $46,420 $48,677 $46,989 $43,327 $41,710 Houston Lubbock San Antonio $30,798 w/ Cardiovascular Disease $49,924 $47,582 $45,057 $43,183 Tyler Nation 1 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 2 Figures reflect the charges generated for Type 2 diabetes patients by the facilities that delivered care. Facility charge data include charges for all services rendered, including prevention and charges associated with the treatment of other diseases. The data also reflect the average amounts charged in Type 2 diabetes patient claims, not the amount paid. 3 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, peripheral artery disease (PAD), and retinopathy. NOTE: Some data were unavailable for the selected markets. 6 TEXAS TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

7 TEXAS: DIABETES THERAPY PERSISTENCY E1: TYPE 2 DIABETES PATIENTS USING VARIOUS INSULIN PRODUCTS, TEXAS, 2015 Percentage of 100% 84% 68% 52% 36% Long-Acting : Pens Short-Acting : Pens Rapid-Acting : Pens Mixed : Pens Long-Acting : Vials Short-Acting : Vials Rapid-Acting : Vials Mixed : Vials Mo. 1 Mo. 2 Mo. 3 Mo. 4 Mo. 5 Mo. 6 Mo. 7 Mo. 8 Mo. 9 Mo. 10 Mo. 11 Mo. 12 E2: TYPE 2 DIABETES PATIENTS OVERALL VS. TYPE 2 DIABETES WITH HYPOGLYCEMIA, VARIOUS INSULIN THERAPIES, TEXAS, Percentage of 100% 85% 70% 55% 40% Long-Acting Rapid-Acting Short-Acting Mixed Overall w/ Hypoglycemia Overall w/ Hypoglycemia Overall w/ Hypoglycemia Overall w/ Hypoglycemia Mo. 1 Mo. 2 Mo. 3 Mo. 4 Mo. 5 Mo. 6 Mo. 7 Mo. 8 Mo. 9 Mo. 10 Mo. 11 Mo. 12 E3: TYPE 2 DIABETES PATIENTS USING VARIOUS NON-INSULIN ANTIDIABETIC PRODUCTS, TEXAS, 2015 Percentage of 100% 86% 72% 58% 44% DPP-4 Inhibitors GLP-1 Receptor Agonists Sensitizing Agents SGLT-2 Inhibitors Mo. 1 Mo. 2 Mo. 3 Mo. 4 Mo. 5 Mo. 6 Mo. 7 Mo. 8 Mo. 9 Mo. 10 Mo. 11 Mo. 12 E4: TYPE 2 DIABETES PATIENTS OVERALL VS. TYPE 2 DIABETES WITH HYPOGLYCEMIA, VARIOUS NON-INSULIN ANTIDIABETIC THERAPIES, TEXAS, Percentage of 100% 83% 66% 49% DPP-4 Inhibitors GLP-1 Receptor Agonists Sensitizing Agents Overall Overall Overall w/ Hypoglycemia w/ Hypoglycemia w/ Hypoglycemia SGLT-2 Inhibitors Overall w/ Hypoglycemia 32% Mo. 1 Mo. 2 Mo. 3 Mo. 4 Mo. 5 Mo. 6 Mo. 7 Mo. 8 Mo. 9 Mo. 10 Mo. 11 Mo A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, peripheral artery disease (PAD), and retinopathy. NOTE: Persistency measures whether patients maintain their prescribed therapy. It is calculated by identifying patients who filled a prescription for the reported drug class in the four months prior to the reported year, and then tracking prescription fills for those same patients in each of the months in the current reported year. If a patient fills a prescription in a month, they are reported among the patients who have continued or restarted on therapy. Continued means that the patient has filled the drug group in each of the preceding months. Restarted means that the patient did not fill in one or more of the preceding months. Continuing and restarting patients are reported together. Persistency data track patients who are New-to-Brand, meaning they have not filled a prescription for their cohort product during the six months prior to initiation of therapy on that product. MANAGED CARE DIGEST SERIES TEXAS TYPE 2 DIABETES REPORT

8 AUSTIN F1: DEMOGRAPHICS: AGE AND GENDER, Percentage of Type 2 Diabetes Austin AGE GROUP % 0.4% 0.4% 0.8% GENDER Male 45.9% 46.4% 46.4% 45.9% Female F2: DEMOGRAPHICS: COMORBIDITIES AND COMPLICATIONS, ,3 Percentage of Type 2 Diabetes Austin ACTUAL COMORBIDITIES Depression 6.3% 6.5% 8.6% 8.6% Hyperlipidemia Hypertension Obesity ACTUAL COMPLICATIONS Cardiovascular Disease 46.3% 40.5% 49.6% 46.4% Hypoglycemia Nephropathy Neuropathy PAD AUSTIN TYPE 2 DIABETES PATIENTS ARE MORE LIKELY TO BE OF WORKING AGE In 2015, the percentage of Austin Type 2 diabetes patients who were between the ages of 18 and 64 (61.0%) was notably higher than the share of such patients across (49.6%) that year. Average Length of Stay (Days) F3: AVERAGE LENGTH OF STAY PER INPATIENT DIABETES MELLITUS CASE, Austin Austin 4.4 F4: CHARGES PER INPATIENT DIABETES MELLITUS CASE, ,5 $56,000 $52,000 $48,000 $44,000 $40,000 $48,292 Austin 2013 $54,050 $53,753 Austin RATE OF HYPERLIPIDEMIA AMONG AUSTIN TYPE 2 DIABETES PTS. IS HIGH VS. TEXAS Austin Type 2 diabetes patients were more likely to be diagnosed with a complication of hyperlipidemia (73.9%) than were similar patients statewide (59.7%). Meanwhile, the rate of hypoglycemia as a complication among Austin Type 2 diabetes patients (10.0%) was just slightly higher than that of (9.9%). $3,200 $2,400 $1,600 $800 $0 F5: PROFESSIONAL CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, COMMERCIAL INSURANCE PAYERS, ,7 $1,997 $2,077 Inpatient $2,952 $992 $1,032 $1,338 Outpatient $2,389 $2,135 $2,455 Ambulatory Surgery Center Austin Austin $1,660 $1,769 $1,635 $1,633 $1,491 Emergency Room Office/ Clinic $1,950 IP CHARGES PER AUSTIN DIABETES MELLITUS CASE INCREASE NOTABLY From 2013 ($48,292) to ($54,050), charges per inpatient diabetes mellitus case grew 11.9%, and exceeded the average ($53,753) in. 1 On all pages, the percentages are representative of the universe of Type 2 diabetes patients on whom claims data have been collected in a given year. 2 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, congestive heart failure, dysmetabolic syndrome, hyperlipidemia, hypertension, and obesity. 3 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, peripheral artery disease (PAD), and retinopathy. 4 Average length of stay (ALOS) and hospital inpatient charge data come from IMS Health s Procedure/Diagnosis (HPD) database and are current as of end-of-year. 5 Charge data are per-case averages for inpatients with a particular diagnosis of interest. Charges may be for treatment related to other diagnoses. Data reflect the total charges billed by the hospital for the entire episode of care, and may include accommodation, pharmacy, laboratory, radiology, and other charges not billed by the physician. Data do not necessarily indicate final amounts paid. 6 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 7 Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. 8 TEXAS TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

9 AUSTIN Percentage of 100% 85% 70% 55% 40% F6: UTILIZATION: PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY SERVICE, 2015 A1c, BLOOD GLUCOSE Austin Austin TESTING RATES FALL FOR AUSTIN TYPE 2 DIABETES PTS. 89.4% 88.7% From to 2015, the 86.4% 84.0% 85.3% 76.2% 78.6% 80.1% 77.5% percentages of Austin Type % 76.4% 66.6% 69.5% 60.9% 67.0% diabetes patients who received 63.0% 63.5% 60.3% either an A1c or blood glucose test declined. For example, the share of such Austin patients A1C Blood Serum Ophthalmologic Test 1 Glucose Test Cholesterol Test Glucose Test Microalbumin Test Examination who received an A1c test decreased to 77.5% from 78.6%. Percentage of 20% 15% 10% 5% 0% F7: PHARMACOTHERAPY: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING VARIOUS COMBINATION THERAPIES, % 7.8% Use of 2 Non- Use of 3 Non- Austin 17.4% 9.0% 18.6% Use of 2 Non Use of 3 Non % F8: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, % Long-Acting Rapid-Acting Short-Acting Mixed Austin 38.2% 24.1% 8.2% 15.0% 7.4% 15.0% 8.8% 2.0% 1.5% Austin % 20.5% 8.0% 10.4% 5.9% 10.4% 7.5% 2.8% 3.2% F9: AVERAGE PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, ,3 Long-Acting Rapid-Acting Short-Acting Mixed Austin $3,399 $2,168 $2,157 $1,993 $2,252 $1,993 $2,330 $2,928 $1,934 Austin ,209 2,683 2,444 2,512 3,017 2,512 3,162 3,354 2, $3,648 $2,464 $2,330 $2,250 $2,427 $2,250 $2,250 $3,319 $2, % 1 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 2 who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. 