better health 2018 Renewal Planning Discussion

City of Los Angeles

JLMBC Meeting – April 6, 2017

Leading the way to

1

TOPICS

Introductions and agenda

review

Enrollment and Demographics

2018 Renewal Methodology

Clinical Observations

Solutions

Agenda

2

Enrollment and Demographics

3

Anthem 2017 Enrollment: Demographics and enrollment segmented*

ENROLLMENT BY PLAN

CURRENT PERCENT OF

TOTAL

Total Subscribers

Select (Narrow) HMO 6,646 66%

PPO 2,580 26%

Vivity (Regional) HMO 750 7%

Traditional (Full) HMO 109 1%

TOTAL: 10,085 100%

DEMOGRAPHICS

CURRENT BENCHMARK** PERCENT ABOVE

BENCHMARK

Medical

HMO Subscriber Average

Age 47.3 44.7 5.8%

HMO Member Average Age 35.2 34.7 1.6%

PPO Subscriber Average Age 49.2 44.7 10%

PPO Member Average Age 39.5 34.7 13.9%

4 *Data as of February 24, 2017

** Benchmark based on Anthem Book of Business (BOB)

2018 Renewal Methodology

5

2018 Renewal Rating Methodology

6

• 2018 rate cap of 9.0% per product in place (does not

include Affordable Care Act fees- estimated at 3.38% of

total premium)

• Renewal calculation based solely on prior plan’s paid

claims from 1/1/2016-12/31/2016

• Substantial HMO medical network adjustment to prior

plan’s claims due to Anthem’s favorable HMO provider

contract/capitation arrangements

• Anthem claim data is immature and is not used in renewal

calculation

• Vivity renewal calculated by proportionally allocating prior

plan’s claims, and accounting for Vivity’s lower trend

Prior Plan 2016 Experience/Loss Ratio Paid Claims 1/1/2016 - 12/31/2016

7

Product Total

Lives (Dec-16)

Premium Medical

Claims* Drug

Claims

Total

Claims

Paid

Loss

Ratio

Narrow HMO 16,639 $79,728,036 $55,991,365 $14,198,657 $70,190,022 88.0%

Full HMO 1,733 $9,019,029 $7,265,302 $2,222,772 $9,488,075 105.2%

PPO 4,674 $38,410,241 $34,920,936 $8,864,858 $43,785,795 114.0%

Total: 23,046 $127,157,306 $98,177,603 $25,286,287 $123,463,892 97.1%

*HMO data includes capitation, mental health/substance abuse, and large claims

8

High Cost Claimants from Prior Plan Paid Claims 1/1/2016-12/31/2016

Product Total Claimants

Over 50K

Total Paid* Average Paid Per

Claimant

Combined HMO* 13 $2,266,873 $174,374

PPO 66 $19,590,840 $296,830

Total: 79 $21,857,713 $276,679

Product Total Claimants

Over 300K

Pooling Level

Total Paid* Amount Paid In

Excess of 300K

Combined HMO* 2 $773,810 $173,810

PPO 18 $9,436,281 $4,033,011

Total: 20 $10,210,091 $4,206,821

*Total paid includes medical and pharmacy, excludes capitated claims

Clinical Observations

9

10

Anthem Medical Management

PHARMACY MANAGEMENT • Best Value Drugs-Generic Fill Rate

• Specialty Drug Clinical Review

• Monitor for Abusive Prescribing

UTILIZATION MANAGEMENT • Approve clinically effective treatments

• Achieve Appropriate Length of Stay

• Monitor for right level of care

• Discharge planning to avoid readmissions

10

CASE MANAGEMENT • Identifying and Managing Gaps in Care

• Managing Care Transitions

• Promoting member self-management

CONDITION MANAGEMENT • Cancer

• Diabetes

• CAD and CHF

• Asthma

11

High Cost Claimants from Prior Plan Top Fifteen High Cost Claimants 1/1/2016-12/31/2016

Top 15 High Cost Claimants

CASE PRODUCT DIAGNOSIS PAID AMOUNT

1 PPO Myeloid Leukemia $1,221,961

2 PPO Other Diseases of Lung $1,131,635

3 PPO Fx Ot/Unsp Femur $822,311

4 PPO Portal Vein Thrombosis $763,723

5 PPO Subarachnoid Hemorrhage $740,496

6 PPO OT Cerebrovascular Disease $490,470

7 HMO Traumatic Pneumothorax $475,185

8 PPO Sec Mal Neo Lymp Nodes $469,089

9 PPO Mal Neo Nasal Cav/Ear/Sinus $445,054

10 PPO Injury to Gastrointest Tract $403,657

11 PPO Infect D/T Cent Ven Cath $385,499

12 PPO Other Disorders of Intestine $378,358

13 PPO Chemotherapy $327,836

14 PPO Chemotherapy $325,261

15 HMO Ulcerative Enterocolitis $316,625

Cancer

Cerebrovascular Accident

12

Key Observations and Opportunities

Cancer

Opportunities:

