New Employee Orientation - SFHSS...Due to the new release of the DxCG Intelligence Model, risk...

SFHSS.ORG

Revised 4/10/2019

— 1 — SFHSS.ORG

SFHSS DxCG Risk Scores Introduction

Risk Scores– April 11, 2019

The SFHSS DxCG Risk Scores are generated using the commercial Cotiviti DxCG (diagnostic cost grouper) models from the diagnoses on the claims in the SFHSS All Payer Claims Database (APCD).

Risk Adjustment is a statistical process that uses predictive models to turn healthcare data into risk scores. Scores correlate with the cost of an individual’s underlying illness burden. Aggregating the scores of individuals generates group-level predictive results that can help predict the future cost of care for a population, assess performance, measure efficiency and assess the disease burden of the HSS population

This study evaluates the SFHSS risk scores based on the current time period (October 2017 to September 2018) and the previous time period (October 2016 to September 2017). Concurrent scores are retrospective and prospective scores are predictive. Payment information (Claims PMPM, Net Payments, etc.) are based on full calendar year. Current is January to December 2018, and previous time period is January to December 2017.

Due to the new release of the DxCG Intelligence Model, risk scores from previous have been restated due to changes in the disease classifications and their associated cost weights. Per member per month (PMPM) metrics include the enrolled HSS member and their dependents.

Refer to the appendix for more information on risk scores.

— 2 — SFHSS.ORG

SFHSS DxCG Risk Scores Executive Summary


The introduction of the Blue Shield Trio plan in the 2018 plan year resulted in the Blue Shield Access+ risk scores increasing. This was due to healthier individuals migrating from Access+ into Trio. The active UHC PPO (City Plan) population risk has improved slightly with the addition of more members.

Within the SFHSS population, Musculoskeletal Disorders are the clinical condition which is the largest driver of the prospective healthcare risk. However, it should be noted that Diabetes, which is in the top 3 drivers of the prospective healthcare risk, is SFHSS’ costliest manageable condition.

Concurrent risk scores have increased for all groups: actives, early retirees and Medicare retirees. The prospective risk scores have improved slightly for the active population, due to the younger average age for this group. The early retirees and Medicare retirees have higher scores than in the previous period.

Early retirees aged 55-64 have a much higher risk score when compared to the same aged active employees. Early retirees claims PMPM are two times that of the actives.

— 3 — SFHSS.ORG

Concurrent Risk Score Trend

SFHSS Risk Scores - April 11, 2019

Concurrent risk scores are trending upwards for early retirees.

The risk score for the Medicare population is higher than expected due to this score being generated from the all medical model instead of a Medicare only model

Kaiser Permanente active population has

the lowest risk

Only baseline information is available for Trio

— 4 — SFHSS.ORG

Prospective Risk Score Trend


SFHSS active and early retiree lives enrolled in Kaiser have a lower prospective risk compared to the other plans

Slight reduction in the City Plan actives risk score due to increased enrollment and a lower average age (see slide 21)

Only baseline information is available for Trio

The SFHSS Medicare risk score is much lower than the MarketScanbenchmark for the US total.

— 5 — SFHSS.ORG

SFHSS Risk Scores– April 11, 2019

% of Current Risk Contribution by Condition

ACTIVES% of Risk

Contribution -Diabetes

% of Risk Contribution -

Cardiovascular Disorders


Musculoskeletal Disorders

% of Risk Contribution -Respiratory Disorders


Substance Abuse


Infections


Neoplasms

Blue Shield Access + 6% 6% 15% 6% 1% 3% 9%Blue Shield Trio 6% 6% 14% 5% 1% 4% 9%UHC PPO (City Plan) 4% 6% 17% 4% 1% 7% 11%Kaiser Permanente 7% 5% 16% 6% 1% 3% 4%

EARLY RETIREESBlue Shield Access + 7% 9% 16% 4% 1% 3% 14%Blue Shield Trio 7% 10% 17% 4% 1% 5% 9%UHC PPO (City Plan) 5% 8% 18% 4% 1% 4% 15%Kaiser Permanente 10% 9% 15% 5% 1% 3% 7%

MEDICARE RETIREESUHC MA PPO 7% 17% 14% 5% 0% 2% 11%Kaiser Permanente 9% 21% 11% 6% 0% 2% 7%

While Diabetes is not the clinical condition that has the largest attribution to the risk score, it is SFHSS’ costliest manageable condition

The percentage of contribution from various clinical conditions to the overall risk score is identified by the “% of Risk Contribution” metric

Musculoskeletal Disorders are the most significant contribution to overall risk score

— 6 — SFHSS.ORG

Paid Medical and Rx Claims PMPM Trend Actives


The Blue Shield Access+ claims PMPM trended down by over $100 according to the claims data provided by BSC for the APCD. However, actual claims paid by SFHSS show a slight increase in the PMPM. Data investigations are underway with Blue Shield.

$363 $377 $3600.79 0.77 0.79

0.50

1.00

1.50

2.00

2.50

3.00

$250

$350

$450

$550

$650

$750

$850

2016 2017 2018

Kaiser Permanente

$870 $872 $886

1.59

1.561.55

0.50

1.00

1.50

2.00

2.50

3.00

$250

$350

$450

$550

$650

$750

$850

2016 2017 2018

UHC PPO (City Plan)

$596$633

$529

0.98

1.021.01

0.50

1.00

1.50

2.00

2.50

3.00

$250

$350

$450

$550

$650

$750

$850

2016 2017 2018

Blue Shield Access+

— 7 — SFHSS.ORG

Typically a higher risk score, indicative of a greater illness burden, results in higher claims. In 2018, despite the increased risk score, Access+ claims paid PMPM decreased over previous period.

Paid Medical and Rx Claims PMPM Trend Early Retirees


$741$656 $689

1.59 1.57 1.74

0.50

1.00

1.50

2.00

2.50

3.00

$500

$1,000

$1,500

$2,000

$2,500

$3,000

2016 2017 2018

Kaiser Permanente

$1,120 $1,207 $1,162

1.92 1.96 2.13

0.50

1.00

1.50

2.00

2.50

3.00

$500

$1,000

$1,500

$2,000

$2,500

$3,000

2016 2017 2018

Blue Shield Access+

$2,135

$2,501 $2,634

2.68 2.67 2.81

0.50

1.00

1.50

2.00

2.50

3.00

$500

$1,000

$1,500

$2,000

$2,500

$3,000

2016 2017 2018

UHC PPO (City Plan)

— 8 — SFHSS.ORG

2018 Paid Medical and Rx Claims PMPM with Risk Score by Plan


$529 $494

$886

$360

1.011.00

1.55

0.79

0.00

0.50

1.00

1.50

2.00

2.50

3.00

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

Blue ShieldAccess+

Blue Shield Trio UHC PPO (CityPlan)

KaiserPermanente

Plan Comparison of Paid Claims PMPM and Risk Score - Actives

$1,162

$754

$2,634

$689

2.13

1.71

2.81

1.74

0.00

0.50

1.00

1.50

2.00

2.50

3.00

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

Blue ShieldAccess+

Blue Shield Trio UHC PPO (CityPlan)

KaiserPermanente

Plan Comparison of Paid Claims PMPM and Risk Score - Early Retirees

The spend PMPM is significantly higher in UHC PPO (City Plan) and Access+

which are the plans with the higher risk scores

— 9 — SFHSS.ORG

Risk Score by Plan and As a Combined Risk PoolNon Kaiser Plans


1.01

1.01

1.55

1.04

0.96

0.98

1.39

0.99

0 0.5 1 1.5 2 2.5 3

Blue Shield Access +

Blue Shield Trio

UHC PPO (City Plan)

Combined Risk Pool

Active Population

2.13

1.71

2.82

2.16

1.89

1.68

2.43

1.94

0 0.5 1 1.5 2 2.5 3


Blue Shield Trio

UHC PPO (City Plan)

Combined Risk Pool

Early Retiree Population

1.17

1.05

1.97

1.17

1.09

1.03

1.74

1.10

0 0.5 1 1.5 2 2.5 3


Blue Shield Trio

UHC PPO (City Plan)

Combined Risk Pool

Active and Early Retiree Population

The effect of combining these plans into one risk pool marginally raises the score from the Access+ and Trio population but dramatically decreases the score from the UHC PPO (City Plan) population

— 10 — SFHSS.ORG


Risk Adjusted Comparison of Plan Performance based on Outpatient Allowed Amount

ACTIVES EARLY RETIREESLives Risk Score

ConcurrentAllow Amt PMPM Med

Dynamic Adjustment

Ratio Lives Risk Score Concurrent

Allow Amt PMPM Med

Dynamic Adjustment

Ratio

CurrentBlue Shield Access+ 19,626 1.015 $472.28 $443.96 1.1 2,462 2.133 $1,017.43 $905.07 1.1Blue Shield Trio 16,227 1.006 $444.39 $440.17 1.0 1,528 1.714 $699.60 $727.31 1.0UHC PPO (City Plan) 1,678 1.546 $768.95 $676.84 1.1 849 2.816 $1,296.33 $1,194.97 1.1Kaiser Permanente 48,044 0.792 $331.82 $346.58 1.0 4,098 1.735 $651.98 $736.11 0.9TOTAL 80,667 0.891 389.18 390.04 1.0 8,554 1.954 827.46 829.08 1.0PreviousBlue Shield Access+ 31,232 1.025 $501.28 $455.20 1.1 3,568 1.964 $963.01 $847.81 1.1UHC PPO (City Plan) 1,474 1.569 $674.46 $697.06 1.0 786 2.673 $1,155.22 $1,152.96 1.0Kaiser Permanente 46,647 0.771 $311.84 $342.56 0.9 4,015 1.567 $555.99 $676.04 0.8TOTAL 79,353 0.886 $393.13 $393.48 1.0 8,369 1.840 $785.79 $794.07 1.0

