UNIVERSITY OF ALASKA · Days Per 1000 Members 193 211 9% 241 ... Paid Claims Per Member Per Month...

L O C K T O N D U N N I N G B E N E F I T S

UNIVERSITY OF ALASKA F Y 1 5 U T I L I Z A T I O N R E V I E W ( 3 R D Q T R ) 7 / 1 / 2 0 1 4 T O 0 3 / 3 1 / 2 0 1 5

Premera- Medical

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Premera Medical – Inpatient & Outpatient

Inpatient

− Paid claims per member per month (PMPM) for inpatient services increased 17% from $70 for FY14 (7/13-3/14) to $82 for FY15 (7/14-3/15) and is above the Premera norm of $80

− The average length of stay for inpatient services decreased from 4.6 days for FY14 to 4.3 days for FY15 and is slightly below the Premera Norm of 4.7 days

− Admissions per 1,000 members increased from 42 for FY14 to 49 for FY15

− Paid claims per admission decreased slightly from $20,178 for FY14 to $20,010 FY15

Outpatient

− Paid claims PMPM for outpatient services increased from $88 for FY14 to $93 for FY15 and was just below the Premera Norm of $94

− Outpatient services per 1,000 members increased from 3,598 for FY14 to 4,018 for FY15 and was above the Premera Norm of 3,643

− Paid claims per service decreased from $294 for FY14 to $277 for FY15 and was below the Premera norm of $308

Norm is based on Premera’s Alaska large group book of business

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Emergency Room

− ER paid claims per visit increased from $1,558 for FY14 to $1,613 for FY15, and was above the Premera Norm of $1,353

− Visits per 1,000 members for ER services remained the same at 142

Large Claims

− The number of large claims decreased slightly from FY14 Q3 compared to FY15 Q3 but the average claim increased 2.4%

47 large claimants over $100k for FY15 Q3 − Largest claimant (Pneumonia) is at $416,958 − $8,292,775 total paid in claims over $100,000

51 large claimants over $100k for FY14 Q3 − One over $400k with largest being a Single Liveborn at $469,515 − $8,785,916 total paid in claims over $100,000

Average claim over $100,000 in FY14 Q3 was $172,273 compared to FY15 Q3 of $176,442

Large claimants as a % of total paid costs in Q3 decreased from 24.6% to 21.9%


Premera Medical – Emergency Room & Large Claims

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Medical Utilization – FY 15 Q3

Utilization CategoryFY14 Q3 FY15 Q3

% Change

over FY14 Q3

Norm

Inpatient

Paid Claims Per Member Per Month $70 $82 17% $80

Admissions Per 1000 Members 42 49 18% 51

Days Per 1000 Members 193 211 9% 241

Average Length of Stay 4.6 4.3 -8% 4.7

Paid Claims Per Admission $20,178 $20,010 -1% $18,625

Outpatient


Visits Per 1000 Members 945 1,063 12% 911

Paid Claims Per Visit $1,118 $1,048 -6% $1,233

Services Per 1000 Members 3,598 4,018 12% 3,643

Services Per Visit 3.8 3.8 -1% 4.0

Paid Claims Per Service $294 $277 -6% $308

ER Utilization: Paid Claims PMPM $18 $19 4% $21

ER Utilization: Visits Per 1000 Members 142 142 0% 185

ER Utilization: Paid Claims Per Visit $1,558 $1,613 3% $1,353

Professional Provider


Services Per 1000 Members 16,465 17,037 3% 15,843

Paid Claims Per Service $148 $149 1% $131

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Large Claims Analysis – FY14 Q3 vs FY15 Q3