3 Figures reflect the per-patient yearly payments for Type 2 diabetes patients receiving a particular type of therapy. These are the actual amounts paid by the insurer and patient for such prescriptions. mainly include copayments, but can also include tax, deductibles, and cost differentials where applicable. Biguanides: Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibitors: Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. Sensitizing Agents: Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting : replacement product with a long duration of action. Mixed : replacement product combining a short-acting and an intermediate-acting insulin product. Rapid-Acting : replacement product with a rapid onset and shorter duration of action than short-acting insulin. Short-Acting : replacement product with a short onset of action and duration. Sodium/Glucose Cotransporter 2 (SGLT-2) Inhibitors: Lower blood glucose concentration so that glucose is excreted instead of reabsorbed. Sulfonylureas: Stimulate the release of insulin in the pancreas. F10: PERCENTAGE OF AND AVERAGE ANNUAL PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING NON-INSULIN THERAPIES, ,3 Non- Antidiabetic Product Biguanides DPP-4 Inhibitors GLP-1 Long-Acting Sensitizing Agents Sulfonylureas SGLT-2 Inhibitors Austin $1, % $ % $2, % $2, % $ % $82 7.3% $1,540 Austin , , , , $1, % $ % $2, % $2, % $ % $63 9.2% $2,111 MANAGED CARE DIGEST SERIES TEXAS TYPE 2 DIABETES REPORT

10 BRYAN/COLLEGE STATION G1: DEMOGRAPHICS: AGE AND GENDER, Percentage of Type 2 Diabetes Bryan/College Station AGE GROUP % 0.3% 1.0% 0.8% GENDER Male 44.2% 45.2% 45.9% 45.9% Female G2: DEMOGRAPHICS: COMORBIDITIES AND COMPLICATIONS, ,3 Percentage of Type 2 Diabetes Bryan/College Station ACTUAL COMORBIDITIES Depression 6.3% 6.9% 8.6% 8.6% Hyperlipidemia Hypertension Obesity ACTUAL COMPLICATIONS Cardiovascular Disease 56.1% 52.2% 49.6% 46.4% Hypoglycemia Nephropathy Neuropathy PAD RATES OF CV DISEASE, HYPOGLYCEMIA ARE ELEVATED IN BRYAN/COLLEGE STATION The percentages of Bryan/ College Station Type 2 diabetes patients diagnosed with a complication of cardiovascular disease (52.2%) or hypoglycemia (14.6%) exceeded the corresponding benchmarks (46.4% and 9.9%, respectively) in 2015, as did the share of Bryan/College Station Type 2 diabetes patients diagnosed with peripheral artery disease (PAD; 15.8% versus 15.3%). PROVIDER CHARGES CLIMB FOR BRYAN/COLLEGE STATION TYPE 2 DIABETES PTS. From to 2015, average annual professional charges for Bryan/College Station Type 2 diabetes patients with commercial insurance increased in four of five profiled settings (hospital outpatient excepted). For example, such emergency room charges grew 12.0%, and corresponding ambulatory surgery center charges jumped 21.7%. Average Length of Stay (Days) G3: AVERAGE LENGTH OF STAY PER INPATIENT DIABETES MELLITUS CASE, $3,200 $2,400 $1,600 $800 $ Bryan/College Station 2013 $1,823 $2,010 Inpatient Bryan/College Station $2,952 $900 $ G5: PROFESSIONAL CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, COMMERCIAL INSURANCE PAYERS, ,7 Bryan/College Station Bryan/College Station $1,338 Outpatient $1,660 $2,020 $2,455 Ambulatory Surgery Center G4: CHARGES PER INPATIENT DIABETES MELLITUS CASE, ,5 $2,084 $1,860 $1,769 Emergency Room $967 $1,151 Office/ Clinic $1,950 1 On all pages, the percentages are representative of the universe of Type 2 diabetes patients on whom claims data have been collected in a given year. 2 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, congestive heart failure, dysmetabolic syndrome, hyperlipidemia, hypertension, and obesity. 3 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, peripheral artery disease (PAD), and retinopathy. 4 Average length of stay (ALOS) and hospital inpatient charge data come from IMS Health s Procedure/Diagnosis (HPD) database and are current as of end-of-year. 5 Charge data are per-case averages for inpatients with a particular diagnosis of interest. Charges may be for treatment related to other diagnoses. Data reflect the total charges billed by the hospital for the entire episode of care, and may include accommodation, pharmacy, laboratory, radiology, and other charges not billed by the physician. Data do not necessarily indicate final amounts paid. 6 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 7 Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. $56,000 $51,000 $46,000 $41,000 $36,000 $46,002 Bryan/College Station 2013 $47,592 Bryan/College Station $53, TEXAS TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

