U N I V E R S I T Y O F A L A S K A 1 ST Q U A R T E R F Y 1 2
UTILIZATION REVIEW – 7/1/2011 TO 9/30/2011
E X P E R T I S E
T R E N D S
PARTNERSHIP
A N A L Y S I S
November 16, 2011
V A L U E
S T A T I S T I C S
P L A N N I N G
T
O
O
L
S
Premera – Medical
Premera Medical – Inpatient & Outpatient
 Inpatient
− Paid claims per member per month for inpatient services decreased significantly
from $85.94 for 1st quarter FY11 (7/10-09/10) to $64.11 for 1st quarter FY12
(07/11-09/11)
 Large Claims stabilized between 1st quarter FY12 compared to FY11
− The average length of stay for inpatient services decreased from 4.03 to 3.61 and
1st quarter FY 12 was below the Premera Norm of 4.19
 Outpatient
− Visits per 1,000 members for outpatient services increased from 1,069 to 1,116
from 1st quarter FY11 to FY12 but was well below the Premera Norm of 1,155
− Services per 1,000 members for outpatient services increased slightly from 4,255 for
1st quarter FY11 to 4,286 for 1st quarter FY12 but was below the Premera Norm of
4,395
− Paid claims per service decreased 10.8% from 1st quarter FY11 to 1st quarter FY12
3
Premera Medical – Emergency Room & Large Claims
 Emergency Room
− Paid claims per member per month for ER services decreased from $17.81 for 1st
quarter FY11 (7/10-09/10) to $16.34 for FY12 (7/11-09/11) and the paid claims per
visit decreased 16% from $1,453.42 to $1,221.75
− Visits per 1,000 members for ER services increased from 147 for 1st quarter FY11 to
160 for 1st quarter FY12 but are below the Premera norm of 209
 Large Claims
− Large Claims stabilized between 1st quarter FY12 compared to FY11
 There are 7 large claimants over $100k for FY12 YTD
 The average large claimant paid amount decreased from $195,549 to $129,591, a 33.7%
decrease from 1st Qtr FY 12 to 1st Qtr FY11
 Large claimants in the 1st quarter FY11 made up 42.6% of the total medical and Rx claims
whereas for 1st quarter FY12 it is 22.4%
 There were 10 large claimants over $100k in the first quarter FY11
−
2 of those 10 claimants were over $300k
4
Medical Utilization
Utilization Category
Medical Contract Months
Medical Member Months
Average Contract Size
Medical Total PMPM
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
Jul 2010 - Sept 2010
July 2011 - Sept 2011
% Over Previous Qtr
Norm
12,733
28,964
2.27
$407.92
12,297
28,789
2.34
$347.48
-3.4%
-0.6%
2.9%
-14.8%
……
……
……
$373.20
$85.94
43.50
175.25
4.03
$23,707.66
$64.11
48.77
175.90
3.61
$15,775.39
-25.4%
12.1%
0.4%
-10.4%
-33.5%
$88.79
59.25
248.50
4.19
$17,982.70
$93.72
1,068.50
$1,052.55
4,254.52
3.98
$264.34
$17.81
147.08
$1,453.42
$87.30
1,115.84
$938.81
4,286.22
3.84
$244.40
$16.34
160.48
$1,221.75
-6.9%
4.4%
-10.8%
0.7%
-3.5%
-7.5%
-8.3%
9.1%
-15.9%
$88.60
1,155.30
$920.29
4,394.87
3.80
$241.92
$16.05
209.17
$921.07
$199.77
17,288.22
$138.66
$167.57
16,284.97
$123.48
-16.1%
-5.8%
-10.9%
$159.54
14,781.30
$129.52
Norm is based on Premera’s Alaska large group book of business
5
Large Claims Analysis
Monthly Medical & Rx Spend
Average Monthly Employees
PEPM Cost
% Change Over Previous Qtr
1st Qtr 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
1ST QTR FY11
$4,593,680
4,244
$1,082
234.91%
$1,955,489
10
$195,549
$2,638,192
$622
1ST QTR FY12
$4,058,430
4,099
$990
-8.5%
447.39%
$907,139
