3 QUARTER FY UTILIZATION REVIEW 7/1/2010 TO … QUARTER FY UTILIZATION REVIEW –7/1/2010 TO...
14
EXPERTISE PARTNERSHIP VALUE May 16, 2011 3 RD QUARTER FY UTILIZATION REVIEW – 7/1/2010 TO 3/31/2011 T R E N D S A N A L Y S I S STATISTICS P L ANNING T O O L S
Transcript of 3 QUARTER FY UTILIZATION REVIEW 7/1/2010 TO … QUARTER FY UTILIZATION REVIEW –7/1/2010 TO...
E X P E R T I S E P A R T N E R S H I P V A L U E M a y 1 6 , 2 0 1 1
3 R D Q U A R T E R F Y U T I L I Z A T I O N R E V I E W – 7 / 1 / 2 0 1 0 T O 3 / 3 1 / 2 0 1 1
T R E N D S A N A L Y S I S S T A T I S T I C S P L A N N I N G T O O L S
Premera – Medical
Premera Medical – Inpatient & Outpatient
3
Inpatient
− Paid claims per member per month for Inpatient services increased significantly from $67.93 for 3rd Qtr FY10 (7/09-03/10) to $102.91 for the 3rd quarter FY11 (7/10-03/11)
Greater intensity and severity of large claims in 3rd Qtr FY11 compared to FY10
One claimant at $950,000
For 3rd Qtr 2010, only one claimant above $500,000 compared to three over $600,000 in FY 2011
− The average length of stay for inpatient services increased from 4.60 to 5.04 and 3rd
Qtr FY 11 was above the Premera Norm of 4.54
Outpatient
− Visits per 1,000 members for Outpatient services remained virtually unchanged from quarter to quarter and was below the Premera Norm
− Services per 1,000 members for Outpatient services decreased from 4,253 for 3rd
Qtr FY10 (7/09-03/10) to 4,214 for the 3rd Qtr FY11 (7/10-03/11) and was below the Premera Norm
− Paid claims per service increased 10% quarter over quarter
Premera Medical – Emergency Room
4
Emergency Room
− Paid claims per member per month for ER services increased from $16.18 for 3rd Qtr FY10 (7/09-03/10) to $17.28 for the 3rd Qtr FY11 (7/10-03/11) and the paid claims per visit increased from $1,189.67 to $1,371.85 a 15.3% increase
− Visits per 1,000 members for ER services decreased from 163 for 3rd Qtr FY10 (7/09-03/10) to 151 for the 3rd Qtr FY11 (7/10-03/11)
FY11 was significantly below the Premera Norm
The increase in the ER per member per month cost coupled with the decrease in the number of ER visits for the 3rd Quarter FY 2011 compared to 3rd Qtr FY 2010 implies that members are going to the ER for more appropriate services.
Large Claims
− The number of large claimants over $100k increased from 29 in FY 10 3rd Qtr to 42 in FY 11 3rd Qtr
− Top 30 claims for FY10 3rd Qtr were $5,442,434 compared to $8,793,507 in 3rd Qtr FY11, which is a 61.6% increase
Medical Utilization
52010 Norm is based on Premera’s Alaska large group book of business
Utilization Category Jul 2009 - Mar 2010 Jul 2010 - Mar 2011 % Over Previous Qtr Norm
Medical Contract Months 38,886 38,456 -1.1% ------
Medical Member Months 88,470 87,108 -1.5% ------
Average Contract Size 2.28 2.27 -0.4% ------
Medical Total PMPM $380.08 $448.79 18.1% $374.52
Inpatient
Paid Claims Per Member Per Month $67.93 $102.91 51.5% $79.27
Admissions Per 1000 Members 44.08 52.35 18.8% 60.54
Days Per 1000 Members 202.64 263.95 30.3% 274.96
Average Length of Stay 4.60 5.04 9.7% 4.54