11 BRYAN/COLLEGE STATION Percentage of 90% 80% 70% 60% 50% G6: UTILIZATION: PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY SERVICE, % 64.2% A1c Test % 84.0% 80.5%81.0% Blood Glucose Test Bryan/College Station Bryan/College Station % 77.5% 80.1% 74.2% 72.7% 76.4% Serum Cholesterol Test Glucose Test 63.0% 62.9% 62.7%63.5% 60.0% 60.2% Microalbumin Test Ophthalmologic Examination TESTING RATES INCREASE FOR BRYAN/COLLEGE STATION TYPE 2 DIABETES PATIENTS The shares of Bryan/College Station Type 2 diabetes patients who received an A1c, blood glucose, serum cholesterol, or urine microalbumin test all grew from to 2015, but still trailed the benchmarks in Percentage of 20% 15% 10% 5% 0% G7: PHARMACOTHERAPY: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING VARIOUS COMBINATION THERAPIES, % G8: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, Long-Acting Rapid-Acting Short-Acting Mixed Bryan/College Station 37.9% 21.1% 7.6% 7.9% 8.3% 7.9% 9.8% 3.3% 3.0% Bryan/College Station % 20.5% 8.0% 10.4% 5.9% 10.4% 7.5% 2.8% 3.2% G9: AVERAGE PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, ,3 8.9% Bryan/College Station Use of 2 Non- Use of 3 Non- 16.8% 9.6% Long-Acting Rapid-Acting Short-Acting Mixed Bryan/College Station $2,988 $1,890 $2,440 $1,639 $2,577 $1,639 $2,578 $2,722 $2,412 Bryan/College Station ,552 2,528 2,748 1,759 2,734 1,759 2,774 3,498 2, $3,648 $2,464 $2,330 $2,250 $2,427 $2,250 $2,250 $3,319 $2, % Use of 2 Non Use of 3 Non % 18.7% 8.8% 1 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 2 who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. 3 Figures reflect the per-patient yearly payments for Type 2 diabetes patients receiving a particular type of therapy. These are the actual amounts paid by the insurer and patient for such prescriptions. mainly include copayments, but can also include tax, deductibles, and cost differentials where applicable. Biguanides: Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibitors: Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. Sensitizing Agents: Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting : replacement product with a long duration of action. Mixed : replacement product combining a short-acting and an intermediate-acting insulin product. Rapid-Acting : replacement product with a rapid onset and shorter duration of action than short-acting insulin. Short-Acting : replacement product with a short onset of action and duration. Sodium/Glucose Cotransporter 2 (SGLT-2) Inhibitors: Lower blood glucose concentration so that glucose is excreted instead of reabsorbed. Sulfonylureas: Stimulate the release of insulin in the pancreas. G10: PERCENTAGE OF AND AVERAGE ANNUAL PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING NON-INSULIN THERAPIES, ,3 Non- Antidiabetic Product Biguanides DPP-4 Inhibitors GLP-1 Long-Acting Sensitizing Agents Sulfonylureas SGLT-2 Inhibitors Bryan/College Station $1, % $ % $1, % $2, % $ % $ % $1,643 Bryan/College Station , , , , $1, % $ % $2, % $2, % $ % $63 9.2% $2,111 MANAGED CARE DIGEST SERIES TEXAS TYPE 2 DIABETES REPORT