Adjusting for risk, Blue Shield Access+ and UHC PPO (City Plan) are less efficient than the Kaiser Permanente and Blue Shield Trio plans for both the active and early retiree population



Risk Adjusted Comparison of Plan Performance based on Inpatient Allowed Amount

The overall risk of the UHC PPO (City Plan) population however, is much higher than in the other plans resulting in very high PMPM claims (refer to slides 6 & 7)

ACTIVES EARLY RETIREESLives Risk Score

Concurrent Allow Amt PMPM Admit

Dynamic Adjustment

Ratio Lives Risk Score Concurrent

Allow Amt PMPM Admit

Dynamic Adjustment

Ratio

CurrentBlue Shield Access+ 19,626 1.015 $157.60 $164.83 1.0 2,462 2.133 $379.50 $349.05 1.1

Blue Shield Trio 16,227 1.006 $139.29 $165.56 0.8 1,528 1.714 $227.36 $228.04 1.0UHC PPO (City Plan) 1,678 1.546 $159.99 $292.13 0.5 849 2.816 $327.31 $457.25 0.7Kaiser Permanente 48,044 0.792 $122.60 $107.87 1.1 4,098 1.735 $248.77 $242.77 1.0TOTAL 80,667 0.891 $133.12 $133.70 1.0 8,554 1.954 $291.31 $292.67 1.0Previous Blue Shield Access+ 31,232 1.025 $174.16 $190.13 0.9 3,568 1.964 $362.60 $336.11 1.1

UHC PPO (City Plan) 1,474 1.569 $150.04 $343.49 0.4 786 2.673 $390.84 $484.42 0.8Kaiser Permanente 46,647 0.771 $127.10 $110.43 1.2 4,015 1.567 $220.43 $231.53 1.0TOTAL 79,353 0.886 $146.05 $146.13 1.0 8,369 1.840 $297.05 $299.86 1.0

Adjusting for risk, UHC PPO (City Plan) allowed amount per admission is considerably less than would be expected



Risk Adjusted Comparison of Plan Performance based on Inpatient Admits Per 1000 – Current Period

ACTIVESLives Risk Score

Concurrent Admits Per 1000 Acute

Dynamic Adjustment

Ratio

Blue Shield Access+ 19,626 1.015 42.87 41.40 1.0Blue Shield Trio 16,227 1.006 38.95 41.00 0.9UHC PPO (City Plan) 1,678 1.546 51.25 71.03 0.7Kaiser Permanente 48,044 0.792 31.12 30.35 1.0TOTAL 80,667 0.891 35.26 35.36 1.0

EARLY RETIREESBlue Shield Access+ 2,462 2.133 71.90 65.91 1.1Blue Shield Trio 1,528 1.714 51.48 51.14 1.0UHC PPO (City Plan) 849 2.816 81.30 89.74 0.9Kaiser Permanente 4,098 1.735 47.83 50.02 1.0TOTAL 8,554 1.954 58.57 58.69 1.0

MEDICARE RETIREESUHC MA PPO 11,390 5.308 196.05 187.22 1.1KP Senior Advantage 9,753 5.045 164.87 174.99 0.9TOTAL 21,144 5.187 181.66 181.58 1.0

City Plan admits per 1000 for early retirees is lower than expected when adjusting for risk, and is an improvement over the previous period performance (found on the next slide)

While financial data is incomplete for Medicare plans, risk adjusted utilization is available to compare plan performance



Risk Adjusted Comparison of Plan Performance based on Inpatient Admits Per 1000 – Previous Period

ACTIVESLives Risk Score

Concurrent Admits Per 1000 Acute

Dynamic Adjustment

Ratio

Blue Shield Access+ 31,232 1.025 43.58 42.98 1.0UHC PPO (City Plan) 1,474 1.569 59.72 73.37 0.8Kaiser Permanente 46,647 0.771 29.76 29.76 1.0TOTAL 79,353 0.886 35.75 35.78 1.0

EARLY RETIREESBlue Shield Access+ 3,568 1.964 72.88 69.39 1.1

UHC PPO (City Plan) 786 2.673 110.64 100.12 1.1Kaiser Permanente 4,015 1.567 45.82 52.73 0.9TOTAL 8,369 1.840 63.45 64.28 1.0

MEDICARE RETIREESUHC MA PPO 8,932 5.308 213.84 200.50 1.1KP Senior Advantage 10,003 4.673 173.55 173.45 1.0

Blue Shield Access + 2,446 4.631 146.58 168.67 0.9

TOTAL 20,216 4.945 188.91 184.82 1.0

In the current period, the ratio has improved to .7 for actives in UHC PPO (City Plan) and .9 for early retirees in UHC PPO (City Plan)



Risk Scores by Plan and Gender

Plan Group Gender % of Members

Average Age

Prospective Risk Score

% of Members

Average Age

Prospective Risk Score

Blue Shield Access+ Female 52% 35.2 1.13 52% 36.2 1.16

Male 48% 34.4 1.02 48% 35.5 1.05Blue Shield Trio Female 52% 36.6 1.16

Male 48% 36.1 1.05UHC PPO (City Plan) Female 48% 38.4 1.70 48% 38.8 1.75

Male 52% 38.9 1.42 52% 39.4 1.50Kaiser Permanente Female 51% 34.1 1.01 51% 34.2 1.01

Male 49% 34.0 0.84 49% 34.0 0.83

Blue Shield Access+ Female 55% 52.5 2.03 55% 53.0 1.94Male 45% 51.3 2.25 45% 52.7 2.15

Blue Shield Trio Female 56% 54.0 1.76Male 44% 54.1 2.07

UHC PPO (City Plan) Female 51% 56.6 2.75 52% 56.9 2.54Male 49% 56.9 2.81 48% 56.9 2.83

Kaiser Permanente Female 55% 54.8 1.87 54% 54.5 1.77Male 45% 54.0 2.17 46% 53.9 2.00

CURRENT PREVIOUS Actives

Early Retirees

Within the early retiree population, females enrolled in Blue Shield Trio have the lowest risk score while males enrolled in UHC PPO (City Plan) have the highest risk score

Amongst actives, males enrolled in Kaiser Permanente have the lowest risk score and females enrolled in UHC PPO (City Plan) have the highest risk score

cOVER-concurrent

KAISER

Oct 15 to Sep 16Oct 16 to Sep 17Oct 17 to Sep 18 92.6950.9269538073

Active0.7950.7710.792186.9091.8690868502

ER1.5921.5671.735490.254.9024576003

MR4.4294.6735.045

Trio


Active1.006271.122.7112360304

ER1.714463.1104.6311

MR

Access

Oct 15 to Sep 16Oct 16 to Sep 17Oct 17 to Sep 18

Active0.9831.0251.015

ER1.9251.9642.133

MR3.9104.631

city Plan


Active1.5921.5661.546

ER2.6872.6732.871

MR5.8495.3085.308

Overview-All Plans-Risk Scores-ACT, ER-trend

Time Period: DCG IncurredOct 15 to Sep 16 {Nonmedicare} CMedRxOct 16 to Sep 17 {Nonmedicare} CMedRx

SubsetsHSS-ACTIVESEarly Retirees & Pre-65HSS-ACTIVESEarly Retirees & Pre-65

Members Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaled

Plan Code

Access+31,697.498.32107.703,930.3192.53205.9031,232.3102.45110.653,567.6196.40203.72

cP1,007.3159.23161.61666.8268.72278.681,473.6156.87161.68786.3267.28264.29

Kp44,842.379.5292.703,919.6159.17186.9146,646.777.1392.044,015.3156.69187.28

Aggregate(Plan Code Values)77,547.188.2499.728,516.6183.14202.8679,352.588.58100.668,369.3184.01201.52

Overview-All Plans-Risk Scores-ActivesOverview-All Plans-Risk Scores-ER

Time Period: DCG IncurredOct 17 to Sep 18 {Nonmedicare} CMedRxTime Period: DCG Incurred

SubsetsHSS-ACTIVESSubsetsEarly Retirees & Pre-65

Members Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaled

Plan CodePlan

Blue Shield Access+19,625.6101.45107.85Blue Shield Access+2,461.7213.27212.89

Blue Shield Trio16,226.5100.59110.69Blue Shield Trio1,528.0171.40189.82

City Plan1,677.9154.64156.78City Plan848.8281.56274.02

Kaiser48,043.779.2192.73Kaiser4,097.7173.50200.72

Aggregate(Plan Code Values)80,667.389.14100.43Aggregate(Plan Values)8,554.1195.39210.03

MR

SubsetsMedicare RetireesOverview-All Plans-Risk Scores-MR-trend

Time Period: DCG IncurredOct 15 to Sep 16 {Medicare} CMedRxSubsetsMedicare Retirees

Plan GroupMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledTime Period: DCG IncurredOct 16 to Sep 17 {Medicare} CMedRxOct 17 to Sep 18 {Medicare} CMedRx


Blue Shield6,077.3390.96370.08Plan

City Plan6,166.2584.88502.57UHC MA PPO8,931.9530.83477.5111,389.4530.80476.80

Kaiser10,140.3442.91444.40KPSA10,003.2467.27462.009,753.4504.53490.25

Aggregate(Plan Group Values)22,383.8467.91440.25Blue Shield2,445.8463.11414.56393.6154.48160.43

