2 ND Q U A R T E R U T I L I Z A T I O N R E V I E W – 7 / 1 / 2 0 1 0 T O
12/31/10
E X P E R T I S E
T R E N D S
PARTNERSHIP
A N A L Y S I S
January 26, 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 increased significantly from
$75.50 for 2nd Qtr FY10 (7/09-12/09) to $100.58 for the 2nd quarter FY11 (7/1012/10)
 Greater intensity and severity of large claims in 2nd Qtr FY11 compared to FY10
− The average length of stay for inpatient services decreased from 4.52 to 4.45 and
2nd Qtr FY 11 was below the Premera Norm
 Outpatient
− Visits per 1,000 members for Outpatient services decreased from 1,071 for 2nd Qtr
FY10 (7/09-12/09) to 1,058 for the 2nd quarter FY11 (7/10-12/10)
 FY11 was below the Premera Norm
− Services per 1,000 members for Outpatient services decreased from 4,222 for 2nd
Qtr FY10 (7/09-12/09) to 4,154 for the 2nd quarter FY11 (7/10-12/10)
 FY11 was below the Premera Norm
3
Premera Medical – Emergency Room
 Emergency Room
− Paid claims per member per month for ER services increased from $15.68 for 2nd Qtr
FY10 (7/09-12/09) to $16.87 for the 2nd quarter FY11 (7/10-12/10) and the paid
claims per visit increased from $1,122.19 to $1,386.04
− Visits per 1,000 members for ER services decreased from 167 for 2nd Qtr FY10
(7/09-12/09) to 146 for the 2nd quarter FY11 (7/10-12/10)
 FY11 was significantly below the Premera Norm
 The increase in the ER per member per month cost coupled with the decrease in the
number of ER visits for the 2nd Quarter FY 2011 compared to 2nd Qtr FY 2010
implies that members are going to the ER for more appropriate services.
 Large Claims
− The number of large claimants over $100k increased from 18 in FY 10 2nd Qtr to 28
in FY 11 2nd Qtr
− Top 30 claims for FY10 2nd Qtr were $4,039,411 compared to $6,428,623 in 2nd Qtr
FY11, which is a 50% increase
− 30% of the Top 30 Large Claimants in FY11 2nd quarter are lifestyle related claims
compared to 20% for the FY10 2nd quarter
4
Medical Utilization
Jul 2009 - Dec 2009
Jul 2010 - Dec 2010
% O v e r P re v io us Q t r
Norm
M e dic a l C o nt ra c t M o nt hs
25,780
25,620
-0.6%
---
M e dic a l M e m be r M o nt hs
58,689
57,935
-1.3%
---
2.28
2.26
-0.7%
---
$378.73
$431.76
14.0%
$379.69
Paid Claims Per Member Per Month
$75.50
$10 0 .58
33.2%
$89.00
Admissions Per 1000 Members
46.41
51.99
12.0%
62.34
Days Per 1000 Members
209.99
231.16
10.1%
281.21
4.52
4 .4 5
-1.7%
4.51
$19,518.86
$2 3 ,2 16 .2 5
18.9%
$17,132.22
$82.29
$88.80
7.9%
$83.07
Visits Per 1000 M embers
1,071.00
1,0 58 .8 4
-1.1%
1,223.80
Paid Claims Per Visit
$922.04
$1,006.39
9.1%
$814.58
Services Per 1000 Members
4,222.87
4 ,154 .3 8
-1.6%
4,328.45
3.94
3.92
-0.5%
3.54
Paid Claims Per Service
$233.85
$256.50
9.7%
$230.31
ER Utilization: Paid Claims PMPM
$15.68
$16 .8 7
7.6%
$17.20
ER Utilization: Visits Per 1000 Members
167.66
14 6 .0 3
-12.9%
211.05
$1,122.19
$1,386.04
23.5%
$977.92
$190.15
$205.97