7
$129,591
-33.7%
$3,151,291
$769
23.7%
6
Top 30 Large Claimants– 1st Quarter FY12
Claimant
ICD9 Description
Paid Claims
1
CHRONIC RENAL FAILURE
$172,329.81
2
OSTEOARTHROSIS AND ALLIED DISORDERS
$142,562.42
3
CHRONIC RENAL FAILURE
$140,753.72
4
OTHER FORMS OF CHRONIC ISCHEMIC HEART DISEASE
$139,384.09
5
CARDIAC DYSRHYTHMIAS
$105,221.45
6
OTHER AND UNSPECIFIED PROTEIN-CALORIE MALNUTRITION
$104,337.85
7
OCCLUSION OF CEREBRAL ARTERIES
$102,649.59
8
OSTEOARTHROSIS AND ALLIED DISORDERS
$93,134.38
9
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
$86,411.10
10
SARCOIDOSIS
$79,508.70
11
OTHER FORMS OF CHRONIC ISCHEMIC HEART DISEASE
$73,929.27
12
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
$73,754.38
13
MIGRAINE
$71,545.40
14
CHOLELITHIASIS
$67,224.80
15
OTHER FORMS OF CHRONIC ISCHEMIC HEART DISEASE
$62,654.07
16
CARDIAC DYSRHYTHMIAS
$58,361.57
17
OTHER NONINFECTIOUS GASTROENTERITIS AND COLITIS
$57,610.21
18
CARDIAC DYSRHYTHMIAS
$57,220.32
19
ACUTE PERICARDITIS
$55,125.25
20
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
$54,638.45
21
OSTEOARTHROSIS AND ALLIED DISORDERS
$53,894.09
22
MALIGNANT NEOPLASM OF STOMACH
$53,361.52
23
MALIGNANT NEOPLASM OF PROSTATE
$52,564.06
24
NEUROTIC DISORDERS
$48,123.40
25
DIVERTICULA OF INTESTINE
$46,849.67
26
CENTRAL PAIN
$46,241.87
27
OSTEOARTHROSIS AND ALLIED DISORDERS
$45,852.90
28
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
$45,664.24
29
CHOLELITHIASIS
$45,556.97
30
OTHER AND UNSPECIFIED DISORDERS OF BACK
$45,506.84
7
Top 30 Large Claimants– 1st Quarter FY11
Claimant
Diagnosis
Paid Claims
1
LYMPHOID LEUKEMIA
$596,100.94
2
OTHER FORMS OF CHRONIC ISCHEMIC HEART DISEASE
$372,659.81
3
OTHER AND ILL-DEFINED CEREBROVASCULAR DISEASE
$158,843.44
4
OTHER CONGENITAL ANOMALIES OF HEART
$142,540.05
5
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
$138,237.12
6
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
$122,303.49
7
MALIGNANT NEOPLASM OF FEMALE BREAST
$109,961.76
8
SPONDYLOSIS AND ALLIED DISORDERS
$109,777.16
9
INTERVERTEBRAL DISC DISORDERS
$105,480.39
10
OTHER AND ILL-DEFINED CEREBROVASCULAR DISEASE
$100,143.59
11
OTHER DISORDERS OF CERVICAL REGION
$93,943.74
12
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
$89,212.84
13
OTHER FORMS OF CHRONIC ISCHEMIC HEART DISEASE
$85,464.90
14
ACUTE MYOCARDIAL INFARCTION
$85,142.88
15
OTHER FORMS OF CHRONIC ISCHEMIC HEART DISEASE
$79,589.40
16
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
$79,416.42
17
OSTEOARTHROSIS AND ALLIED DISORDERS
$78,242.63
18
MALIGNANT NEOPLASM OF ESOPHAGUS
$77,793.62
19
MALIGNANT NEOPLASM OF FEMALE BREAST
$75,018.47
20
SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES
$71,836.69
21
DIABETES MELLITUS
$70,073.47
22
OTHER MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE
$69,561.81
23
CHRONIC SINUSITIS
$66,891.03
24
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
$63,457.21
25
MALIGNANT NEOPLASM OF FEMALE BREAST
$63,422.35
26
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
$59,385.95
27
OBESITY AND OTHER HYPERALIMENTATION
$58,524.47
28
CARCINOMA IN SITU OF BREAST AND GENITOURINARY SYSTEM
$53,354.71
29
OTHER AND UNSPECIFIED DISORDERS OF BACK
$53,350.04
30
OSTEOARTHROSIS AND ALLIED DISORDERS
$51,113.86
Claimant #’s 1, 2, and
4 dropped off in 2012.