FY14 Q3 FY15 Q3

Medical & Rx Plan Spend $35,648,516 $37,930,089

Average Monthly Employees 3,948 3,853

PEPM Cost $1,003 $1,094

% Change Over Previous Fiscal Year 9.0%405.75% 457.39%

Total Paid for Large Claimants (Over $100k) $8,785,916 $8,292,775

# of Large Claimants (Over $100k) 51 47

Average Large Claimant $172,273 $176,442

% Change Over Previous Yr 2.4%

Without large claims $26,862,600 $29,637,314

PEPM Cost $756 $855

% Change Over Previous Yr 13.0%

24.6% 21.9%

75.35% 78.14%

Large Claims above $100k as a percentage of

Total Medical & Rx Claims

24.6%

FY14

21.9%

FY15

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Top 25 Claimants – FY15 Q3 (July 2014 to March 2015)

# Claimaint Number* Diagnosis YTD Claims1 20 Pneumonia $416,958

2 11 Neoplasm of Female Breast $365,790

3 12 Multiple Myeloma and Immunoproliferative Neoplasms $323,570

4 1 Malignant Neoplasm of Lymph Nodes $283,270

5 4 Curvature of Spine $281,739

6 8 Neoplasm of Female Breast $277,015

7 19 Myeloid Leukemia $276,489

8 7 Neoplasm of Rectum $254,147

9 9 Neoplasm of Tongue $251,284

10 18 Malignant Neoplasm of Brain $248,012

11 17 Malignant Neoplasm of Colon $242,599

12 39 Single Liveborn $212,987

13 30 Cardiac Dysrhythmias $200,952


15 23 Malignant Neoplasm of Female Breast $194,137

16 21 Malignant Neoplasm of Trachea, Bronchus, and Lung $193,137



19 2 Fracture of Pelvis $160,072

20 3 Spondylosis $158,234

21 30 Neuroendocrine Tumors $155,904

22 29 Malignant Neoplasm of Stomach $141,105

23 40 Osteomyelitis, Periostitis, and Other Infections Involving Bones $140,574

24 41 Intracranial Hemorrhage $139,054

25 42 Spondylosis and Allied Disorders $138,516

Total $5,616,054

*Claimant number based on when member claims exceeded $100,000 in the plan year

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Major Diagnostic Category – Medical Only

Paid PMPMTotal Paid

Claims

Percentage of

Overall TotalPaid PMPM

Total Paid

Claims

Percentage of

Overall Total

Musculoskeletal System $69.78 $5,527,100 18.01% $89.48 $6,916,767 21.35%

Health Status & Services $57.56 $4,559,199 14.86% $57.76 $4,464,545 13.78%

Neoplasms $40.54 $3,210,654 10.46% $45.64 $3,527,847 10.89%

Ill-Defined Conditions $29.83 $2,362,678 7.70% $30.83 $2,383,046 7.36%

Circulatory System $26.93 $2,132,730 6.95% $30.26 $2,339,314 7.22%

Injury and Poisoning $28.97 $2,294,500 7.48% $27.54 $2,129,226 6.57%

Digestive System $25.83 $2,045,926 6.67% $21.12 $1,632,594 5.04%

Nervous System $15.30 $1,211,847 3.95% $20.91 $1,616,616 4.99%

Mental Disorders $17.35 $1,374,155 4.48% $20.68 $1,598,543 4.93%

Genitourinary System $19.54 $1,547,786 5.04% $17.61 $1,361,312 4.20%

Respiratory System $13.63 $1,079,868 3.52% $16.14 $1,247,820 3.85%

Pregnancy and Related $13.09 $1,037,091 3.38% $15.54 $1,201,290 3.71%

Endocrine, Metabolic and Immunity $11.28 $893,383 2.91% $11.30 $873,209 2.70%

Skin and Tissue $4.71 $372,660 1.21% $4.19 $324,252 1.00%

Infectious and Parasitic $3.52 $279,007 0.91% $3.50 $270,903 0.84%

Congenital Anomalies $3.53 $279,626 0.91% $3.24 $250,680 0.77%

Blood $4.44 $351,835 1.15% $1.90 $146,748 0.45%

Perinatal $1.64 $129,833 0.42% $1.42 $109,398 0.34%

Other $0.02 $1,621 0.01% $0.01 $798 0.00%

Injury and Poisoning External Causes ($0.00) ($371) 0.00% $0.00 $120 0.00%

Total $387.50 $30,691,127 100.00% $419.08 $32,395,028 100.00%

7/1/2013 - 3/31/2014 7/1/2014 - 3/31/2015

Major Diagnosis Category

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Member cost share includes Medical/Rx/Dental

