UNIVERSITY OF ALASKA
F Y 1 6 U T I L I Z A T I O N R E V I E W ( 1 ST Q T R )
7/1/2015 TO 09/30/2015
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Premera- Medical
Premera Medical – Inpatient & Outpatient
 Inpatient
− Paid claims per member per month (PMPM) for inpatient services increased 42%
from $80 for FY15 (7/14-9/14) to $114 for FY16 (7/15-9/15) and is above the
Premera norm of $106
− The average length of stay for inpatient services increased from 3.1 days for FY15 to
5.7 days for FY16 and is above the Premera Norm of 4.0 days
− Days per 1,000 members increased 78% from 152 in FY15 to 270 in FY16
− Admissions per 1,000 members decreased from 49 for FY15 to 47 for FY16 and is
below the Premera norm of 52
− Paid claims per admission increased 49% from $19,439 for FY15 to $29,006 FY16
 Large claimants will have a significant impact on cost
 Outpatient
− Paid claims PMPM for outpatient services increased from $75 for FY15 to $109 for
FY16 and is above the Premera Norm of $100
− Outpatient services per 1,000 members increased from 3,695 for FY15 to 4,285 for
FY16 and is above the Premera Norm of 3,727
− Paid claims per service increased from $245 for FY15 to $304 for FY16 and is below
the Premera norm of $323
Norm is based on Premera’s Alaska large group book of business
2
Premera Medical – Emergency Room & Large Claims
 Emergency Room
− ER paid claims per visit increased 51% from $1,326 for FY15 to $2,006 for FY16, and is
above the Premera Norm of $1,497
− Visits per 1,000 members for ER services increased slightly from 148 in FY15 to 152
in FY 16 and is below the Premera norm of 198
 Large Claims – Update
− The number and severity of large claims in FY16 has increased compared to FY 15
 20 large claimants over $100k for FY 16
− Largest claimant (Fracture of Vertebral Column) is $484,000
− $3,163,764 total paid in claims over $100,000
− Average number of members in Q1: 8,148
 9 large claimants over $100k for FY 15
− Largest claimant (Cancer) was $193,310
− $1,276,635 total paid in claims over $100,000
− Average number of members in Q1: 8,595
Norm is based on Premera’s Alaska large group book of business
3
Medical Utilization – FY 15 Q1 vs FY 16 Q1
Utilization Category
Inpatient
Paid Claims Per Member Per Month
Admissions Per 1000 Members
Days Per 1000 Members
Average Length of Stay
Paid Claims Per Admission
Outpatient
Paid Claims Per Member Per Month
Visits Per 1000 Members
Paid Claims Per Visit
Services Per 1000 Members
Services Per Visit
Paid Claims Per Service
ER Utilization: Paid Claims PMPM
ER Utilization: Visits Per 1000 Members
ER Utilization: Paid Claims Per Visit
Professional Provider
Paid Claims Per Member Per Month
Services Per 1000 Members
Paid Claims Per Service
FY15 Q1
FY16 Q1
% Change
over FY15 Q1
Norm
$80
49
152
3.1
$19,439
$114
47
270
5.7
$29,006
42%
-4%
78%
85%
49%
$106
52
210
4.0
$24,344
$75
1,061
$852
3,695
3.5
$245
$16
148
$1,326
$109
1,098
$1,187
4,285
3.9
$304
$25
152
$2,006
45%
4%
39%
16%
11%
24%
59%
3%
51%
$100
934
$1,291
3,727
4.0
$323
$25
198
$1,497
$192
17,027
$135
$197
16,745
$141
2%
-2%
4%
$172
14,879
$138
Norm is based on Premera’s Alaska large group book of business
4
Large Claims Analysis – FY15 Q1 vs FY16 Q1
Medical & Rx Plan Spend