8.3%
$169.64
17,357.05
17,2 0 9 .0 8
-0.9%
15,222.06
$131.46
$143.63
9.3%
$133.74
Utilization Category
A v e ra ge C o nt ra c t S ize
M e dic a l T o t a l P M P M
Inpatient
Average Length of Stay
Paid Claims Per Admission
Outpatient
Paid Claims Per Member Per Month
Services Per Visit
ER Utilization: Paid Claims Per Visit
Professional Provider
Paid Claims Per Member Per Month
Services Per 1000 Members
Paid Claims Per Service
2010 Norm is based on Premera’s Alaska large group book of business
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Top 30 Claimants – 2nd Qtr FY 2011
IC D 9 D e s c ript io n
P a id C la im s
C la im a nt
E nro llm e nt S t a t us
1
Active
LYM PHOID LEUKEM IA
$637,444.16
2
Active
ABSCESS OF LUNG AND M EDIASTINUM
$596,946.25
3
Active
SUBARACHNOID HEM ORRHAGE
4
Inact ive
C HR ON IC ISC HEM IC HEA R T D ISEA SE
$407,432.60
$3 9 8 ,4 12 .15
5
Inactive
INTRACEREBRAL HEM ORRHAGE
6
A ct ive
C HR ON IC R EN A L F A ILU R E
7
Active
8
A ct ive
9
Active
M ALIGNANT NEOPLASM
10
Active
M ALIGNANT NEOPLASM OF ESOPHAGUS
$216,179.57
11
Active
M ALIGNANT NEOPLASM
$214,206.56
12
A ct ive
13
Active
M ALIGNANT NEOPLASM OF STOM ACH
$167,695.86
14
Active
M ALIGNANT NEOPLASM OF FEM ALE BREAST
$167,424.31
15
Active
INTERVERTEBRAL DISC DISORDERS
$165,856.79
16
Active
M ALIGNANT NEOPLASM
$162,320.61
OTHER M ALIGNANT NEOPLASM S OF LYM PHOID AND HISTIOCYTIC TISSUE
SEPTICEM IA
C HR ON IC ISC HEM IC HEA R T D ISEA SE
A C U T E M Y OC A R D IA L IN F A R C T ION
17
Active
18
A ct ive
OT HER C ON GEN IT A L A N OM A LIES OF HEA R T
$362,998.06
$2 8 6 ,552 .2 5
$284,553.80
$2 72 ,9 70 .3 4
$232,411.38
$18 5,50 2 .0 6
$149,910.68
$14 6 ,12 8 .0 5
19
A ct ive
D ISEA SES OF OT HER EN D OC A R D IA L ST R U C T U R ES
$14 2 ,52 9 .2 1
20
A ct ive
D IA B ET ES M ELLIT U S
$13 4 ,8 6 6 .57
21
Active
TWIN BIRTH, M ATE LIVEBORN
$126,545.56
22
Active
SPONDYLOSIS AND ALLIED DISORDERS
$125,642.66
23
Active
M ALIGNANT NEOPLASM
$120,684.21
24
Active
M ALIGNANT NEOPLASM M OUTH
$114,832.69
25
Active
M ALIGNANT NEOPLASM
$111,887.70
26
A ct ive
A C U T E M Y OC A R D IA L IN F A R C T ION
$10 2 ,2 2 0 .4 6
27
A ct ive
C ER EB R OV A SC U LA R D ISEA SE
$10 0 ,8 8 1.79
28
Active
INTERVERTEBRAL DISC DISORDERS
$100,152.28
29
Active
M ALIGNANT NEOPLASM
30
A ct ive
C A R D IA C D Y SR HY T HM IA S
$98,437.11
$9 4 ,9 9 7.4 4
6
Major Diagnostic Category
Major Diagnosis Category
Musculoskeletal System
Circulatory System
Health Status & Services
Neoplasms
Other
Ill-Defined Conditions
Digestive System
Injury and Poisoning
Nervous System
Genitourinary System
Respiratory System
Mental Disorders
Endocrine, Metabolic and
Immunity
Pregnancy and Related
Skin and Tissue
Infectious and Parasitic
Congenital Anomalies
Blood
Perinatal
Injury and Poisoning External
Causes
Total
7/1/2009 to 12/31/2009
Percentage
Total Paid
Paid PMPM
of Overall
Claims
Total
$72.99 $4,283,540.39
17.46%