Member Responsibility

FY 15 Q3

Allowed Charges $54,012,143

Subrogation, COB, Etc. $2,459,792

Deductible $4,275,185

Copays $495,246

Coinsurance $5,459,784

Member Responsibility $10,230,215Member Cost Share

(% of Allowed Charges)18.9%

FY 14 Q3

Allowed Charges $51,823,239

Subrogation, COB, Etc. $2,410,583

Deductible $4,218,292

Copays $670,911

Coinsurance $5,591,125

Member Responsibility $10,480,328Member Cost Share

(% of Allowed Charges)20.2%

Employee Out of Pocket

Employee Out of Pocket

Premera - Pharmacy

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Pharmacy Observations – FY14 Q3 and FY15 Q3

The total gross costs increased slightly from FY14 Q3 to FY15 Q3 from $5,625,470 to $5,629,446

The percent of mail order scripts/claims increased from 16.7% to 18.8% for FY15 Q3

The generic dispensing rate increased from 79.6% to 80.6%

Total number of prescriptions increased 2.5% in FY15 Q3 from FY 14 Q3 from 48,408 to 49,607

Specialty drug costs increased 27% from FY 14 to FY 15 Q3

Specialty pharmacy cost increased as a percentage of total gross pharmacy costs from 21.8% in FY14 Q3 to 27.7% in FY15 Q3

10 out of the top 25 paid drugs are specialty drugs

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Cost FY14 Q3 FY15 Q3 % ChangeTotal Gross Cost $5,625,470 $5,629,446 0.1%

Total Net Cost $4,993,390 $4,991,905 0.0%

Drug Mix

% Single Source Brands 19.0% 18.1% -5%

% Multi Source Brands 1.4% 1.3% -8%

Generic Dispensing Rate 79.6% 80.6% 1%

Utilization

Total Prescriptions 48,408 49,607 2.5%

% Retail Prescriptions 83.3% 81.2% -3%

% Mail Prescriptions 16.7% 18.8% 13%

Specialty

Specialty Total Gross Cost $1,227,133 $1,558,255 27.0%

Specialty % of Total Gross Cost 21.8% 27.7% 27%

Pharmacy FY14 Q3 to FY15 Q3 Comparison

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10 out of the top 25 are Specialty Drugs

Top 25 Drugs by Gross Cost

Rank Specialty Plan Cost

1 Yes $294,980

2 Yes $234,746

3 Yes $185,807

4 No $140,264

5 No $128,430

6 No $102,652

7 Yes $98,450

8 No $94,495

9 Yes $84,448

10 No $80,871

11 Yes $77,906

12 Yes $75,716

13 Yes $67,406

14 Yes $58,724

15 No $54,209

16 No $52,329

17 No $51,413

18 No $49,617

19 No $46,140

20 No $45,932

21 No $43,937

22 No $43,812

23 Yes $41,873

24 No $39,732

25 No $38,381

$2,232,269Total

LYRICA Anticonvulsants

OXYCONTIN Narcotics

ANDROGEL Androgens

AVONEX Interferons

LANTUS Insulin Therapy

ONE TOUCH ULTRA TEST S Blood Glucose Monitoring Devices

NOVOLOG Insulin Therapy

SYMBICORT Pulmonary

TRUVADA HIV/AIDS Therapy

HUMALOG Insulin Therapy

KUVAN Miscellaneous (Used to treat PKU)

RESTASIS Ophthalmologics

ENOXAPARIN SODIUM Heparin

REVLIMID Antineoplastic Drugs

LANTUS SOLOSTAR Insulin Therapy

COPAXONE Neurological Therapy

CRESTOR Lipid/Cholesterol Lowering

XENAZINE Neurological Therapy

NEXIUM Proton Pump Inhibitors

REBIF Interferons

DULOXETINE HCL Antidepressant

ABILIFY Antipsychotics

TECFIDERA Neurological Therapy

ENBREL Rheumatological

Drug Name Drug Chapter

HUMIRA Rheumatological

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Top 25 Drugs by Script Count