Aggregate(Plan Values)20,565.6494.54464.9721,536.4512.02477.11

Kaiser

Active

Oct 15 to Sep 16Oct 16 to Sep 17Oct 17 to Sep 18 0.795000000000000040.771000000000000020.79200000000000004ER

Oct 15 to Sep 16Oct 16 to Sep 17Oct 17 to Sep 18 1.59200000000000011.56699999999999991.7350000000000001MR

Oct 15 to Sep 16Oct 16 to Sep 17Oct 17 to Sep 18 4.42900000000000034.6735.0449999999999999

Blue Shield Trio

Oct 17 to Sep 18

ActiveERMR1.00591.714Oct 15 to Sep 16

ActiveERMROct 16 to Sep 17

ActiveERMR

Blue Shield Access+

Active




City Plan

Active




cOVER-PROS

KAISER


Active0.9270.9200.927186.9091.8690868502

ER1.8691.8732.007490.254.9024576003

MR4.4444.6204.902

Trio


Active1.107414.564.1456409077

ER1.8980

MR

Access


Active1.0771.1061.079

ER2.0592.0372.129

MR3.7014.146

city Plan/uhc


Active1.6161.6141.551

ER2.7872.6772.782

MR5.0264.7754.768

Overview-All Plans-Risk Scores-ACT, ER-trend


SubsetsHSS-ACTIVESEarly Retirees & Pre-65HSS-ACTIVESEarly Retirees & Pre-65

Members Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaled

Plan Code

Access+31,697.498.32107.703,930.3192.53205.9031,232.3102.45110.653,567.6196.40203.72

cP1,007.3159.23161.61666.8268.72278.681,473.6156.87161.68786.3267.28264.29

Kp44,842.379.5292.703,919.6159.17186.9146,646.777.1392.044,015.3156.69187.28

Aggregate(Plan Code Values)77,547.188.2499.728,516.6183.14202.8679,352.588.58100.668,369.3184.01201.52

Overview-All Plans-Risk Scores-ActivesOverview-All Plans-Risk Scores-ER

Time Period: DCG IncurredOct 17 to Sep 18 {Nonmedicare} CMedRxTime Period: DCG Incurred

SubsetsHSS-ACTIVESSubsetsEarly Retirees & Pre-65


Plan CodePlan

Blue Shield Access+19,625.6101.45107.85Blue Shield Access+2,461.7213.27212.89

Blue Shield Trio16,226.5100.59110.69Blue Shield Trio1,528.0171.40189.82

City Plan1,677.9154.64156.78City Plan848.8281.56274.02

Kaiser48,043.779.2192.73Kaiser4,097.7173.50200.72

Aggregate(Plan Code Values)80,667.389.14100.43Aggregate(Plan Values)8,554.1195.39210.03

MR

SubsetsMedicare RetireesOverview-All Plans-Risk Scores-MR-trend

Time Period: DCG IncurredOct 15 to Sep 16 {Medicare} CMedRxSubsetsMedicare Retirees

Plan GroupMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledTime Period: DCG IncurredOct 16 to Sep 17 {Medicare} CMedRxOct 17 to Sep 18 {Medicare} CMedRx


Blue Shield6,077.3390.96370.08Plan

City Plan6,166.2584.88502.57UHC MA PPO8,931.9530.83477.5111,389.4530.80476.80

Kaiser10,140.3442.91444.40KPSA10,003.2467.27462.009,753.4504.53490.25

Aggregate(Plan Group Values)22,383.8467.91440.25Blue Shield2,445.8463.11414.56393.6154.48160.43


Kaiser

Active




Blue Shield Trio

Oct 15 to Sep 16



ActiveERMR1.106902482615531.8982104421175101


Active




City Plan / UHC MA PPO

Active




Overview

Overview-All Plans-Risk Scores-ActivesOverview-All Plans-Risk Scores-Actives


ACTIVESSubsetsHSS-ACTIVESHSS-ACTIVES

Risk Score ConcurrentRisk Score Prospective110.651.1064713244Members Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaled

LivesCurrentPreviousCurrentPrevious0Plan Code

Blue Shield Access +19,6261.0151.0251.0791.106161.681.6167997512Blue Shield Access+19,625.6101.45107.8531,232.3102.45110.65

Blue Shield Trio16,2271.0061.10792.040.9203728467Blue Shield Trio16,226.5100.59110.69

City Plan1,6731.5461.5691.5681.617100.661.0065592966City Plan1,677.9154.64156.781,473.6156.87161.68

Kaiser48,0440.7920.7710.9270.920Kaiser48,043.779.2192.7346,646.777.1392.04

All Plans80,6620.8910.8861.0041.007Aggregate(Plan Code Values)80,667.389.14100.4379,352.588.58100.66

Overview-All Plans-Risk Scores-ER

EARLY RETIREESTime Period: DCG IncurredOct 16 to Sep 17 {Nonmedicare} CMedRx

Risk Score ConcurrentRisk Score ProspectiveSubsetsEarly Retirees & Pre-65Early Retirees & Pre-65

LivesCurrentPreviousCurrentPrevious203.722.0371710542Members Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaled

Blue Shield Access +2,4622.1331.9642.1292.0370Plan

Blue Shield Trio1,5281.7141.898264.292.6428635062Blue Shield Access+2,461.7213.27212.893,567.6196.40203.72

City Plan8492.8162.6732.7402.643187.281.872827549Blue Shield Trio1,528.0171.40189.82

Kaiser4,0981.7351.5672.0071.873201.522.0151990719City Plan848.8281.56274.02786.3267.28264.29

All Plans8,4911.9541.8402.1002.015Kaiser4,097.7173.50200.724,015.3156.69187.28


MR

MEDICARE RETIREESSubsetsMedicare Retirees

Risk Score ConcurrentRisk Score Prospective477.514.775079257Time Period: DCG IncurredOct 17 to Sep 18 {Medicare} CMedRxOct 16 to Sep 17 {Medicare} CMedRx

LivesCurrentPreviousCurrentPrevious462.004.6199762575Members Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaled

UHC MA PPO11,3895.3085.3084.7684.775469.314.6931402907Plan

KPSA9,7535.0454.6734.9024.620UHC MA PPO11,389.4530.80476.808,931.9530.83477.51

All Plans21,1435.1874.9724.8304.693KPSA9,753.4504.53490.2510,003.2467.27462.00


NEW

Time Period: DCG IncurredOct 17 to Sep 18 {Nonmedicare} CMedRx

SubsetsActives not in Trio

Members Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaled

Plan Code

Blue Shield Access+19,538.0101.31107.711.0131.077

Aggregate(Plan Code Values)19,538.0101.31107.71


SubsetsBSC Trio-Actives

Members Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaled

Plan Code

Trio11,120.897.94110.670.9791.107

Aggregate(Plan Code Values)11,120.897.94110.67

Employer

ACTIVESOverview-All Plans-Risk Scores-EMPLOYERS-Actives

Risk Score ConcurrentRisk Score ProspectiveSubsetsHSS-ACTIVES

LivesCurrentPreviousCurrentPreviousTime Period: DCG IncurredOct 17 to Sep 18 {Nonmedicare} CMedRxOct 16 to Sep 17 {Nonmedicare} CMedRx

City & County of San Francisco67,2720.8810.8700.9860.984Members Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaled

City College of SF2,3041.1201.0591.2811.264Business Unit

Superior Court9050.9090.9961.0191.116City & County of San Francisco67,272.288.0698.6365,997.086.9698.40

SF Unified School District10,1860.9100.9421.0591.085Community College District2,303.8111.96128.122,307.3105.89126.40

Total80,6670.8910.8861.0041.007Court904.890.91101.94944.899.63111.58

EARLY RETIREESUnified School District10,186.490.97105.9410,103.594.22108.49

Risk Score ConcurrentRisk Score ProspectiveAggregate(Business Unit Values)80,667.389.14100.4379,352.588.58100.66

LivesCurrentPreviousCurrentPrevious98.400.9840191978

City & County of San Francisco7,5981.9281.8332.0761.997126.401.2639501355

City College of SF2101.7001.4651.8851.768111.581.1158295845

Superior Court1192.4391.7542.6462.252108.491.0848812236

SF Unified School District6282.2542.0742.3582.285100.661.0065592966

Total8,5541.9541.8402.1002.015

MEDICARE RETIREESOverview-All Plans-Risk Scores-EMPLOYERS-ER

Risk Score ConcurrentRisk Score ProspectiveSubsetsEarly Retirees & Pre-65

LivesCurrentPreviousCurrentPreviousTime Period: DCG IncurredOct 17 to Sep 18 {Nonmedicare} CMedRxOct 16 to Sep 17 {Nonmedicare} CMedRx

City & County of San Francisco15,7745.1555.1054.8254.760Members Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaled

City College of SF9804.8654.8764.5334.472Business Unit

Superior Court2825.1024.3424.4294.200City & County of San Francisco7,597.8192.85207.647,462.7183.29199.68

SF Unified School District4,5025.0555.0044.6564.592Community College District209.6169.98188.47201.3146.45176.82

Total21,5375.1205.0634.7714.704Court119.1243.88264.65112.0175.38225.15

Unified School District627.6225.43235.80593.3207.37228.55

Aggregate(Business Unit Values)8,554.1195.39210.038,369.3184.01201.52

476.024.7601960074

447.174.471729583

419.974.1997341513

459.174.5916584181

470.354.703516761

199.681.9968225426

176.821.7681987578

225.152.2515029762

228.552.2854648876

201.522.0151990719

Overview-All Plans-Risk Scores-EMPLOYERS-MR

SubsetsMedicare Retirees

Time Period: DCG IncurredOct 17 to Sep 18 {Medicare} CMedRxOct 16 to Sep 17 {Medicare} CMedRx