• Anthem Cancer Care Quality program

• Anthem Case Management

Coronary Artery Disease

Opportunities:

• Anthem ConditionCare program

Diabetes

Opportunities:

• Anthem ConditionCare program

• Anthem Diabetes Prevention

Program

• Wellness Program

Cerebrovascular Accidents (CVA)

Opportunities:

• Wellness/lifestyle interventions to

impact blood pressure, obesity

• Anthem Diabetes Prevention

Program

Solutions

Cancer Care Quality

ConditionCare

Diabetes Prevention Program

13

14

Cancer Care Quality Program objectives:

• Improve cancer outcomes

• Promote access to cost-effective care

• Keep oncologists up to date on the latest

medical evidence

Cancer Care Quality - Our resources help members and providers work together for the best outcome

Personal support. Anthem Case Management.

Case management provides 1:1

education for members about their

treatment options and proactively

addresses complications and gaps in

care.

• Symptom management

during active treatment

• Complete assessment

including palliative

needs assessment

• Access to a variety of

health professionals

• End-of-life planning

15

Cancer Care Quality- Include Pathways for cancers contributing to 90% of chemotherapy spend

Tumor Types Cumulative

Chemotherapy Cost

%

Breast Cancer 27%

Colorectal Cancer 45%

Lung Cancer 56%

Lymphoma 67%

Myeloma 71%

Ovarian Cancer 75%

Pancreatic Cancer 78%

CNS 81%

Melanoma 82%

Leukemia 88%

Prostate Cancer ~90%

16

Cancer Care Quality- US Oncology found pathways associated with same overall survival and 30% lower cost

Outcomes associated with pathways

vs. usual care for advanced non-small cell lung cancer

Overall survival by Pathway status 12-month cumulative cost by Pathway status

Source: Neubauer M A et al. JOP 2010;6:12-18

17

Anthem ConditionCare Supports members with chronic conditions

• Disease management for prevalent,

high-cost conditions (diabetes, asthma,

chronic obstructive pulmonary disease,

coronary artery disease, and heart

failure

• Designed to improve member outcomes

through self-management

of conditions, healthy strategies

and preventive care

• Touchpoints can include telephonic

outreach, mailings, online resources,

phone access to nurses, guidance and

professional support

17

Anthem Diabetes Prevention Program Why focus on diabetes prevention?

Who is at risk?

• Body Mass Index (BMI) >25

• Over 40 years old

• Parent or sibling with diabetes

• Hispanic or African-American

• Sedentary lifestyle

More than 20% of healthcare dollars

in the United States are

spent on care for people

with diabetes.

Luckily, for the

1 in 3 people at risk of developing diabetes,

there is hope.

In 2001, the National Institutes of

Health (NIH) and the Centers for

Disease Control (CDC) proved that

losing 5-7% of body weight could reduce the risk of

developing diabetes by 58%.

18

Anthem Diabetes Prevention Program How it Works

Through a partnership with Solera Health, eligible members can access Diabetes

Prevention services and have them billed as preventive care claims.

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1. ANTHEM Identifies qualified members via care gap analysis and covers the

Diabetes Prevention Program as an ACA-covered preventive

medical benefit.

2. PROVIDERS Use EMR data to identify and refer patients to Solera for

enrollment in a Diabetes Prevention Program.

3. QUALIFIED MEMBERS Choose from a variety of qualified local, digital, and community

DPP providers (including Weight Watchers, Jenny Craig, Retrofit) to

find the best match for success.

4. COMMUNITY/DIGITAL DPP PROVIDERS Provide a variety of options for the Diabetes Prevention Program

(DPP), driving consumer choice and member engagement.

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Anthem Clinical Programs

Addressing all

aspects of health,

not just the physical

A team approach

to care

WELLNESS COORDINATED CARE

Support for City’s Wellness Program

Mobile Health Consumer

Weight management

Wellness tools

Biometric screening

Wellness calendars

Health assessments

Smoking cessation

Gym discounts

Cancer Quality

Diabetes Prevention Program (DPP)

ConditionCare

LiveHealth Online

Future Moms

Behavioral Health Resource

24/7 NurseLine

Care gap alerts

Pharmacy coordination

Case management

We take care of the City’s employee population with coordinated programs that influence member

health in a meaningful way and reduces your cost trend.