$32.63 $1,914,920.94
7.80%
$41.96 $2,462,572.87
10.04%
$29.69 $1,742,734.62
7.10%
$39.34 $2,308,722.83
9.41%
$32.48 $1,905,970.45
7.77%
$29.02 $1,702,904.93
6.94%
$27.78 $1,630,364.10
6.64%
$22.72 $1,333,152.63
5.43%
$21.49 $1,261,117.03
5.14%
$16.25
$953,551.62
3.89%
$18.20 $1,068,080.90
4.35%
7/1/10 to 12/31/2010
Paid PMPM
Total Paid
Claims
$72.21
$55.01
$48.41
$44.05
$40.63
$31.72
$27.60
$26.93
$22.88
$21.64
$19.54
$15.90
$4,183,260.55
$3,187,103.13
$2,804,881.77
$2,552,074.11
$2,353,835.37
$1,837,462.80
$1,598,787.40
$1,560,049.66
$1,325,725.43
$1,253,743.55
$1,132,307.28
$921,243.97
Percentage
of Overall
Total
15.29%
11.65%
10.25%
9.33%
8.60%
6.71%
5.84%
5.70%
4.84%
4.58%
4.14%
3.37%
$10.72
$629,178.84
2.56%
$13.92
$806,641.56
2.95%
$12.23
$4.42
$1.58
$2.16
$1.72
$0.69
$717,511.59
$259,455.57
$92,710.17
$127,059.43
$100,888.47
$40,264.72
2.92%
1.06%
0.38%
0.52%
0.41%
0.16%
$12.24
$6.26
$6.17
$5.26
$1.31
$0.62
$709,293.22
$362,547.54
$357,488.98
$304,900.99
$76,008.99
$35,922.11
2.59%
1.32%
1.31%
1.11%
0.28%
0.13%
$0.01
$738.00
0.00%
$0.05
$3,059.58
0.01%
$418.06 $24,535,440.10
100.00%
$472.36 $27,366,337.99
Circulatory system jumped from #4 in 2nd Qtr FY 10 to number #2 in FY 11
100.00%
7
Caremark - Pharmacy
Pharmacy Observations
 The number of total scripts/claims from FY11 2nd quarter (7/1/10 to 12/31/10)
increased 4% compared to FY10 2nd quarter (7/1/09 to 12/31/09)
 The number of mail order scripts/claims increased 9% from FY 10 to FY11 2nd
quarter
− The University as well as the member receives costs savings with the utilization of
mail order
 The total gross cost increased 8% from FY10 2nd quarter to FY11 2nd quarter
− Pharmacy trend is currently around 10% nationwide and 14.5% for Premera Alaska
 The total amount paid by members decreased 1% and the average amount
paid per member per claim decreased from $12.87 to $12.21, a 5% decrease
from the FY10 2nd quarter
 The generic dispensing rate increased from 58.9% to 62.1%, a 5% increase
− Caremark’s book of business is 66.1% and its Colleges and Universities benchmark
is 65.2%
− The increased utilization of generic drugs provides cost savings to the University and
its employees
9
Pharmacy 2nd Qtr Comparison
UNIVERSITY OF ALASKA
Metrics
Member Utilization
Total Claims
Distribution of Payable Claims
Average Eligible Members Per Month
Average Utilizing Members Per Month
Percent of Utilizing Members
Eligible Member Utiliz. Rate Per Month
Gross Cost
Total Gross Cost
Average Gross Cost Paid/Claim
Total Gross Cost PMPM
Net Cost
Total Net Cost
Average Net Cost Paid/Claim
Total Net Cost PMPM
Member Paid
Total Member Paid
Average Member Paid/Claim
Average Member Paid/Brand
Average Member Paid/Generic
Percent Member Amount Paid
Drug Mix
Single-Source Brand Dispensing Rate
Multi-Source Brand Dispensing Rate
Generic Dispensing Rate
Generic Substitution Rate
Jul 08-Dec 09
Combined
Retail
Benefit
Claims