Business Unit

City & County of San Francisco15,774.1515.50482.4815,883.8510.45476.02

Community College District979.6486.47453.271,013.3487.60447.17

Court281.6510.17442.87285.3434.18419.97

Unified School District4,501.8505.50465.604,664.1500.45459.17


Apr 3, 2019-1-12:37:54 PM

Overview-All Plans-Risk Scores-EMPLOYERS-Actives

SubsetsHSS-ACTIVES


Business UnitMembers AvgRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers AvgRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaled


Community College District2,303.8126.74134.032,307.3120.34132.37

Court904.8102.57107.45944.8110.67116.90

Unified School District10,186.4103.40111.4110,103.5107.57114.21


Overview-All Plans-Risk Scores-EMPLOYERS-ER

SubsetsEARLY RETIREES-NON MEDICARE


Business UnitMembers AvgRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaledMembers AvgRelative Risk Score Concurrent NonRescaledRelative Risk Score Prosp NonRescaled


Community College District209.8200.57203.77201.9174.19193.86

Court119.3281.71281.22112.0195.27231.59

Unified School District628.8261.55256.41593.7239.47244.32


Comm-combined-55-64

ACTIVES

Risk Score ConcurrentRisk Score Prospective211.842.1183829869

LivesCurrentPreviousCurrentPrevious259.442.5943738417

Blue Shield Access +3,4221.7531.7601.7681.792188.931.8892774814

Blue Shield Trio3,1021.6331.701205.582.055849034

City Plan3642.5082.9012.3092.535209.512.0950925213

Kaiser6,8611.4401.4211.6191.644

All Plans12,8941.5791.6101.6881.733

EARLY RETIREES

Risk Score ConcurrentRisk Score Prospective

LivesCurrentPreviousCurrentPrevious

Blue Shield Access +1,7412.4602.2482.2022.118

Blue Shield Trio1,1641.8211.841

City Plan6752.9822.8872.6522.594

Kaiser3,0931.8901.7381.9851.889

All Plans6,3822.1522.0672.0952.056

Overview-All Plans-Risk Scores-Actives & ER-55-64SubsetsHSS-ACTIVESEarly Retirees & Pre-65

SubsetsHSS-ACTIVESEarly Retirees & Pre-65Time Period: DCG IncurredOct 16 to Sep 17 {Nonmedicare} CMedRxOct 16 to Sep 17 {Nonmedicare} CMedRx

Time Period: DCG IncurredOct 17 to Sep 18 {Nonmedicare} CMedRxOct 17 to Sep 18 {Nonmedicare} CMedRxMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score ProspectiveMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score Prospective

Members Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score ProspectiveMembers Avg MedRelative Risk Score Concurrent NonRescaledRelative Risk Score ProspectivePlan CodeAge Group Medstat

Plan CodeAge Group MedstatBlue Shield Access +55-645,792.7176.05179.182,609.8224.80211.84

Blue Shield Access +55-643,421.8175.31176.781,740.6245.98220.17City Plan55-64320.5290.14253.46630.1288.70259.44

Blue Shield Trio55-643,101.7163.28170.141,163.8182.12184.10Kaiser55-646,756.3142.06164.453,015.6173.82188.93

City Plan55-64365.2250.81230.85675.3298.16265.20Aggregate(Plan Code Values)12,869.5161.05173.306,255.4206.66205.58

Kaiser55-646,860.8143.98161.903,093.3189.03198.52

Aggregate(Plan Code Values)12,894.0157.88168.806,382.1215.17209.51

Claims

CITY PLANCITY PLAN

ACTIVESERAccess-ERACTIVES201620172018

Kaiser201620172018Kaiser201620172018Access-ACTIVES201620172018201620172018Paid Claims$2,135$2,501$2,634

Paid Claims$363$377$360Paid Claims$741$656$689201620172018Paid Claims$1,120$1,207$1,162Paid Claims$870$1,803$2,047MEMBERS8859961,001

MEMBERS46,50848,37349,671MEMBERS45294,6154,616Paid Claims PMPM$596$633.45$528.81MEMBERS4,3103,7782,273MEMBERS1,215$1,689.001,829

MEMBERS32,67832,12220,189

Time Period: Paid Year2018

SubsetsHSS-ACTIVESEarly Retirees & Pre-65

Members Avg Med or RxNet Pay PMPMMembers Avg Med or RxNet Pay PMPM

Plan

Blue Shield Access20,189.1$529.582,272.7$1,352.58

Blue Shield Trio11,647.5$671.951,692.3$754.32

City Plan1,805.3$886.50782.4$1,455.34

New City Plan24.0$1,160.62218.5$1,178.93

Kaiser49,671.1$359.964,616.4$689.43

Aggregate(Plan Values)83,336.9$456.299,582.3$931.87



Members Avg Med or RxNet Pay PMPM MedNet Pay PMPM RxNet Pay PMPMMembers Avg Med or RxNet Pay PMPM MedNet Pay PMPM RxNet Pay PMPM

Plan Code

access+32,678.3$489.71$106.37$596.084,310.2$900.55$219.29$1,119.84

cp1,214.5$688.36$182.04$870.39885.0$1,093.94$348.33$1,442.27Trio-ER

kp46,508.3$307.72$55.11$362.834,529.1$632.86$108.00$740.86Trio-ACTIVES201620172018

Aggregate(Plan Code Values)80,401.0$387.44$77.86$465.309,724.3$793.47$179.20$972.67201620172018Paid Claims$754

Paid Claims$494MEMBERS3,7781,819

Time Period: Paid Year2017MEMBERS32,12210,848


Members Avg Med or RxNet Pay PMPM MedNet Pay PMPM RxNet Pay PMPMMembers Avg Med or RxNet Pay PMPM MedNet Pay PMPM RxNet Pay PMPM

Plan Code

access+32,114.8$526.17$107.28$633.453,777.8$956.03$251.23$1,207.26

cp1,677.0$678.87$193.62$872.49996.2$906.58$321.26$1,227.84

kp48,372.6$325.74$51.69$377.434,615.3$552.34$104.12$656.45

Aggregate(Plan Code Values)82,164.3$411.29$76.32$487.609,389.3$752.35$186.34$938.69

BSC-pmpm


SubsetsActives & Er Combined-NonMedicare

Members Avg Med or RxNet Pay PMPM MedNet Pay PMPM RxNet Pay PMPM

Plan

Blue Shield Access22,474.2$486.92$125.96$612.88

Blue Shield Trio13,345.8$559.63$123.61$683.24

Aggregate(Plan Values)35,819.9$514.01$125.08$639.09

KAISER - ACTIVE

Paid Claims

201620172018362.82682020573401377.433233770507359.95804725418702MEMBERS

20162017201846508.2548372.58333333329949671.083333333299

Kaiser Permanente

Paid Claims

201620172018740.86155292645697656.45117055467301689.43421466866403MEMBERS

2016201720184529.08333333333034615.33333333333034616.4166666666697

Blue Shield Access+

Paid Claims PMPM

201620172018596.06063719752399633.451469522053528.80999999999995MEMBERS

20162017201832678.253212220189

Blue Shield Access+

Paid Claims

2016201720181119.83736881790991207.25707570476991162.1199999999999MEMBERS

2016201720184310.16666666666973777.83333333332982272.6666666666702

City Plan - Active

Paid Claims

201620172018870.3911808700429418032047MEMBERS

2016201720181214.516891829.25

City Plan

Paid Claims

201620172018213525012634MEMBERS

2016201720188859961001

Blue Shield Trio

Paid Claims

201620172018493.76MEMBERS

2016201720183212210848

Blue Shield Trio

Paid Claims

201620172018754.31798355327896MEMBERS

20162017201837781819

HCC

ACTIVES

Claims 50-100K Claims 100-250K Claims 250-500K Claims >500K

Claims PaidNet PaymentClaims PaidNet PaymentClaims PaidNet PaymentClaims PaidNet Payment

Blue Shield Access +112$7,557,01440$6,001,0098$2,329,3394$2,470,825

Blue Shield Trio138$9,278,23452$7,319,1428$2,804,0841$1,073,099new

City Plan14$864,39011$1,666,229Time Period: Paid Rolling YearJan 2018 - Dec 2018

Kaiser185$11,448,09688$13,577,46516$3,846,2307$5,780,503SubsetsClaims bet 50-100K - ActivesClaims bet 100-250K - ActivesClaims bet 250-500K - ActivesClaims >500K - Actives

All Plans449$29,147,735191$28,563,84532$8,979,65312$9,324,427Claims PaidNet PaymentClaims PaidNet PaymentClaims PaidNet PaymentClaims PaidNet Payment

EARLY RETIREESPlanService Date MMDDYYYY

Blue Shield Access +38$2,467,23422$3,330,3704$1,602,401Blue Shield Trio01/01/2018 - 12/31/201871$4,837,747.2020$2,888,239.954$1,211,436.0397$10,303,269.61

Blue Shield Trio16$1,086,6962$351,1702$809,164Blue Shield Access01/01/2018 - 12/31/2018138$9,278,234.2651$7,168,203.478$2,804,084.29198$20,323,620.90

City Plan18$1,143,2617$1,112,5024$1,266,937Aggregate(Plan Values)209$14,115,981.4671$10,056,443.4212$4,015,520.32295$30,626,890.51