Paid Claims Per Admission $18,490.73 $23,589.32 27.6% $15,711.82
Outpatient
Paid Claims Per Member Per Month $86.91 $94.74 9.0% $84.95
Visits Per 1000 Members ² 1,070.06 1,071.50 0.1% 1,115.15
Paid Claims Per Visit $974.63 $1,060.97 8.9% $914.18
Services Per 1000 Members 4,253.51 4,213.94 -0.9% 4,437.16
Services Per Visit 3.98 3.93 -1.1% 3.98
Paid Claims Per Service $245.19 $269.78 10.0% $229.75
ER Utilization: Paid Claims PMPM $16.18 $17.28 6.8% $16.41
ER Utilization: Visits Per 1000 Members 163.17 151.12 -7.4% 225.27
ER Utilization: Paid Claims Per Visit $1,189.67 $1,371.85 15.3% $874.15
Professional Provider
Paid Claims Per Member Per Month $198.83 $218.08 9.7% $160.74
Services Per 1000 Members 17,556.73 17,366.17 -1.1% 15,053.32
Paid Claims Per Service $135.90 $150.69 10.9% $128.14
Top 30 Claimants – 3rd Qtr FY 2011
6
Claimant Enrollment Status Paid Claims
1 Active $950,726.50
2 Active $686,523.12
3 Active $602,724.96
4 Act ive $487,659.25
5 Active $427,484.75
6 Inactive $425,795.67
7 Active $409,225.06
8 Inact ive $398,216.15
9 Inactive $362,569.67
10 Active $320,385.69
11 Active $302,197.00
12 Act ive $297,992.84
13 Active $255,530.00
14 Active $241,915.72
15 Active $221,386.66
16 Active $219,029.71
17 Inactive $209,918.53
18 Active $189,999.96
19 Act ive $189,334.31
20 Active $187,626.04
21 Inactive $167,601.87
22 Act ive $159,341.79
23 Active $152,278.35
24 Active $147,626.34
25 Active $139,512.51
26 Active $138,389.63
27 Active $128,154.19
28 Active $125,198.39
29 Active $124,782.97
30 Inactive $124,379.59
LYMPHOID LEUKEMIA
SEPTICEMIA
ABSCESS OF LUNG AND MEDIASTINUM
CHRONIC RENAL FAILURE
SEPTICEMIA
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
ICD9 Description
MALIGNANT NEOPLASM OF COLON
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
SPONDYLOSIS AND ALLIED DISORDERS
FRACTURE OF VERTEBRAL COLUMN WITHOUT MENTION OF SPINAL CORD INJURY
OTHER FORMS OF CHRONIC ISCHEMIC HEART DISEASE
OTHER MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE
SUBARACHNOID HEMORRHAGE
CHRONIC ISCHEM IC HEART DISEASE
INTRACEREBRAL HEMORRHAGE
MALIGNANT NEOPLASM OF FEMALE BREAST
INJURY TO PELVIC ORGANS
CHRONIC ISCHEM IC HEART DISEASE
OSTEOARTHROSIS AND ALLIED DISORDERS
BENIGN NEOPLASM OF BRAIN AND OTHER PARTS OF NERVOUS SYSTEM
TWIN BIRTH, MATE LIVEBORN
MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED PARTS OF MOUTH
CARDIAC DYSRHYTHMIAS
OTHER COMPLICATIONS OF PROCEDURES, NOT ELSEWHERE CLASSIFIED
ACUTE M YOCARDIAL INFARCTION
MALIGNANT NEOPLASM OF STOMACH
INTERVERTEBRAL DISC DISORDERS
DIABETES M ELLITUS
DISEASES OF OTHER ENDOCARDIAL STRUCTURES
OTHER CONGENITAL ANOMALIES OF HEART
Paid PMPMTotal Paid
Claims
Percentage of
Overall TotalPaid PMPM
Total Paid
Claims
Percentage of
Overall Total
Musculoskeletal System $74.67 $6,605,755.15 19.65% $75.98 $6,618,407.39 16.93%
Health Status & Services $42.42 $3,752,560.50 11.16% $50.07 $4,361,797.23 11.16%
Circulatory System $29.98 $2,652,320.50 7.89% $46.12 $4,017,033.09 10.28%
Neoplasms $31.22 $2,762,220.98 8.21% $43.77 $3,812,514.93 9.75%