Average Monthly Employees
PEPM Cost
% Change Over Previous Fiscal Year
Total Paid for Large Claimants (Over $100k)
# of Large Claimants (Over $100k)
Average Large Claimant
% Change Over Previous Yr
Without large claims
PEPM Cost
% Change Over Previous Yr
FY15
$11,156,661
3,876
$959
873.91%
$1,276,635
9
$141,848
$9,880,026
$212
FY16
$13,157,719
3,641
$1,205
25.5%
415.89%
$3,163,764
20
$158,188
11.5%
11.4%
$9,993,955
$229
7.7%
24.0%
88.56%
75.96%
Large Claims above $100k as a percentage of
Total Medical & Rx Claims
FY15
11.4%
FY16
24.0%
5
Claims Stratification – FY 15 vs. FY 16
FY 15
FY 16
Prior Period
Claimants with Claims
Above
$10,000
$25,000
$50,000
$75,000
$100,000
$150,000
$250,000
All Claims
All Claims excluding
Claimants Above $10,000
Claimant
Count
213
79
27
17
9
4
0
5,881
5,668
% of Total
Claimants
3.62%
1.34%
0.46%
0.29%
0.15%
0.07%
0.00%
100.00%
96.38%
Claimants
per 1,000
99.13
36.77
12.57
7.91
4.19
1.86
0.00
Paid
$6,419,320
$4,366,315
$2,533,248
$1,958,705
$1,276,635
$660,345
$0
$11,288,831
$4,869,511
Current Period
% of Total
Paid
56.86%
38.68%
22.44%
17.35%
11.31%
5.85%
0.00%
100.00%
43.14%
PMPM
$248.97
$169.34
$98.25
$75.97
$49.51
$25.61
$0.00
$437.82
$188.86
Claimant
Count
233
94
37
25
20
5
1
5,594
5,361
% of Total
Claimants
4.17 %
1.68 %
0.66 %
0.45 %
0.36 %
0.09 %
0.02 %
100.00 %
95.83 %
Claimants
per 1,000
114.38
46.14
18.16
12.27
9.82
2.45
0.49
Paid
% Change
% of Total
Paid
PMPM
$8,485,168 64.49% $347.11
$6,323,522 48.06% $258.68
$4,306,073 32.73% $176.15
$3,599,427 27.36% $147.25
$3,163,764 24.04% $129.42
$1,331,210 10.12% $54.46
$484,016
3.68% $19.80
$13,157,719 100.00% $538.26
$4,672,552 35.51% $191.15
Claimants
Per 1,000
15.4%
25.5%
44.5%
55.1%
134.4%
31.7%
N/A
PMPM
39.4%
52.8%
79.3%
93.8%
161.4%
112.6%
N/A
16.6%
-4.0%
Paid claims include Medical/Rx
6
Top 20 Claimants – FY16 (July 2015 to September 2015)
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Top Diagnosis
Fracture of Vertebral Column without Mention of Spinal Cord Injury
Multiple Myeloma and Immunoproliferative Neoplasms
Myeloid Leukemia
Benign Neoplasm of Brain
Malignant Neoplasm of Brain
Disorders of Back
Wilson's Disease - Genetic (Pharmacy)
Diseases of Upper Respiratory Tract
Acute Myocardial Infarction
Fracture of Ankle
Diabetes Mellitus
Malignant Neoplasm of Rectum, Rectosigmoid Junction, and Anus
Malignant Neoplasm of Female Breast
Diseases of Lung
Malignant Neoplasm of Female Breast
Single Liveborn
Hepatitis C (Pharmacy)
Acquired Deformities of Toe
Other Forms of Chronic Ischemic Heart Disease
Symptoms Involving Respiratory System and Other Chest Symptoms
Total
YTD Claims
$484,016
$242,293
$241,094
$212,040
$151,767
$144,228
$143,349
$140,074
$136,107
$131,805
$129,662
$127,991
$123,892
$114,665
$112,624
$111,789
$109,136
$104,053
$101,594
$101,586
$3,163,764
7
Major Diagnostic Category – Medical Only
7/1/2014 - 9/30/2014
Major Diagnosis Category
Health Status & Services
Neoplasms
Musculoskeletal System
Injury and Poisoning
Ill-Defined Conditions
Mental Disorders
Respiratory System
Circulatory System
Digestive System
Nervous System
Genitourinary System
Endocrine, Metabolic and Immunity
Pregnancy and Related
Blood
Skin and Tissue
Infectious and Parasitic
Congenital Anomalies
Perinatal