Kaiser43$2,729,49221$2,945,5853$994,3304$2,997,505

All Plans125$8,010,56456$8,439,31214$5,116,6324$2,997,505new

Jan 2018 - Dec 2018

SubsetsClaims bet 50-100K - Early RetireesClaims bet 100-250K - Early RetireesClaims bet 250-500K - Early RetireesClaims >500K - Early Retirees

Claims PaidNet PaymentClaims PaidNet PaymentClaims PaidNet PaymentClaims PaidNet Payment

PlanService Date MMDDYYYY

All Plans-HCC- ActivesBlue Shield Trio01/01/2018 - 12/31/201816$1,086,696.302$351,170.432$809,164.3720$2,247,031.10

Time Period: Paid Rolling YearJan 2018 - Dec 2018Blue Shield Access01/01/2018 - 12/31/201838$2,467,233.8322$3,330,369.784$1,602,401.2064$7,400,004.81

SubsetsClaims bet 50-100K - ActivesClaims bet 100-250K - ActivesClaims bet 250-500K - ActivesClaims >500K - ActivesAggregate(Plan Values)54$3,553,930.1324$3,681,540.216$2,411,565.5784$9,647,035.91

PlanClaims PaidNet PaymentClaims PaidNet PaymentClaims PaidNet PaymentClaims PaidNet Payment

Blue Shield Trio112$7,557,014.1840$6,001,009.338$2,329,339.104$2,470,825.30

Blue Shield Access138$9,278,234.2652$7,319,142.008$2,804,084.291$1,073,098.88

City Plan14$864,390.3211$1,666,228.86

Kaiser185$11,448,096.0888$13,577,465.2416$3,846,229.817$5,780,503.27

Aggregate(Plan Values)449$29,147,734.84191$28,563,845.4332$8,979,653.2012$9,324,427.45

All Plans-HCC- Early Retirees

Time Period: Paid Rolling YearJan 2018 - Dec 2018

SubsetsClaims bet 50-100K - Early RetireesClaims bet 100-250K - Early RetireesClaims bet 250-500K - Early RetireesClaims >500K - Early Retirees

PlanClaims PaidNet PaymentClaims PaidNet PaymentClaims PaidNet PaymentClaims PaidNet Payment

Blue Shield Trio16$1,086,696.302$351,170.432$809,164.37

Blue Shield Access48$3,051,114.8726$4,030,053.425$2,046,200.73

City Plan18$1,143,260.897$1,112,502.234$1,266,936.81

Kaiser43$2,729,492.4221$2,945,585.483$994,329.784$2,997,505.23

Aggregate(Plan Values)125$8,010,564.4856$8,439,311.5614$5,116,631.694$2,997,505.23

RX-Gen,Br,Spec-Act

acces+ - activestrio- actives

GenericBrandSpecialtyTotalGenericBrandSpecialtyTotal

2016$23.06$82.11$57.79$162.962016$0.00

2017$21.11$84.98$60.51$166.602017$0.00

KAISER-actives2018$21.44$83.67$59.02$164.122018$17.47$93.80$69.66$180.93

GenericBrandSpecialtyTotaltotaltotal

2016$14.50$39.50$34.95$88.94

2017$12.48$38.00$32.27$82.75

2018$10.46$36.75$30.69$77.90acces+ - er

totalGenericBrandSpecialtyTotalCP-active

2016$41.89$174.91$116.88$333.69GenericBrandSpecialty

KAISER-er2017$43.95$204.96$149.92$398.832016$46.97$133.40$90.88$271.25

GenericBrandSpecialtyTotal2018$45.03$254.40$191.47$490.892017$47.36$144.60$109.50$301.46

2016$31.81$73.10$64.58$169.49total2018$46.86$149.69$114.27$310.82

2017$25.49$75.05$62.77$163.31

2018$20.48$74.05$60.15$154.68CP-er

totalGenericBrandSpecialty

2016$115.99$227.76$90.88$434.63

2017$78.04$238.59$109.50$426.13

SubsetsHSS-ACTIVES2018$61.92$238.90$114.27$415.08

Net Pay PMPM RxScripts PMPY RxScripts PMPM RxScripts RxClaims PaidClaims Paid w Adjustments

Generic CategoryGenericBrandGenericBrandGenericBrandGenericBrandGenericBrandGenericBrandtrio- er

PlanTime Period: Paid YearGenericBrandSpecialtyTotal

Blue Shield - Access+2018$21.44$83.679.461.240.790.10191,06024,948204,05127,816204,05327,8162016$0.00

Blue Shield - Trio2018$17.47$93.809.441.310.790.11109,91315,256118,39617,203119,05217,3352017$0.00

City Plan2018$46.86$149.6911.681.910.970.1621,3613,48522,3053,69222,3443,6972018$47.54$152.97$113.47$313.98

Kaiser2018$10.46$36.753.940.430.330.04195,63121,245197,78321,462197,93121,476total

Aggregate(Plan Values)$14.90$58.576.220.780.520.06517,96564,934542,53570,173543,38070,324

SubsetsEarly Retirees & Pre-65

Net Pay PMPM RxScripts PMPY RxScripts RxScripts PMPM RxClaims PaidClaims Paid w Adjustments

Generic CategoryGenericBrandGenericBrandGenericBrandGenericBrandGenericBrandGenericBrand

PlanTime Period: Paid Year

Blue Shield - Access+2018$45.03$254.4020.152.5545,7965,8041.680.2148,3756,30948,5176,338

Blue Shield - Trio2018$47.54$152.9719.092.3032,3083,8911.590.1934,0454,25834,0454,258

City Plan2018$61.92$238.9019.782.7919,7972,7941.650.2320,3792,92020,4082,921

Kaiser2018$20.48$74.058.100.6737,4063,0870.680.0637,6083,09737,6243,097

Aggregate(Plan Values)$35.41$147.9814.121.63135,30715,5761.180.14140,40716,584140,59416,614

SubsetsHSS-ACTIVES

Net Pay PMPM RxScripts PMPY RxScripts PMPM RxScripts RxClaims PaidClaims Paid w Adjustments


Plan CodeTime Period: Paid Year

access2017$21.11$84.989.651.360.800.11309,84943,702330,37248,324350,89552,946

2016$23.06$82.119.201.330.770.11300,56543,444314,41846,375328,27249,306

cp2017$47.36$144.6011.591.990.970.1719,4363,33120,2653,50920,3053,526

2016$46.97$133.4011.812.340.980.2014,3412,84614,8702,99714,8892,998

kp2017$12.48$38.004.340.470.360.04209,91922,870212,27423,170212,48223,200

2016$14.50$39.504.400.440.370.04204,63120,436207,02420,674207,33020,706

Aggregate(Plan Code Values)$17.50$58.396.510.840.540.071,058,741136,6291,098,317144,9331,133,060152,526

SubsetsEarly Retirees & Pre-65




Blue Shield - Access+2017$43.95$204.9619.802.6274,7889,8971.650.2278,45110,71482,11411,531

2016$41.89$174.9117.902.6577,15411,4121.490.2279,90711,94482,66012,475

City Plan2017$78.04$238.5919.882.9819,7992,9661.660.2520,3823,09120,4313,101

2016$115.99$227.7621.423.4418,9553,0481.780.2919,4363,14419,4633,151

Kaiser2017$25.49$75.058.970.7641,4213,5230.750.0641,7103,54841,7703,557

2016$31.81$73.109.000.7440,7403,3610.750.0640,9873,38241,0123,383



Net Pay PMPM RxScripts PMPY RxScripts RxScripts PMPM RxClaims PaidClaims Paid w AdjustmentsNet Pay PMPM RxScripts PMPY RxScripts RxScripts PMPM RxClaims PaidClaims Paid w Adjustments

Service Category Medstat w CodeSpecialtySpecialtySpecialtySpecialtySpecialtySpecialtySpecialtySpecialtySpecialtySpecialtySpecialtySpecialty


Blue Shield - Access+2018$59.020.285,5960.027,9797,983$191.470.661,4990.052,3552,385

Blue Shield - Trio2018$69.660.384,4830.036,5146,586$113.470.589790.051,2261,226

City Plan2018$114.270.691,2640.061,6611,664$173.390.636350.05965972

Kaiser2018$30.690.115,6360.018,0628,067$60.150.198820.021,4591,465

Aggregate(Plan Values)$44.840.2016,9790.0224,21624,300$112.540.423,9950.036,0056,048


Net Pay PMPM RxScripts PMPY RxScripts RxScripts PMPM RxClaims PaidClaims Paid w AdjustmentsNet Pay PMPM RxScripts PMPY RxScripts RxScripts PMPM RxClaims PaidClaims Paid w Adjustments

Service Category Medstat w CodeSpecialtySpecialtySpecialtySpecialtySpecialtySpecialtySpecialtySpecialtySpecialtySpecialtySpecialtySpecialty