12 DALLAS H1: DEMOGRAPHICS: AGE AND GENDER, Percentage of Type 2 Diabetes Dallas AGE GROUP % 0.7% 0.9% 0.8% GENDER Male 47.0% 46.8% 46.9% 45.9% Female H2: DEMOGRAPHICS: COMORBIDITIES AND COMPLICATIONS, ,3 Percentage of Type 2 Diabetes Dallas ACTUAL COMORBIDITIES Depression 8.4% 8.5% 8.6% 8.6% Hyperlipidemia Hypertension Obesity ACTUAL COMPLICATIONS Cardiovascular Disease 46.4% 42.5% 49.6% 46.4% Hypoglycemia Nephropathy Neuropathy PAD MORE THAN 50% OF DALLAS TYPE 2 DIABETES PATIENTS ARE OF WORKING AGE In 2015, 51.3 Dallas Type 2 diabetes patients were between the ages of 18 and 64, compared with 49.6 such patients across. RATES OF NEPHROPATHY AND NEUROPATHY INCREASE FOR DALLAS TYPE 2 DIABETES PTS. The percentages of Dallas Type 2 diabetes patients diagnosed with a complication of nephropathy (42.5%) or neuropathy (35.7%) in 2015 were both higher than in (41.6% and 34.1%, respectively). ALOS PER IP DIABETES MELLITUS CASE IN DALLAS JUMPS, TOPS TEXAS MEAN From 2013 (4.1 days) to (4.6), average length of stay (ALOS) per inpatient (IP) diabetes mellitus case in Dallas grew by half a day, and exceeded the average (4.4) in. Meanwhile, charges per inpatient diabetes mellitus case in Dallas rose 14.0%, to $54,797 from $48,048, and eclipsed the statewide average ($53,753) in. H3: AVERAGE LENGTH OF STAY PER INPATIENT DIABETES MELLITUS CASE, Average Length of Stay (Days) $4,000 $3,000 $2,000 $1,000 $0 4.1 Dallas 2013 H5: PROFESSIONAL CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, COMMERCIAL INSURANCE PAYERS, ,7 $3,799 $3,423 Inpatient 4.6 Dallas $2,952 $1,729$1, $1,338 Outpatient $2,683 $2,570$2,455 Ambulatory Surgery Center H4: CHARGES PER INPATIENT DIABETES MELLITUS CASE, ,5 Dallas Dallas $1,636 $1,802 $1,769 Emergency Room $2,316 $2,198 $1,950 Office/Clinic 1 On all pages, the percentages are representative of the universe of Type 2 diabetes patients on whom claims data have been collected in a given year. 2 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, congestive heart failure, dysmetabolic syndrome, hyperlipidemia, hypertension, and obesity. 3 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, peripheral artery disease (PAD), and retinopathy. 4 Average length of stay (ALOS) and hospital inpatient charge data come from IMS Health s Procedure/Diagnosis (HPD) database and are current as of end-of-year. 5 Charge data are per-case averages for inpatients with a particular diagnosis of interest. Charges may be for treatment related to other diagnoses. Data reflect the total charges billed by the hospital for the entire episode of care, and may include accommodation, pharmacy, laboratory, radiology, and other charges not billed by the physician. Data do not necessarily indicate final amounts paid. 6 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 7 Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. $56,000 $52,000 $48,000 $44,000 $40,000 $48,048 Dallas 2013 $54,797 Dallas $53, TEXAS TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

13 DALLAS Percentage of Percentage of 86% 77% 68% 59% 50% 20% 15% 10% 5% 0% H6: UTILIZATION: PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY SERVICE, %68.0% 69.5% A1c Test % 84.0% Blood Glucose Test 19.1% 19.2% 8.2% Dallas 79.8% 79.4% 80.1% Serum Cholesterol Test Use of 2 Non- Use of 3 Non- 9.0% Dallas Dallas % 77.4% 76.4% Glucose Test H7: PHARMACOTHERAPY: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING VARIOUS COMBINATION THERAPIES, % 62.9% 62.3% 62.5% 63.0% 62.8% 63.5% Microalbumin Test Use of 2 Non Use of 3 Non % 18.7% Ophthalmologic Examination H8: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, Long-Acting Rapid-Acting Short-Acting Mixed Dallas 34.5% 17.4% 7.6% 9.3% 5.4% 9.3% 7.6% 3.5% 5.6% Dallas % 20.5% 8.0% 10.4% 5.9% 10.4% 7.5% 2.8% 3.2% H9: AVERAGE PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, ,3 Long-Acting Rapid-Acting Short-Acting Mixed Dallas $2,922 $2,011 $1,919 $1,790 $2,133 $1,790 $1,851 $2,727 $1,705 Dallas ,518 2,437 2,314 2,182 2,551 2,182 2,234 3,365 2, $3,648 $2,464 $2,330 $2,250 $2,427 $2,250 $2,250 $3,319 $2, % RATE OF A1c TESTING FALLS FOR DALLAS TYPE 2 DIABETES PATIENTS, TRAILS TEXAS MARK The share of Dallas Type 2 diabetes patients who received an A1c test in 2015 (68.0%) declined from (68.8%), and was lower than that of in 2015 (69.5%). Test rates for serum cholesterol, urine glucose, and urine microalbumin rose for similar Dallas patients. 