Other
Injury and Poisoning External Causes
Total
7/1/2015 - 9/30/2015
Paid PMPM
Total Paid Claims
$52.02
$41.41
$83.01
$30.74
$22.19
$13.72
$9.81
$26.82
$21.44
$19.90
$14.21
$8.96
$12.16
$1.61
$3.28
$3.92
$4.84
$0.44
$0.00
$1,341,266
$1,067,666
$2,140,305
$792,618
$572,019
$353,875
$252,994
$691,528
$552,887
$512,993
$366,333
$230,940
$313,584
$41,539
$84,589
$101,037
$124,917
$11,415
$125
Percentage of
Overall Total
14.04%
11.18%
22.41%
8.30%
5.99%
3.70%
2.65%
7.24%
5.79%
5.37%
3.83%
2.42%
3.28%
0.43%
0.89%
1.06%
1.31%
0.12%
0.00%
Paid PMPM
Total Paid Claims
$74.41
$63.72
$59.94
$54.87
$26.91
$25.99
$25.20
$25.02
$23.59
$22.38
$20.62
$15.96
$11.86
$3.73
$2.82
$2.22
$1.26
$1.08
$0.01
$1,819,061
$1,557,647
$1,465,206
$1,341,244
$657,798
$635,226
$616,015
$611,612
$576,649
$546,972
$504,073
$390,088
$289,903
$91,271
$68,954
$54,261
$30,903
$26,495
$314
Percentage of
Overall Total
16.12%
13.80%
12.99%
11.89%
5.83%
5.63%
5.46%
5.42%
5.11%
4.85%
4.47%
3.46%
2.57%
0.81%
0.61%
0.48%
0.27%
0.23%
0.00%
$0.00
$0
0.00%
$0.00
$15
0.00%
$370.48
$9,552,631
100.00%
$461.60
$11,283,706
100.00%
8
Member Responsibility
Allowed Charges
Subrogation, COB, Etc.
Employee Out of Pocket
Deductible
Copays
Coinsurance
Member Responsibility
Member Cost Share
(% of Allowed Charges)
Allowed Charges
Subrogation, COB, Etc.
Employee Out of Pocket
Deductible
Copays
Coinsurance
Member Responsibility
Member Cost Share
(% of Allowed Charges)
FY 16
$19,196,508
$685,817
$2,114,942
$156,465
$1,739,126
$4,010,534
20.9%
FY 15
$17,138,609
$681,617
$2,061,871
$214,459
$1,734,358
$4,010,688
23.4%
Member cost share includes Medical/Rx/Dental
9
Premera - Pharmacy
Pharmacy Observations – FY15 and FY16 Q1
 The total gross costs decreased 4.0% from FY 15 to FY 16 from $1,951,566 to
$1,874,013
 Overall number of scripts decreased 14.9% (membership decreased 6%)
 The percent of mail order scripts/claims decreased slightly from 18.5% FY 15
to 18.4% for FY 16
 The generic dispensing rate decreased from 81.0% FY 15 to 80.2% FY 16
 Specialty drug costs increased 12.4% from FY 15 to FY 16
 Specialty pharmacy cost increased as a percentage of total gross pharmacy costs
from 25.1% in FY 15 to 29.4% in FY 16
 9 out of the top 25 paid drugs are specialty drugs
11
Pharmacy FY15 to FY16 Comparison
Cost
Total Gross Cost
Total Net Cost
FY15 Q1
FY16 Q1
% Change
$1,951,566
$1,737,107
$1,874,013
$1,649,275
-4.0%
-5.1%
17.7%
1.3%
81.0%
18.4%
1.5%
80.2%
3.8%
12.3%
-1.0%
16,210
81.5%
18.5%
13,792
81.6%
18.4%
-14.9%
0.1%
-0.4%
$490,684
25.1%
$551,747
29.4%
12.4%
17.3%
Drug Mix
% Single Source Brands
% Multi Source Brands
Generic Dispensing Rate
Utilization
Total Prescriptions
% Retail Prescriptions
% Mail Prescriptions
Specialty
Specialty Total Gross Cost
Specialty % of Total Gross Cost
12
Top 25 Drugs by Plan Cost
Rank
Drug Name
Patient
Count
Drug Chapter
Specialty
Plan Cost
Paid Per
Script
1
SYPRINE
No
Miscellaneous Agents
1
$135,032
$67,516
2
HARVONI
Yes
Miscellaneous Antivirals
2
$125,197
$31,299
3
HUMIRA
Yes
Miscellaneous Rheumatological Agents
11
$81,277
$3,694
4
TECFIDERA
Yes
Miscellaneous Neurological Therapy
8
$80,544
$5,753
5
ENBREL
Yes
Miscellaneous Rheumatological Agents
10
$72,116
$3,135
6
ARIPIPRAZOLE
No
Antipsychotics
22
$33,805