Ill-Defined Conditions $32.98 $2,917,377.55 8.68% $33.90 $2,953,143.85 7.55%
Injury and Poisoning $24.66 $2,181,962.55 6.49% $33.27 $2,897,688.07 7.41%
Digestive System $28.67 $2,536,806.05 7.54% $27.46 $2,392,156.70 6.12%
Genitourinary System $21.84 $1,931,750.39 5.74% $24.02 $2,092,653.01 5.35%
Nervous System $23.83 $2,107,936.81 6.27% $22.88 $1,992,929.55 5.10%
Respiratory System $15.72 $1,391,042.64 4.14% $20.87 $1,817,663.90 4.65%
Mental Disorders $16.50 $1,459,532.16 4.34% $18.22 $1,587,482.44 4.06%
Endocrine, Metabolic and Immunity $12.54 $1,109,132.64 3.30% $14.12 $1,229,701.84 3.15%
Pregnancy and Related $12.36 $1,093,292.29 3.25% $12.93 $1,126,586.25 2.88%
Infectious and Parasitic $3.38 $298,728.51 0.89% $9.91 $863,387.76 2.21%
Skin and Tissue $4.73 $418,161.30 1.24% $6.02 $524,232.60 1.34%
Congenital Anomalies $2.07 $183,170.50 0.54% $4.51 $392,957.61 1.01%
Blood $1.76 $155,720.19 0.46% $4.03 $350,951.24 0.90%
Perinatal $0.74 $65,837.36 0.20% $0.65 $56,597.05 0.14%
Injury and Poisoning External Causes $0.01 $1,256.32 0.00% $0.04 $3,450.58 0.01%
Other $0.01 $879.56 0.00% $0.02 $1,759.80 0.00%
Total $380.08 $33,625,443.95 100.00% $448.79 $39,093,094.89 100.00%
July 1, 2009 to March 31, 2010 July 1, 2010 to March 31, 2011
Major Diagnosis Category
Major Diagnostic Category
7Circulatory system jumped from #5 in 3rd Qtr FY 10 to number #2 in FY 11
Caremark - Pharmacy
Pharmacy Observations
9
The number of total scripts/claims from FY11 3rd quarter (7/1/10 to 03/31/11) increased 0.3% compared to FY10 3rd quarter (7/1/09 to 03/31/10)
The number of mail order scripts/claims increased 6.7% from FY 10 to FY11 3rd
quarter
− The University as well as the member receives costs savings with the utilization of mail order
The total gross costs decreased $38,746 from FY10 3rd quarter to FY11 3rd
quarter from $6,254,316 to $6,215,570
− Pharmacy trend is currently around 10% nationwide and 14.5% for Premera Alaska
The total amount paid by members increased 7.2% and the average amount paid per member per claim increased from $12.33 to $13.18, a 6.7% increase from the FY10 3rd quarter
The generic dispensing rate increased from 60.3% to 65.8%, a 9.1% increase
− Caremark’s book of business is 66.1% and its Colleges and Universities benchmark is 65.2%
− The increased utilization of generic drugs provides cost savings to the University and its employees
MetricsCombined
Benefit
Retail
Claims
Claims
Combined
Benefit
Retail
Claims
Claims
Member Utilization
Total Claims 67,382 58,869 8,513 67,199 59,219 7,980
Distribution of Payable Claims 100.0% 87.4% 12.6% 100.0% 88.1% 11.9%
Average Eligible Members Per Month 9,921 10,021
Average Utilizing Members Per Month 2,832 2,805
Percent of Utilizing Members 28.5% 28.0%
Eligible Member Utiliz. Rate Per Month 0.75 0.66 0.10 0.75 0.66 0.09
Gross Cost
Total Gross Cost $6,215,570 $4,536,614 $1,678,956 $6,254,316 $4,621,137 $1,633,179
Average Gross Cost Paid/Claim $92.24 $77.06 $197.22 $93.07 $78.03 $204.66
Total Gross Cost PMPM $69.61 $50.81 $18.80 $69.35 $51.24 $18.11
Net Cost