Drug Name Specialty Drug Drug Type Rx Count Total Net Paid

LISINOPRIL N Generic 1,138 $2,691

LEVOTHYROXINE SODIUM N Generic 1,115 $14,617

ATORVASTATIN CALCIUM N Generic 1,053 $23,751

HYDROCODONE-ACETAMINOP N Generic 840 $2,736

OMEPRAZOLE N Generic 613 $2,219

ESCITALOPRAM OXALATE N Generic 594 $16,495

FLUTICASONE PROPIONATE N Generic 575 $4,684

MONTELUKAST SODIUM N Generic 562 $32,142

SYNTHROID N Brand 559 $2,571

BUPROPION XL N Generic 521 $17,829

HYDROCHLOROTHIAZIDE N Generic 518 $1,461

AZITHROMYCIN N Generic 505 $1,301

ZOLPIDEM TARTRATE N Generic 502 $363

FLUVIRIN N Brand 481 $13,760

AMOXICILLIN N Generic 477 $224

METFORMIN HCL N Generic 466 $1,975

SERTRALINE HCL N Generic 465 $3,535

SIMVASTATIN N Generic 452 $6,035

AMLODIPINE BESYLATE N Generic 446 $3,014

ALPRAZOLAM N Generic 433 $334

OXYCODONE-ACETAMINOPHE N Generic 408 $6,666

LOSARTAN POTASSIUM N Generic 406 $6,268

VALACYCLOVIR N Generic 394 $19,648

FLUOXETINE HCL N Generic 388 $5,067

AMOX TR-POTASSIUM CLAV N Generic 364 $2,747

$192,135Total

Appendix

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Medical Utilization Definitions

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

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The Major Diagnostic categories are aligned with the major sections of the

ICD9-CM. In general, categories 780-796 include the more ill-defined

conditions and symptoms that point with perhaps equal suspicion to two or

more diseases or to two or more systems of the body, and without the

necessary study of the case to make a final diagnosis. Practically all

categories in this group could be designated as "not otherwise specified,"

or as "unknown etiology," or as "transient."

Examples: Fever, Convulsions, Chest Pain, Abdominal Pain.

Other

The Major Diagnostic categories are aligned with the major sections of the

ICD9-CM. The “Other” category consists of claims with diagnoses that

don’t map to the ICD9-CM, mostly Rx and Dental claims. Excluding those

benefits from the Benefit checkbox list will usually reduce “Other” to a

negligible amount.

Also known as "V-Codes" (i.e., V70.0) Usually used as a secondary

diagnosis, but sometimes appears in the primary. Full details available in

the ICD9 diagnosis book. General Medical Examination is common

1. Non-sick persons encountering the system (donors, family doc

counseling, vaccines, etc)

2. Sick person encountering the system for treatment of a known

(ongoing) disease or injury.

3. When a circumstance or problem is present that influences the

patient's health, but isn't itself an illness (personal or family history health

hazards, circumstances related to reproduction and development, etc)

Injury & PoisoningFactures, Wounds, Burns, Poisoning by Drugs, Medicinal and Biological

Substances (DX Code 800 - 999)

Factures, Wounds, Burns, Poisoning by Drugs, Medicinal and Biological

Substances (DX Code E800 - E999)Transport accidents (E800-E848) include accidents involving:

aircraft and space craft (E840-E845)

watercraft (E830-E838)

motor vehicle (E810-E825)

railway (E800-E807)

other road vehicles (E826-E829)

Injury & Poisoning

External Causes

Ill Defined category

Health Status and

Services

Major Diagnostic Code Definitions

UNIVERSITY OF ALASKA · Days Per 1000 Members 193 211 9% 241 ... Paid Claims Per Member Per Month...

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