$690
7
ESOMEPRAZOLE MAGNESIUM
No
Proton Pump Inhibitors
48
$27,730
$440
8
DULOXETINE HCL
No
Antidepressant Agents
60
$27,120
$280
9
CRESTOR
No
Lipid/Cholesterol Lowering Agents
57
$25,221
$304
10
COPAXONE
Yes
Miscellaneous Neurological Therapy
3
$24,508
$4,902
11
TRUVADA
No
HIV/AIDS Therapy
6
$23,620
$1,968
12
OPSUMIT
Yes
Miscellaneous Pulmonary Agents
1
$21,764
$7,255
13
RESTASIS
No
Miscellaneous Ophthalmologics
29
$19,218
$620
14
LANTUS SOLOSTAR
No
Insulin Therapy
25
$19,088
$516
15
NOVOLOG
No
Insulin Therapy
15
$18,898
$859
16
LANTUS
No
Insulin Therapy
14
$17,411
$829
17
ANDROGEL
No
Androgens
14
$16,890
$804
18
SYMBICORT
No
Miscellaneous Pulmonary Agents
31
$16,080
$392
19
HUMALOG
No
Insulin Therapy
11
$16,018
$942
20
REBIF
Yes
Interferons
1
$15,594
$5,198
21
PLEGRIDY PEN
Yes
Interferons
1
$14,968
$4,989
22
EPIPEN 2-PAK
No
Adrenergics
32
$14,084
$454
23
TEMOZOLOMIDE
Yes
Alkylating Agents
24
DULERA
No
Miscellaneous Pulmonary Agents
25
OXYCONTIN
No
Narcotics
Total
1
$13,758
$3,440
30
$12,633
$308
9
$12,150
$486
442
$884,727
$1,313
9 out of the top 25 are Specialty Drugs
13
Top 25 Drugs by Script Count
Drug Name
LISINOPRIL
LEVOTHYROXINE SODIUM
ATORVASTATIN CALCIUM
HYDROCODONE-ACETAMINOP
ESCITALOPRAM OXALATE
OMEPRAZOLE
SYNTHROID
HYDROCHLOROTHIAZIDE
METFORMIN HCL
MONTELUKAST SODIUM
BUPROPION XL
ZOLPIDEM TARTRATE
OXYCODONE-ACETAMINOPHE
FLUTICASONE PROPIONATE
IBUPROFEN
ALPRAZOLAM
AMLODIPINE BESYLATE
AZITHROMYCIN
AMOXICILLIN
SIMVASTATIN
SERTRALINE HCL
VENLAFAXINE HCL ER
FLUOXETINE HCL
FLUCONAZOLE
AMOX TR-POTASSIUM CLAV
Total
Specialty Drug
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Drug Type Patient Count
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
219
209
197
175
115
136
84
104
94
107
87
90
82
102
95
73
81
96
99
82
63
56
60
77
85
2,668
Total Net Paid Paid Per Script
$911.83
$1,974.42
$3,397.19
$654.61
$1,396.22
$215.09
$176.91
$542.55
$693.16
$2,078.65
$2,610.97
$11.62
$2,199.12
$58.74
$7.84
$5.85
$429.34
$46.63
$9.73
$670.78
$111.75
$955.80
$1,350.57
$312.58
$115.81
$20,938
$3.39
$7.84
$14.97
$3.15
$8.36
$1.33
$1.20
$4.14
$5.50
$16.63
$21.23
$0.10
$18.64
$0.50
$0.07
$0.06
$4.17
$0.46
$0.10
$6.92
$1.16
$10.39
$14.84
$3.51
$1.32
$6.22
14
FY 17 Plan Opportunities
 Reduce compound drug threshold from $200 to $50
 Exclude Non-Sedative Anti-Histamines
 Investigate Mandatory Centers of Excellence (Blue Distinction) Facilities
for Hip, Knee and Back
 Incentive for Medical Travel Support Benefit
 Increase visibility of Best Doctors for 2nd opinions through integration
with Premera (Vendor Summit)
 Cancer diagnosis/Musculoskeletal
 Investigate on-site clinic (Use of University PA Program)
 Premera projects/deals with other clinics
 Standalone kiosks
 50% coinsurance for out-of-network services
 Communications on preventive exams/cancer screenings
15
Appendix
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
17
Major Diagnostic Code Definitions
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
Ill Defined category 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)
Health Status and
Services
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 & Poisoning
Injury & Poisoning
External Causes
Factures, 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)
18