Plan CodeTime Period: Paid Year

access+2017$60.510.319,9800.0314,20315,086$149.920.682,5680.064,0074,223

2016$57.790.299,4290.0212,81113,217$116.880.572,4760.053,7653,833

cp2017$109.500.651,0920.051,3581,363$172.240.656450.05853856

2016$90.880.698400.061,0451,046$157.870.766760.06948950

kp2017$32.270.125,8340.018,2938,303$62.770.219480.021,4571,459

2016$34.950.135,8270.017,9968,005$64.580.219470.021,4411,442

Blue Shield Trio- Cost Rx PMPM

Generic

20162017201847.543458735473003Brand

201620172018152.965407721095Specialty

201620172018113.467747685641

$169.49

$163.31

$154.68

RX Cost-PMPM

acces+ - activestrio- actives


2016$23.06$82.11$57.79$162.962016$0.00

2017$21.11$84.98$60.51$166.602017$0.00

2018$21.44$83.67$59.02$164.122018$17.47$93.80$69.66$180.93

totaltotal

acces+ - ertrio- er


2016$41.89$174.91$116.88$333.692016$0.00

2017$43.95$204.96$149.92$398.832017$0.00

2018$45.03$254.40$191.47$490.892018$47.54$152.97$113.47$313.98

totaltotal

SubsetsHSS-ACTIVES



PlanTime Period: Paid YearService Date MMDDYYYY

Blue Shield - Access+201801/01/2018 - 12/31/2018$21.44$83.679.461.24191,06224,9480.790.10204,05127,816204,05127,816

Blue Shield - Trio201801/01/2018 - 12/31/2018$17.62$93.569.471.32110,28515,3420.790.11118,10817,157118,10817,157

City Plan201801/01/2018 - 12/31/2018$46.93$149.6811.691.9121,3823,4850.970.1622,2733,68222,2733,682

Kaiser201801/01/2018 - 12/31/2018$10.46$36.753.940.43195,68921,2540.330.04196,79321,370196,80121,370


SubsetsHSS-ACTIVES

Net Pay PMPM RxScripts PMPY RxScripts RxClaims PaidClaims Paid w Adjustments

Service Category Medstat w CodeSpecialtySpecialtySpecialtySpecialtySpecialty

PlanTime Period: Paid YearService Date MMDDYYYY

Blue Shield - Access+201801/01/2018 - 12/31/2018$59.020.285,5967,9797,983

Blue Shield - Trio201801/01/2018 - 12/31/2018$69.310.384,4795,8705,874

Aggregate(Plan Values)$62.790.3210,07513,84913,857

Rx-Combo

KAISER

GenericBrandSpecialtyTotal

2016$15.94$42.26$37.39$95.59

2017$13.53$40.85$34.59$88.97

2018$40.8539.403$32.73$112.99

total

CP

GenericBrandSpecialty

2016$75.33$171.59$116.80

2017$57.21$172.37$125.61

2018$48.98$168.35$123.37

All Plans--Rx-Generic, Brand




Plan GroupGeneric Category

Blue ShieldGeneric$22.86$23.49$25.2110.5910.7210.22379,289384,959378,339405,066409,123394,946405,868433,287411,554

Brand$101.03$97.60$92.671.391.491.4849,94553,64354,85155,63259,08258,29155,79364,52161,730

City PlanGeneric$48.98$57.21$75.3314.1514.3915.9641,89040,26534,95043,46341,70035,99243,53141,79136,039

Brand$168.35$172.37$171.592.112.292.796,2596,4046,1206,6216,7146,3746,6276,7426,383

KaiserGeneric$11.24$13.53$15.944.264.714.78231,382249,642244,218233,735252,283246,735233,899252,554247,011

Brand$39.40$40.85$42.260.440.490.4624,13426,20623,66424,35826,53023,90624,37226,56923,932

Aggregate(Plan Group Values)$84.12$85.84$87.237.878.308.22732,899761,119742,142799,979829,575798,644801,374860,604819,624

All Plans-- RX-Specialty Drugs




Plan GroupService Category Medstat w Code

Blue ShieldSpecialty Drugs$73.39$69.88$64.390.350.350.3212,56812,56111,86217,91618,02516,31418,01919,11516,778

City PlanSpecialty Drugs$123.37$125.61$116.800.600.600.721,7671,6681,5732,5102,0912,0032,5202,0982,006

KaiserSpecialty Drugs$32.73$34.59$37.390.120.130.136,4446,7016,7269,4239,6459,3649,4349,6579,376


KAISER - COST PMPM

Generic

20162017201815.94244895596113.52522290260640.853341558715002Brand

20162017201842.25693200868799740.85334155871500239.402559970422999Specialty

20162017201837.39482186772200134.59010258675100132.730971553838003

CITY PLAN - COST PMPM

2016

GenericBrandSpecialty75.332846487555997171.58819735139701116.7962242179772017



$95.59

$88.97

$112.99

RX-SCRIPTS-PMPY

KAISERBSCCP

GenericBrandSpecialtyGenericBrandSpecialtyGenericBrandSpecialty

20164.780.460.13201610.221.480.32201615.962.790.32

20174.710.490.13201710.721.490.35201714.392.290.35

20184.260.440.12201810.591.390.35201814.152.110.35

All Plans--Rx-Generic, Brand





Blue ShieldGeneric$22.86$23.49$25.2110.5910.7210.22379,289384,959378,339405,066409,123394,946405,868433,287411,554

Brand$101.03$97.60$92.671.391.491.4849,94553,64354,85155,63259,08258,29155,79364,52161,730


Brand$168.35$172.37$171.592.112.292.796,2596,4046,1206,6216,7146,3746,6276,7426,383

KaiserGeneric$11.24$13.53$15.944.264.714.78231,382249,642244,218233,735252,283246,735233,899252,554247,011

Brand$39.40$40.85$42.260.440.490.4624,13426,20623,66424,35826,53023,90624,37226,56923,932







Blue ShieldSpecialty Drugs$73.39$69.88$64.390.350.350.3212,56812,56111,86217,91618,02516,31418,01919,11516,778


KaiserSpecialty Drugs$32.73$34.59$37.390.120.130.136,4446,7016,7269,4239,6459,3649,4349,6579,376


KAISER - SCRIPTS PMPY

Generic

2016201720184.77924839692300024.70843484083099994.2594594262900003Brand

2016201720180.463094997358000030.4942647608920.44427740184600001Specialty

2016201720180.131625124755999990.1263858720420.11862615304099999

BLUE SHIELD - SCRIPTS PMPY

2016GenericBrandSpecialty10.2243651530019991.4823125636190.320562827107000012017GenericBrandSpecialty10.7198819295051.4937866794760.349783839101000032018GenericBrandSpecialty10.5887739362871.39433601883399990.350866254574

BLUE SHIELD - SCRIPTS PMPY

Generic

20162017201810.22436515300199910.71988192950510.588773936287Brand

2016201720181.4823125636191.4937866794761.3943360188339999Specialty

2016201720180.320562827107000010.349783839101000030.350866254574

CITY PLAN - SCRIPTS PMPY

Generic

20162017201815.96011873049699914.38677981241614.146053186998Brand

2016201720182.79473323692799982.28816435908799992.113634444913Specialty

2016201720180.320562827107000010.349783839101000030.350866254574

RX-# of rx scripts

KAISER

GenericBrandSpecialty

2016244,21823,6646,726

2017249,64226,2066,701

2018231,38224,1346,444

BSCCP

GenericBrandSpecialtyGenericBrandSpecialty

2016378,33954,85111,862201634,9506,1201,573

2017384,95953,64312,561201740,2656,4041,668

All Plans--Rx-Generic, Brand2018379,28949,94512,568201841,8906,2591,767



Time Period: Paid Year201820172016201820172016201820172016201820172016201820172016bsckp


Blue ShieldGeneric$22.86$23.49$25.2110.5910.7210.22379,289384,959378,339405,066409,123394,946405,868433,287411,554490,06284%280,31988%

Brand$101.03$97.60$92.671.391.491.4849,94553,64354,85155,63259,08258,29155,79364,52161,73013%9%


Brand$168.35$172.37$171.592.112.292.796,2596,4046,1206,6216,7146,3746,6276,7426,383

KaiserGeneric$11.24$13.53$15.944.264.714.78231,382249,642244,218233,735252,283246,735233,899252,554247,011

Brand$39.40$40.85$42.260.440.490.4624,13426,20623,66424,35826,53023,90624,37226,56923,932







Blue ShieldSpecialty Drugs$73.39$69.88$64.390.350.350.3212,56812,56111,86217,91618,02516,31418,01919,11516,7783%


KaiserSpecialty Drugs$32.73$34.59$37.390.120.130.136,4446,7016,7269,4239,6459,3649,4349,6579,3763%


KAISER - # of Rx Scripts

Generic

201620172018244218249642231382Brand

201620172018236642620624134Specialty

201620172018672667016444

BLUE SHIELD - # of Rx Scripts

Generic

201620172018378339384959379289Brand

201620172018548515364349945Specialty

201620172018118621256112568

CITY PLAN - # of Rx Scripts

Generic

201620172018349504026541890Brand

201620172018612064046259Specialty

201620172018157316681767

Paid Claims Drivers (2)

Kaiser Outpatient


Plan GroupKaiser

Time Period: Paid Rolling YearJan 2018 - Dec 2018Jan 2017 - Dec 2017

Kaiser NPS Service CategoryPatients with ER VisitsPatients MedVisits Per 1000 ERVisits Per 1000 OP Fac MedVisits OP Fac MedNet Pay PMPM OP Fac MedNet Pay PMPM OP MedNet Pay OP MedNet Pay OP Fac MedNet Pay Per Visit Office MedPatients with ER VisitsPatients MedVisits Per 1000 ERVisits Per 1000 OP Fac MedVisits OP Fac MedNet Pay PMPM OP Fac MedNet Pay PMPM OP MedNet Pay OP MedNet Pay OP Fac MedNet Pay Per Visit Office Med

ER6,9147,261168.55169.679,217$22.71$26.50$17,273,660.05$14,804,770.38$681.107,1667,396185.82186.579,892$20.56$24.97$15,885,173.00$13,080,156.90

OP Surgery8672,29736.912,005$32.93$38.18$24,885,496.42$21,465,683.46$580.805171,43930.051,593$29.86$35.79$22,770,882.00$18,999,174.01