UNIVERSITY OF ALASKA
Mail
Claims
130,311
100.0%
9,927
2,743
27.6%
0.73
114,905
88.2%
15,406
11.8%
0.64
$11,663,853
$89.51
$65.28
Combined
Benefit
Jul 09-Dec 10
Retail
Claims
Mail
Claims
118,882
87.7%
16,736
12.3%
0.09
135,618
100.0%
10,016
2,822
28.2%
0.75
0.66
0.09
$8,536,815
$74.29
$47.78
$3,127,037
$202.98
$17.50
$12,634,997
$93.17
$70.08
$9,181,360
$77.23
$50.93
$3,453,637
$206.36
$19.16
$9,986,111
$76.63
$55.89
$7,255,281
$63.14
$40.60
$2,730,829
$177.26
$15.28
$10,979,723
$80.96
$60.90
$7,934,029
$66.74
$44.01
$3,045,694
$181.98
$16.89
$1,677,742
$12.87
$23.60
$4.97
14.4%
$1,281,534
$11.15
$21.17
$4.54
15.0%
$396,208
$25.72
$42.02
$9.47
12.7%
$1,655,274
$12.21
$23.78
$4.76
13.1%
$1,247,331
$10.49
$21.26
$4.34
13.6%
$407,943
$24.38
$42.00
$9.06
11.8%
38.1%
3.1%
58.9%
95.1%
36.8%
3.0%
60.2%
95.2%
47.3%
2.6%
50.1%
95.0%
35.0%
3.0%
62.1%
95.4%
33.5%
2.9%
63.6%
95.7%
44.0%
2.4%
53.5%
95.6%
10
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
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Top 30 Claimants – 2nd Qtr FY 2010
IC D 9 D e s c ript io n
C la im a nt
E nro llm e nt S t a t us
P a id C la im s
1
Inactive
OTHER AND ILL-DEFINED CEREBROVASCULAR DISEASE
$456,517.00
2
Active
CHRONIC RENAL FAILURE
$365,543.64
3
Active
CARE INVOLVING USE OF REHABILITATION PROCEDURES
$219,824.84
4
Inactive
M ALIGNANT NEOPLASM OF BRAIN
$211,650.97
5
Active
ENCOUNTER FOR OTHER AND UNSPECIFIED PROCEDURES AND AFTERCARE
$181,150.39
6
Active
OTHER FORM S OF CHRONIC ISCHEM IC HEART DISEASE
$173,402.09
7
Inactive
LYM PHOID LEUKEM IA
$165,240.29
8
Active
POLYARTERITIS NODOSA AND ALLIED CONDITIONS
$156,331.18
9
Inactive
M ALIGNANT NEOPLASM OF PANCREAS
$132,186.15
10
Active
OTHER DISEASES OF LUNG
$129,902.27
11
Active
DIVERTICULA OF INTESTINE
$117,407.24
12
Active
ATHEROSCLEROSIS
$113,823.53
13
Active
M ALIGNANT NEOPLASM OF BODY OF UTERUS
$106,721.36
14
Active
SYM PTOM S INVOLVING HEAD AND NECK
$105,626.39
15
Active
OTHER DISEASES OF LUNG
$104,227.67
16
Inactive
PLEURISY
$103,975.20
17
Active
COM PLICATIONS PECULIAR TO CERTAIN SPECIFIED PROCEDURES
$103,067.50
18
Active
M ALIGNANT NEOPLASM OF FEM ALE BREAST
$102,124.21
19
Active
OSTEOARTHROSIS AND ALLIED DISORDERS
$96,458.03
20
Active
INTERVERTEBRAL DISC DISORDERS
$91,949.18
21
Active
ACUTE M YOCARDIAL INFARCTION
$90,321.39
22
Active
ACUTE M YOCARDIAL INFARCTION
$87,048.39
23
Active
OSTEOARTHROSIS AND ALLIED DISORDERS
$83,581.03
24
Active
M ENINGITIS OF UNSPECIFIED CAUSE
$79,800.97
25
Active
OSTEOARTHROSIS AND ALLIED DISORDERS
$79,689.79
26
Active
OTHER COM PLICATIONS OF INTERNAL PROSTHETIC DEVICE, IM PLANT, AND GRAFT
$79,579.22
27
Active
M ALIGNANT NEOPLASM OF FEM ALE BREAST
$77,066.53
28
Active
SPONDYLOSIS AND ALLIED DISORDERS
$75,572.52
29
Active
OSTEOARTHROSIS AND ALLIED DISORDERS
$74,936.13
30
Inactive
OSTEOARTHROSIS AND ALLIED DISORDERS
$74,686.34
13
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