Claimant #3 remains
#3 in 2012
8
Major Diagnostic Category
J uly 1, 2 0 10 t o S e pt e m be r 3 0 , 2 0 10
M a jo r D ia gno s is C a t e go ry
P a id P M P M
T o t a l P a id C la im s
J uly 1, 2 0 11 t o S e pt e m be r 3 0 , 2 0 11
P e rc e nt a ge o f O v e ra ll
T o tal
P a id P M P M
T o t a l P a id C la im s
P e rc e nt a ge o f O v e ra ll
T o tal
M usculoskeletal System
$72.81
$2,108,988.11
17.85%
$62.28
$1,793,095.40
17.92%
Health Status & Services
$50.16
$1,452,843.77
12.30%
$43.02
$1,238,452.58
12.38%
Genitourinary System
$17.38
$503,522.44
4.26%
$28.31
$815,070.03
8.15%
$39.89
$1,155,364.51
9.78%
$28.11
$809,222.39
8.09%
Circulatory System
Ill-Defined Conditions
$31.63
$916,266.66
7.76%
$27.39
$788,579.33
7.88%
Neoplasms
$54.40
$1,575,540.94
13.34%
$25.94
$746,891.32
7.47%
Digestive System
$24.74
$716,482.23
6.06%
$24.96
$718,498.26
7.18%
Nervous System
$18.63
$539,601.72
4.57%
$24.61
$708,607.96
7.08%
Injury and Poisoning
$30.28
$876,964.01
7.42%
$18.43
$530,557.81
5.30%
Respiratory System
$13.32
$385,668.55
3.26%
$13.77
$396,336.41
3.96%
M ental Disorders
$12.97
$375,615.04
3.18%
$13.24
$381,156.91
3.81%
Endocrine, M etabolic and Immunity
$13.21
$382,574.88
3.24%
$12.36
$355,715.11
3.56%
Pregnancy and Related
$10.35
$299,840.31
2.54%
$11.50
$331,146.48
3.31%
Skin and Tissue
$7.24
$209,811.02
1.78%
$5.08
$146,179.71
1.46%
Infectious and Parasitic
$3.09
$89,443.70
0.76%
$4.24
$122,034.08
1.22%
Congenital Anomalies
$6.19
$179,147.27
1.52%
$2.15
$61,915.48
0.62%
Blood
$1.05
$30,298.71
0.26%
$1.23
$35,459.10
0.35%
Perinatal
$0.46
$13,339.89
0.11%
$0.81
$23,357.06
0.23%
Other
$0.02
$672.00
0.01%
$0.05
$1,377.51
0.01%
$0.11
$3,059.58
0.03%
$0.00
$0.00
0.00%
$407.92
$11,815,045.34
100.00%
$347.48
$10,003,652.93
100.00%
Injury and Poisoning External Causes
Total
Musculoskeletal system continue to be #1
Genitourinary Systems jumped from #9 to #3
Neoplams dropped from #2 to #6
9
Caremark - Pharmacy
Pharmacy Observations
 The number of total scripts/claims from FY12 1st quarter (7/1/11 to 09/30/11)
decreased 4.9% compared to FY11 1st quarter (7/1/10 to 09/30/10)
 The number of mail order scripts/claims increased 52.3% from FY11 to FY12
1st quarter
− Introduction of mail order for maintenance drugs at 7/1/2011
 The total gross costs increased $205,641 from FY11 to FY12 1st Quarter from
$1,965,996 to $2,171,637
 The generic dispensing rate increased from 65.1% to 68.1%, a 4.7% increase
 Specialty drug gross costs increased 25.7% and made up 13.8% of the total
gross pharmacy cost
11
Pharmacy 1st Qtr FY 11 to FY12 Comparison
Eligibility
Average Eligible Members per Month
Avg. Monthly Utilizers as % of Members
Jul-Sep 10 Jul-Sep 11 % Change
9,974
27.6%
9,734
27.2%
-2.4%
-1.7%
$1,965,996
$1,669,777
$66
$56
15.1%
$2,171,637
$1,856,867
$74
$64
14.5%
10.5%
11.2%
13.2%
13.9%
-3.8%
32.4%
2.5%
65.1%
96.3%
29.8%
2.1%
68.1%
97.0%
-8.1%
-16.1%
4.7%
0.7%
21,660
87.0%
13.0%
24