OUTPATIENT VISITS6,25044,878$73.00$47,582,885.09$243.296,41241,863$68.17$43,373,855.09$234.78

OUTPATIENT LAB4,34830,165$19.71$12,849,488.60$61.564,77230,294$16.49$10,489,750.00

OUTPATIENT RADIOLOGY3,76614,255$21.62$14,094,090.25$499.304,64817,951$26.20$16,668,174.60$495.69

Aggregate(Kaiser NPS Service Category Values)6,97346,818168.55206.5811,222$55.64$179.00$116,685,620.41$36,270,453.84$253.697,22944,690185.82216.6211,485$50.42$171.61$109,187,834.69$32,079,330.91$274.96

ACTIVES & EARLY RETIREES (Combined)

KAISER - OUTPATIENT

Visits Per 1000 Net Pay PMPM Net Pay Per Visit

ER168.55$26.50$681.10

OP Surgery36.91$38.18$580.80

OUTPATIENT VISITS3,484.85$73.00$243.29

OUTPATIENT LAB171.00$19.71$61.56

OUTPATIENT RADIOLOGY277.46$21.62$499.30

Aggregate(Kaiser NPS Service Category Values)$179.00$253.69

Kaiser Outpatient


Plan GroupKaiser


Kaiser NPS Service CategoryVisits Per 1000 Office MedNet Pay PMPM OP MedNet Pay Per Visit Office Med

ER168.55$26.50$681.10

OP Surgery36.91$38.18$580.80

OUTPATIENT VISITS3,484.85$73.00$243.29

OUTPATIENT LAB171.00$19.71$61.56

OUTPATIENT RADIOLOGY277.46$21.62$499.30

Aggregate(Kaiser NPS Service Category Values)$179.00$253.69

BSC-Outpatient


Plan GroupBlue ShieldCity PlanKaiser

SubsetsActives & Er Combined-NonMedicareActives & Er Combined-NonMedicareActives & Er Combined-NonMedicare

Service Category Medstat w CodeNet Pay PMPM MedNet Pay PMPM OP MedNet Pay PMPM MedNet Pay PMPM OP MedNet Pay PMPM MedNet Pay PMPM OP Med

OP Surgical$81.38$81.37$168.60$168.59$42.19$42.19

OP ER$49.30$49.30$55.09$55.07$25.16$25.16

OP Radiology$52.68$52.48$82.75$81.60$28.59$28.56

OP Other$9.68$9.64$32.18$28.36$12.79$12.66

OP DME$8.88$8.88$8.69$3.03$3.90$3.85

OP Home Health$1.09$1.09$1.50$1.09$0.87$0.87

OP Visits$36.73$36.73$61.75$61.72$29.48$29.48

OP Laboratory$26.97$26.97$40.64$39.40$19.41$19.41

Transportation$5.34$5.34$10.07$10.07$4.52$4.52

All Plans-Inpatient


Time Period: Paid Rolling YearJan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018

Net Pay PMPMNet Pay PMPM IP AcuteNet Pay PMPM MedNet Pay PMPM Adm Acute MHSA

Plan GroupBlue ShieldCity PlanKaiserBlue ShieldCity PlanKaiserBlue ShieldCity PlanKaiserBlue ShieldCity PlanKaiser

DRG

IP-MED$51.44$70.33$35.82$50.92$67.37$35.03$51.44$70.33$35.82

IP-SURG$79.75$128.80$46.10$79.59$128.28$45.82$79.75$128.80$46.10$0.04$0.05

IP-MAT$19.96$11.57$22.85$19.93$11.56$22.83$19.96$11.57$22.85

IP-PSYCH / SA$6.40$14.49$2.94$6.02$13.77$2.55$6.40$14.49$2.94$6.40$14.49$2.94

Aggregate(DRG Values)$157.54$225.19$107.70$156.47$220.98$106.23$157.54$225.19$107.70$6.44$14.49$2.98

Paid Claims Drivers

BSC-Outpatient


Plan GroupBlue ShieldCity PlanKaiser

SubsetsActives & Er Combined-NonMedicareActives & Er Combined-NonMedicareActives & Er Combined-NonMedicare

Service Category Medstat w CodeNet Pay PMPM MedNet Pay PMPM OP MedNet Pay PMPM MedNet Pay PMPM OP MedNet Pay PMPM MedNet Pay PMPM OP Med

OP Surgical$81.38$81.37$168.60$168.59$42.19$42.19

OP ER$49.30$49.30$55.09$55.07$25.16$25.16

OP Radiology$52.68$52.48$82.75$81.60$28.59$28.56

OP Other$9.68$9.64$32.18$28.36$12.79$12.66

OP DME$8.88$8.88$8.69$3.03$3.90$3.85

OP Home Health$1.09$1.09$1.50$1.09$0.87$0.87

OP Visits$36.73$36.73$61.75$61.72$29.48$29.48

OP Laboratory$26.97$26.97$40.64$39.40$19.41$19.41

Transportation$5.34$5.34$10.07$10.07$4.52$4.52

All Plans-Inpatient


Time Period: Paid Rolling YearJan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018Jan 2018 - Dec 2018

Net Pay PMPMNet Pay PMPM IP AcuteNet Pay PMPM MedNet Pay PMPM Adm Acute MHSA

Plan GroupBlue ShieldCity PlanKaiserBlue ShieldCity PlanKaiserBlue ShieldCity PlanKaiserBlue ShieldCity PlanKaiser

DRG

IP-MED$51.44$70.33$35.82$50.92$67.37$35.03$51.44$70.33$35.82

IP-SURG$79.75$128.80$46.10$79.59$128.28$45.82$79.75$128.80$46.10$0.04$0.05

IP-MAT$19.96$11.57$22.85$19.93$11.56$22.83$19.96$11.57$22.85

IP-PSYCH / SA$6.40$14.49$2.94$6.02$13.77$2.55$6.40$14.49$2.94$6.40$14.49$2.94

Aggregate(DRG Values)$157.54$225.19$107.70$156.47$220.98$106.23$157.54$225.19$107.70$6.44$14.49$2.98

Unions

CCSF ACTIVES

Risk Score ProspectiveRisk Score Concurrent

Top 10 UnionsCurrentPreviousCurrentPrevious

INSTITUTIONAL POLICE OFFICERS ASSOCIATION1.8001.7032.2051.840

MUNICIPAL EXECUTIVES ASSOCIATION (MEA)1.1431.1161.1341.046

SERVICE EMPLOYEES INTERNATIONAL UNION (SEIU), LOCAL 10211.1261.1051.0631.029

TRADES1.0981.1161.0691.111

Transit Workers1.0921.1031.0681.065

HEALTH1.0811.0911.0611.057

MISC. SAFETY1.0541.0191.0750.969

PROFESSIONAL AND TECHNICAL ENGINEERS, LOCAL 211.0081.0080.9490.950

MUNICIPAL ATTORNEYS ASSOCIATION (MAA)0.9300.9650.8580.935

SHF0.8930.9120.8590.894

Total1.0831.0801.0371.029

Overview-All Plans-Risk Scores-UNIONS-Actives

HSS-ACTIVES

Oct 17 to Sep 18 {Nonmedicare} CMedRx

Relative Risk Score Prosp NonRescaledRelative Risk Score Concurrent NonRescaled

Labor Union Code

INSTITUTIONAL POLICE OFFICERS ASSOCIATION180.00220.50

MUNICIPAL EXECUTIVES ASSOCIATION (MEA)114.32113.39

SERVICE EMPLOYEES INTERNATIONAL UNION (SEIU), LOCAL 1021112.58106.29

TRADES109.85106.91

Transit Workers109.24106.85

HEALTH108.10106.12

MISC. SAFETY105.40107.47

PROFESSIONAL AND TECHNICAL ENGINEERS, LOCAL 21100.8394.86

MUNICIPAL ATTORNEYS ASSOCIATION (MAA)93.0485.83

SHF89.2585.89

Aggregate(Labor Union Code Values)108.29103.73

Oct 16 to Sep 17 {Nonmedicare} CMedRx

Relative Risk Score Prosp NonRescaledRelative Risk Score Concurrent NonRescaled

Labor Union Code

INSTITUTIONAL POLICE OFFICERS ASSOCIATION

TRADES

MUNICIPAL EXECUTIVES ASSOCIATION (MEA)

SERVICE EMPLOYEES INTERNATIONAL UNION (SEIU), LOCAL 1021

Transit Workers

HEALTH

MISC. SAFETY

PROFESSIONAL AND TECHNICAL ENGINEERS, LOCAL 21

MUNICIPAL ATTORNEYS ASSOCIATION (MAA)

SHF

Aggregate(Labor Union Code Values)

by Gender, Avg Age & Status

Actives

CURRENTPREVIOUS

Plan GroupGender% of MembersAverage AgeProspective Risk Score% of MembersAverage AgeProspective Risk Score