1 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 2 who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. 3 Figures reflect the per-patient yearly payments for Type 2 diabetes patients receiving a particular type of therapy. These are the actual amounts paid by the insurer and patient for such prescriptions. mainly include copayments, but can also include tax, deductibles, and cost differentials where applicable. Biguanides: Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibitors: Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. Sensitizing Agents: Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting : replacement product with a long duration of action. Mixed : replacement product combining a short-acting and an intermediate-acting insulin product. Rapid-Acting : replacement product with a rapid onset and shorter duration of action than short-acting insulin. Short-Acting : replacement product with a short onset of action and duration. Sodium/Glucose Cotransporter 2 (SGLT-2) Inhibitors: Lower blood glucose concentration so that glucose is excreted instead of reabsorbed. Sulfonylureas: Stimulate the release of insulin in the pancreas. H10: PERCENTAGE OF AND AVERAGE ANNUAL PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING NON-INSULIN THERAPIES, ,3 Non- Antidiabetic Product Biguanides DPP-4 Inhibitors GLP-1 Long-Acting Sensitizing Agents Sulfonylureas SGLT-2 Inhibitors Dallas $ % $ % $1, % $2, % $ % $63 6.8% $1,387 Dallas , , , , $1, % $ % $2, % $2, % $ % $63 9.2% $2,111 MANAGED CARE DIGEST SERIES TEXAS TYPE 2 DIABETES REPORT

14 EL PASO I1: DEMOGRAPHICS: AGE AND GENDER, Percentage of Type 2 Diabetes El Paso AGE GROUP % 0.5% 1.0% 0.8% GENDER Male 40.1% 41.0% 41.2% 45.9% Female I2: DEMOGRAPHICS: COMORBIDITIES AND COMPLICATIONS, ,3 Percentage of Type 2 Diabetes El Paso ACTUAL COMORBIDITIES Depression 8.7% 8.8% 8.6% 8.6% Hyperlipidemia Hypertension Obesity ACTUAL COMPLICATIONS Cardiovascular Disease 48.4% 43.7% 49.6% 46.4% Hypoglycemia Nephropathy Neuropathy PAD RATES OF HYPERTENSION, OBESITY ARE HIGH AMONG EL PASO TYPE 2 DIABETES PTS. The percentages of El Paso Type 2 diabetes patients diagnosed with a comorbidity of hypertension (84.7%) or obesity (26.5%) in 2015 both surpassed the benchmarks (80.3% and 17.0%, respectively). El Paso Type 2 diabetes patients also had elevated rates of hypoglycemia (15.8%), neuropathy (36.9%), and peripheral artery disease (PAD; 20.2%) than their peers (9.9%, 36.5%, and 15.3%, respectively) that year. ALOS, CHARGES FOR EL PASO IP DIABETES MELLITUS CASES TOP TEXAS AVERAGES Average length of stay (ALOS) per inpatient (IP) diabetes mellitus case in El Paso rose notably from 2013 (7.0 days) to (7.8), and far exceeded the mean (4.4) in. Inpatient charges for such cases in El Paso grew 6.0% over this time, to $76,080 from $71,745, and also surpassed the benchmark ($53,753) by a substantial margin in. Average Length of Stay (Days) I3: AVERAGE LENGTH OF STAY PER INPATIENT DIABETES MELLITUS CASE, $3,600 $2,700 $1,800 $900 $0 7.0 El Paso 2013 I5: PROFESSIONAL CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, COMMERCIAL INSURANCE PAYERS, ,7 $2,247 $2,154 Inpatient 7.8 El Paso $2, $939 $1,008 $1,338 Outpatient $2,455 $2,168 $1,975 Ambulatory Surgery Center I4: CHARGES PER INPATIENT DIABETES MELLITUS CASE, ,5 El Paso El Paso $1,178 $1,950 $1,809 $1,859 $1,769 $1,723 Emergency Room Office/ Clinic 1 On all pages, the percentages are representative of the universe of Type 2 diabetes patients on whom claims data have been collected in a given year. 2 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, congestive heart failure, dysmetabolic syndrome, hyperlipidemia, hypertension, and obesity. 