20,599
80.1%
19.9%
26
-4.9%
-7.8%
52.3%
8.1%
$276,273
0.6%
$9
14.1%
1.0%
$347,199
0.7%
$12
16.0%
1.1%
25.7%
17.1%
28.8%
13.8%
13.7%
Cost
Total Gross Cost
Total Net Cost
Gross Cost PMPM
Net Cost PMPM
Member Cost Share
Drug Mix
% Single Source Brands
% Multi Source Brands
Generic Dispensing Rate
Generic Substitution Rate
Utilization
Total Prescriptions
% Retail Prescriptions
% Mail Prescriptions
Days' Supply PMPM
Specialty
Specialty Total Gross Cost
Specialty Utilizers as % of Members
Specialty Gross Cost PMPM
Specialty % of Total Gross Cost
Specialty % of Total Prescriptions
12
Top 25 Drugs by Gross Cost
Book of
Business Prior Current
Rank* Rank Rank Drug Name
1
6
2
7
10
12
11
8
5
41
4
13
37
15
35
43
23
21
39
69
9
40
64
14
49
1
3
2
4
9
10
7
5
6
8
11
13
12
17
16
21
23
25
71
45
14
0
20
26
24
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Lipitor
Humira
Nexium
Singulair
Copaxone
Cymbalta
Lexapro
Advair Diskus
Crestor
Rebif
Enbrel
Abilify
One Touch Ultra Test Strips
Celebrex
Humalog
Lovaza
Seroquel
Venlafaxine Hcl Er
Zolpidem Tartrate
Restasis
Actos
Gleevec
Bupropion Xl
Januvia
Valacyclovir
Dispense
Type
Therapeutic Class
Brand
Specialty
Brand
Brand
Specialty
Brand
Brand
Brand
Brand
Specialty
Specialty
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Brand
Brand
Specialty
Generic
Brand
Generic
Antihyperlipidemics
Analgesics - Anti-Inflammatory
Ulcer Drugs
Antiasthmatic And Bronchodilator Agents
Psychotherapeutic And Neurological Agents - Misc.
Antidepressants
Antidepressants
Antiasthmatic And Bronchodilator Agents
Antihyperlipidemics
Psychotherapeutic And Neurological Agents - Misc.
Analgesics - Anti-Inflammatory
Antipsychotics/Antimanic Agents
Diagnostic Products
Analgesics - Anti-Inflammatory
Antidiabetics
Antihyperlipidemics
Antipsychotics/Antimanic Agents
Antidepressants
Hypnotics
Ophthalmic Agents
Antidiabetics
Antineoplastics And Adjunctive Therapies
Antidepressants
Antidiabetics
Antivirals
Generic
Gross
Launch
Total
Cost
Date** Gross Cost Prescriptions Per Day
Q4-2011
NA
Q2-2014
Q3-2012
Q4-2014
Q4-2013
Q1-2012
NA
NA
NA
NA
Q2-2015
NA
Q2-2014
Q4-2014
NA
Q2-2012
NA
Q3-2012
NA
NA
$110,362
$67,683
$57,446
$55,032
$42,561
$38,661
$38,091
$36,160
$33,996
$31,544
$31,381
$30,957
$23,809
$23,562
$22,479
$19,563
$19,347
$18,095
$17,538
$17,460
$16,861
$16,202
$15,988
$15,583
$15,393
488
33
192
254
12
149
236
118
171
10
17
43
98
105
55
82
48
141
343
52
50
3
216
49
158
$4.14
$74.38
$5.70
$4.50
$118.22
$6.18
$3.55
$6.28
$4.16
$112.66
$65.93
$17.06
$4.94
$4.77
$8.73
$4.68
$11.17
$2.68
$1.48
$7.35
$6.83
$180.02
$1.72
$6.57
$3.77
13
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
15
Our Mission
To be the worldwide value and service leader in insurance brokerage and risk management services
Our Goal
To be the best place to do business and to work
www.lockton.com
© 2009 Lockton, Inc. All rights reserved.
Images in this publication © 2009 Jupiterimages Corporation
16