Blue Shield Access+Female52%35.21.1352%36.21.16

Male48%34.41.0248%35.51.05

Blue Shield TrioFemale52%36.61.16

Male48%36.11.05

UHC PPO (City Plan)Female48%38.41.7048%38.81.75

Male52%38.91.4252%39.41.50

Kaiser PermanenteFemale51%34.11.0151%34.21.01

Male49%34.00.8449%34.00.83

Early Retirees

Blue Shield Access+Female55%52.52.0355%53.01.94

Male45%51.32.2545%52.72.15

Blue Shield TrioFemale56%54.01.76

Male44%54.12.07

UHC PPO (City Plan)Female51%56.62.7552%56.92.54

Male49%56.92.8148%56.92.83

Kaiser PermanenteFemale55%54.81.8754%54.51.77

Male45%54.02.1746%53.92.00

All Plans-Risk Scores-by Gender-Act, ER

Time Period: DCG IncurredOct 17 to Sep 18 {Nonmedicare} CMedRx20182017

SubsetsHSS-ACTIVESEarly Retirees & Pre-65aeraer

PlanGenderMembersMember Age AvgRelative Risk Score Prosp NonRescaledMembersMember Age AvgRelative Risk Score Prosp NonRescaled52%56%52%55%

Blue Shield TrioFemale16,64536.6116.0398254.0176.0948%44%48%45%

Male15,46136.1105.0578754.1207.30

Aggregate(Gender Values)32,10636.4110.691,76954.0189.8252%55%

Bkue Shield AccessFemale10,90435.2113.052,33952.5202.9248%45%

Male9,97634.4102.151,90051.3225.05

Aggregate(Gender Values)20,88034.9107.854,23952.0212.8948%51%

City PlanFemale1,05238.4169.9953756.6275.4452%49%

Male1,15538.9141.5751856.9281.19

Aggregate(Gender Values)2,20738.6155.071,05556.8278.22

KaiserFemale27,64434.1100.632,72454.8187.0451%55%

Male26,31534.084.502,25154.0217.3649%45%




MembersMember Age AvgRelative Risk Score Prosp NonRescaledMembersMember Age AvgRelative Risk Score Prosp NonRescaled

PlanGender

Bkue Shield AccessFemale18,50236.2115.742,60353.0194.45

Male17,06635.5105.152,11952.7214.94


City PlanFemale94838.8174.5754356.9253.54

Male1,04239.4149.8049356.9283.17


KaiserFemale27,61534.2100.782,74854.5177.01

Male26,29634.082.932,30353.9199.87


Kaiser

ACTIVESEARLY RETIREES

CURRENTPREVIOUSCURRENTPREVIOUS

Age BandsLivesAverage AgeRisk Score ProspectiveLivesAverage AgeRisk Score ProspectiveLivesAverage AgeRisk Score ProspectiveLivesAverage AgeRisk Score Prospective

Female



Risk Scores by Relationship – All SFHSS Population

ACTIVES EARLY RETIREES MEDICARE RETIREESRelationship Members Member

Age AvgRisk Score Concurrent

Risk Score Prospective

Members Member Age Avg

Risk Score Concurrent


Members Member Age Avg



Current Employee / Retiree

39,362 45.3 1.068 1.240 5,588 59.8 2.337 2.477 16,145 75.6 5.529 5.104

Spouse 14,486 46.6 1.210 1.364 1,797 57.8 1.624 1.885 4,803 72.1 4.202 4.068Children 26,819 13.0 0.461 0.464 1,169 19.0 0.627 0.633 195 22.1 1.128 0.950

TOTAL 80,667 34.8 0.891 1.004 8,554 53.8 1.954 2.100 21,143 74.3 5.187 4.830

Previous Employee / Retiree

38,632 45.5 1.075 1.260 5,556 59.8 2.105 2.326 14,396 75.2 5.295 4.956

Spouse 14,349 46.7 1.177 1.337 1,682 57.6 1.746 1.897 4,325 71.6 4.085 3.998Children 26,372 13.0 0.450 0.455 1,131 19.2 0.680 0.664 214 22.3 1.218 1.060

TOTAL 79,352.5 34.9 0.886 1.007 8,369 53.8 1.840 2.015 18,935 73.8 4.972 4.693

For active employees, spouses have a higher risk score

In the early retiree and Medicare retiree population, the retiree has a much higher risk score than the spouse



Concurrent and Prospective Risk Scores for Ages 55-64ACTIVESRisk Score Concurrent Risk Score Prospective

Employees Current Previous Current PreviousBlue Shield Access+ 2,425 1.649 1.720 1.719 1.760Blue Shield Trio 2,298 1.615 n/a 1.693 n/aUHC PPO (City Plan) 266 2.303 2.604 2.224 2.369Kaiser Permanente 5,006 1.421 1.422 1.603 1.656All Plans 9,389 1.538 1.587 1.665 1.721

EARLY RETIREESRisk Score Concurrent Risk Score Prospective

Retirees Current Previous Current PreviousBlue Shield Access+ 1,331 2.626 2.302 2.329 2.176Blue Shield Trio 915 1.891 n/a 1.909 n/aUHC PPO (City Plan) 549 3.107 2.822 2.711 2.580Kaiser Permanente 2,432 2.029 1.800 2.082 1.958All Plans 4,998 2.287 2.116 2.193 2.113

Claims paid PMPM for early retirees is at least two times that of the active population (see slides 6 and 7)

Focusing on those aged 55-64, the risk scores (indicative of illness burden) are much higher for the early retirees compared to the active employees

SFHSS.ORG

APPENDIX


DxCG Risk Scores


It is important to consider that chronic conditions can become uncontrollable and acute conditions can be sudden and expensive.

Risk scores enable a fair evaluation of health plans adjusting for difference in underlying population risk

Risk scores trend risk over time by indicating whether a population is becoming sicker or healthier

Risk scores facilitate identification of current and future high-risk patients in order to intervene and manage risk

The risk scores were calculated from the Cotiviti DxCG Intelligence (formerly Verisk Risk Solutions) software version 5.0 and the IBM Watson Health Advantage Suite version 5.4. This new release of DxCG Intelligence includes enhancements to the classification system and new cost weights based on a more current MarketScan development data set. The model used is the commercial population version and therefore the Medicare risk scores may calculate higher than with a Medicare model.

The Concurrent models measure current illness burden of our population which includes chronic and current acute conditions ofindividuals. Age and Gender are less important because all the conditions are known.

The Prospective model measures the chronic condition illness burden since that affects future cost. This scores provides the ability to predict future healthcare spending. Current acute conditions are relatively less important since they don’t affect the future cost. For this model Age and Gender play a significant role. Included in the risk pool are acute or new conditions based on age and gender.

Ratios are generated by risk adjusting the financial or utilization performance to measure efficiency. A ratio lower than 1.0 indicates plan performance better than expected, a ratio of 1.0 indicates performance is as expected, and a ratio greater than 1.o indicates performance is worse than expected.



Concurrent and Prospective Risk Score Current vs. Previous

ACTIVESRisk Score Concurrent Risk Score Prospective

Lives Current Previous Current PreviousBlue Shield Access + 19,626 1.015 1.025 1.079 1.106Blue Shield Trio 16,227 1.006 1.107UHC PPO (City Plan) 1,673 1.546 1.566 1.551 1.614

Kaiser Permanente 48,044 0.792 0.771 0.927 0.920All Plans 80,662 0.891 0.886 1.004 1.006


Lives Current Previous Current PreviousBlue Shield Access + 2,462 2.133 1.958 2.129 2.034Blue Shield Trio 1,528 1.714 2.455 1.898 2.288UHC PPO (City Plan) 786 2.871 2.711 2.782 2.677Kaiser Permanente 4,098 1.735 1.567 2.007 1.873All Plans 8,491 1.953 1.839 2.099 2.015

MEDICARE RETIREESRisk Score Concurrent Risk Score Prospective

Lives Current Previous Current PreviousUHC MA PPO 11,389 5.308 5.308 4.768 4.775KP Senior Advantage 9,753 5.045 4.673 4.902 4.620Blue Shield Access + 2,446 4.631 4.146All Plans 21,143 5.187 4.945 4.830 4.650



Concurrent and Prospective Risk Score by EmployerACTIVES

Risk Score Concurrent Risk Score ProspectiveLives Current Previous Current Previous

City & County of San Francisco

67,272 0.881 0.870 0.986 0.984

City College of SF 2,304 1.120 1.059 1.281 1.264Superior Court 905 0.909 0.996 1.019 1.116SF Unified School District 10,186 0.910 0.942 1.059 1.085Total 80,667 0.891 0.886 1.004 1.007


Lives Current Previous Current PreviousCity & County of San Francisco

7,598 1.928 1.833 2.076 1.997

City College of SF 210 1.700 1.465 1.885 1.768Superior Court 119 2.439 1.754 2.646 2.252SF Unified School District 628 2.254 2.074 2.358 2.285Total 8,554 1.954 1.840 2.100 2.015

MEDICARE RETIREES

Risk Score Concurrent Risk Score ProspectiveLives Current Previous Current Previous

City & County of San Francisco

15,774 5.155 5.105 4.825 4.760

City College of SF 980 4.865 4.876 4.533 4.472Superior Court 282 5.102 4.342 4.429 4.200SF Unified School District 4,502 5.055 5.004 4.656 4.592Total 21,537 5.120 5.063 4.771 4.704



Risk Scores by Gender and Age – Kaiser Permanente

ACTIVES EARLY RETIREESAge Bands Lives Average

AgeRisk Score Concurrent


Lives Average Age Risk Score Concurrent


Female



Risk Scores by Gender and Age – UHC PPO (City Plan)

ACTIVES EARLY RETIREESAge Lives Average Age Risk Score

ConcurrentRisk Score Prospective



Female



Risk Scores by Gender and Age – Blue Shield Access +

ACTIVES EARLY RETIREESAge Lives Average



Lives Average Age



Female



Risk Scores by Gender and Age – Blue Shield Trio

ACTIVES EARLY RETIREESAge Lives Average





Female

New Employee Orientation - SFHSS...Due to the new release of the DxCG Intelligence Model, risk...

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