3 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, peripheral artery disease (PAD), and retinopathy. 4 Average length of stay (ALOS) and hospital inpatient charge data come from IMS Health s Procedure/Diagnosis (HPD) database and are current as of end-of-year. 5 Charge data are per-case averages for inpatients with a particular diagnosis of interest. Charges may be for treatment related to other diagnoses. Data reflect the total charges billed by the hospital for the entire episode of care, and may include accommodation, pharmacy, laboratory, radiology, and other charges not billed by the physician. Data do not necessarily indicate final amounts paid. 6 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 7 Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. $78,000 $69,000 $60,000 $51,000 $42,000 $71,745 El Paso 2013 $76,080 El Paso $53, TEXAS TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

15 EL PASO Percentage of Percentage of 88% 76% 64% 52% 40% 20% 15% 10% 5% 0% 84.0% I6: UTILIZATION: PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY SERVICE, 2015 A1c TESTING RATE FOR El Paso El Paso EL PASO TYPE 2 DIABETES PATIENTS RISES, LAGS TX MEAN From (64.1%) to % 82.8% 79.1% 78.6% 80.1% 76.0%75.8% 76.4% (65.7%), the share of El Paso 69.5% Type 2 diabetes patients who 64.1% 65.7% 61.7% 61.9% 63.0% 64.0% 65.4% 63.5% received an A1c test grew, but trailed the mark (69.5%) in Similar El Paso patients A1c Test % Blood Glucose Test 8.2% El Paso 18.3% Serum Cholesterol Test Use of 2 Non- Use of 3 Non- 8.9% Glucose Test 18.6% Microalbumin Test I7: PHARMACOTHERAPY: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING VARIOUS COMBINATION THERAPIES, % 18.7% Ophthalmologic Examination Use of 2 Non Use of 3 Non I8: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, Long-Acting Rapid-Acting Short-Acting Mixed El Paso 36.4% 21.7% 11.2% 10.9% 5.6% 10.9% 6.3% 2.5% 3.6% El Paso % 20.5% 8.0% 10.4% 5.9% 10.4% 7.5% 2.8% 3.2% I9: AVERAGE PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, ,3 Long-Acting Rapid-Acting Short-Acting Mixed El Paso $2,962 $1,997 $1,978 $1,769 $1,672 $1,769 $1,610 $2,350 $1,699 El Paso ,756 2,539 2,468 2,276 2,143 2,276 2,024 3,183 2, $3,648 $2,464 $2,330 $2,250 $2,427 $2,250 $2,250 $3,319 $2, % were also less apt than their peers to have a blood or urine glucose test in The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 2 who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. 3 Figures reflect the per-patient yearly payments for Type 2 diabetes patients receiving a particular type of therapy. These are the actual amounts paid by the insurer and patient for such prescriptions. mainly include copayments, but can also include tax, deductibles, and cost differentials where applicable. Biguanides: Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibitors: Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. Sensitizing Agents: Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting : replacement product with a long duration of action. Mixed : replacement product combining a short-acting and an intermediate-acting insulin product. Rapid-Acting : replacement product with a rapid onset and shorter duration of action than short-acting insulin. Short-Acting : replacement product with a short onset of action and duration. Sodium/Glucose Cotransporter 2 (SGLT-2) Inhibitors: Lower blood glucose concentration so that glucose is excreted instead of reabsorbed. Sulfonylureas: Stimulate the release of insulin in the pancreas. I10: PERCENTAGE OF AND AVERAGE ANNUAL PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING NON-INSULIN THERAPIES, ,3 Non- Antidiabetic Product Biguanides DPP-4 Inhibitors GLP-1 Long-Acting Sensitizing Agents Sulfonylureas SGLT-2 Inhibitors El Paso $ % $ % $2, % $1, % $ % $68 2.9% $1,383 El Paso , , , , $1, % $ % $2, % $2, % $ % $63 9.2% $2,111 MANAGED CARE DIGEST SERIES TEXAS TYPE 2 DIABETES REPORT