Total Net Cost $5,327,169 $3,877,328 $1,449,841 $5,425,871 $3,990,470 $1,435,401
Average Net Cost Paid/Claim $79.06 $65.86 $170.31 $80.74 $67.38 $179.87
Total Net Cost PMPM $59.66 $43.42 $16.24 $60.16 $44.25 $15.92
Member Paid
Total Member Paid $888,402 $659,287 $229,115 $828,445 $630,667 $197,778
Average Member Paid/Claim $13.18 $11.20 $26.91 $12.33 $10.65 $24.78
Average Member Paid/Brand $28.38 $25.26 $50.50 $22.94 $20.62 $41.23
Average Member Paid/Generic $4.88 $4.42 $9.42 $4.87 $4.46 $9.39
Percent Member Amount Paid 14.3% 14.5% 13.6% 13.3% 13.6% 12.1%
Drug Mix
Single-Source Brand Dispensing Rate 31.8% 30.1% 40.6% 36.7% 35.4% 45.7%
Multi-Source Brand Dispensing Rate 2.4% 2.4% 2.0% 3.0% 2.9% 2.6%
Generic Dispensing Rate 65.8% 67.5% 57.4% 60.3% 61.7% 51.6%
Generic Substitution Rate 96.4% 96.6% 96.6% 95.3% 95.5% 95.2%
Jul 09-Mar 10Jul 10-Mar 11
UNIVERSITY OF ALASKA UNIVERSITY OF ALASKA
Pharmacy 3rd Qtr Comparison
10
Appendix
Medical Utilization Definitions
12
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
Top 30 Claimants – 3rd Qtr FY 2010
13
Claimant Enrollment Status Paid Claims
1 Active $577,186.53
2 Inactive $462,408.89
3 Inactive $312,439.01
4 Active $299,072.49
5 Inactive $262,683.05
6 Active $255,075.84
7 Inactive $232,189.72
8 Active $199,708.39
9 Active $185,738.82
10 Active $180,163.54
11 Inactive $171,708.10
12 Active $166,384.98
13 Active $163,734.85
14 Active $142,064.22
15 Active $135,593.50
16 Active $135,092.62
17 Active $125,636.27
18 Active $122,659.56
19 Active $121,274.09
20 Active $119,182.05
21 Active $116,145.58
22 Active $112,730.06
23 Active $111,091.64
24 Active $109,513.21
25 Active $107,226.32
26 Active $106,869.86
27 Active $104,882.81
28 Inactive $104,680.20
29 Active $100,597.89
30 Active $98,700.10
CHRONIC RENAL FAILURE
CEREBROVASCULAR DISEASE
LYMPHOID LEUKEMIA
DIABETES MELLITUS
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
CARE INVOLVING USE OF REHABILITATION PROCEDURES
ICD9 Description
POLYARTERITIS NODOSA AND ALLIED CONDITIONS
SEPTICEMIA
LYMPHOID LEUKEMIA
OTHER COMPLICATIONS OF INTERNAL PROSTHETIC DEVICE, IMPLANT, AND GRAFT
CHRONIC ISCHEMIC HEART DISEASE
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
MALIGNANT NEOPLASM OF BRAIN
CHRONIC ISCHEMIC HEART DISEASE
COMPLICATIONS PECULIAR TO CERTAIN SPECIFIED PROCEDURES
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
MALIGNANT NEOPLASM OF PANCREAS
OTHER PERIPHERAL VASCULAR DISEASE
MALIGNANT NEOPLASM OF BODY OF UTERUS
MALIGNANT NEOPLASM OF FEMALE BREAST
INTERVERTEBRAL DISC DISORDERS
PLEURISY
OSTEOARTHROSIS AND ALLIED DISORDERS
ACUTE MYOCARDIAL INFARCTION
DIVERTICULA OF INTESTINE
OTHER DISEASES OF LUNG
INTERVERTEBRAL DISC DISORDERS
SYMPTOMS INVOLVING HEAD AND NECK
COMPLICATIONS PECULIAR TO CERTAIN SPECIFIED PROCEDURES
OTHER ANEURYSM
14
Our Mission
To be the worldwide value and service leader in insurance brokerage and risk management services
Our Goal
To be the best place to do business and to work
www.lockton.com
© 2009 Lockton, Inc. All rights reserved.Images in this publication © 2009 Jupiterimages Corporation
