UNIVERSITY OF ALASKA
2ND QTR FY13 UTILIZATION REVIEW
7/1/2012 TO 12/31/2012
L
O
C
K
T
O
N
D
U
N
N
I
N
G
B
E
N
E
F
I
T
S
Premera- Medical
Premera Medical – Inpatient & Outpatient
 Inpatient
− Paid claims per member per month (PMPM) for inpatient services increased
significantly from $66.80 for FY12 (07/11-12/11) to $92.82 for FY13
(07/12-12/12)
− The average length of stay for inpatient services increased from 4.06 to
5.57 and FY13 was above the Premera Norm of 4.62
− Paid claims per admissions increased from $19,825 for FY12 to $21,246 for
FY13
 Outpatient
− Paid claims PMPM for outpatient services decreased from $80.80 for FY12
to $77.03 for FY13 and was below the Premera Norm of $83.45
− Outpatient services per 1,000 members decreased slightly from 3,976 for
FY12 to 3,829 for FY13
2
Premera Medical – Emergency Room & Large Claims
 Emergency Room
− ER paid claims per visit decreased from $1,286 for 2nd Qtr FY12 to $1,198 for
2nd Qtr FY13, but was above the Premera Norm of $1,138
− Visits per 1,000 members for ER services increased from 148 for 2nd Qtr FY12
to 152 for 2nd Qtr FY13 and was below the Premera norm of 208
 Large Claims
− Large Claims have increased from FY12 compared to FY13
 18 large claimants over $100k through FY12
− None were over $400k
− $2,913,620 total paid
 25 large claimants over $100k through FY13
− 2 are over $400k
− $5,009,186 total paid
 Estimate 37 claims over $100k in a 12 month period
 2 claims over $500k
 1 claim over $700k
3
Medical Utilization
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
% Change
2nd Qtr FY12 2nd Qtr FY13
over
Previous Qtr
Norm
$66.80
40.44
164.23
4.06
$19,825.22
$92.82
52.42
291.89
5.57
$21,246.09
39%
30%
78%
37%
7%
$82.70
58.99
272.50
4.62
$16,823.53
$80.80
1,037.86
$934.17
3,976.01
3.83
$243.85
$15.92
148.47
$1,286.44
$77.03
1,054.70
$876.37
3,828.73
3.63
$241.41
$15.14
151.72
$1,197.72
-5%
2%
-6%
-4%
-5%
-1%
-5%
2%
-7%
$83.45
1,013.16
$988.40
3,979.58
3.93
$251.64
$19.73
208.04
$1,138.35
$169.63
15,867.56
$128.29
$180.42
16,301.22
$132.81
6%
3%
4%
$168.94
16,112.73
$125.82
Norm is based on Premera’s Alaska large group book of business
4
Large Claims Analysis
FY12
$23,376,987
4,114
$5,682
Medical & Rx Spend
Average Monthly Employees
PEPM Cost
% Change Over Previous Fiscal Year
802.33%
$2,913,620
18
$161,868
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
Large Claims
percentage of Total
Medical & Rx
Claims
FY13
$23,913,208
3,962
$6,036
6.2%
477.39%
$5,009,186
25
$200,367
23.8%
$20,463,367
$553
FY12
12.5%
$18,904,022
$530
-4.1%
FY13
20.9%
5
Claimants over $100k – FY13 ( July 2012 – December 2012)
Claimant
Diagnosis
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
UNSPECIFIED ANEMIAS- CLAIMANT TERMED 8/31/12
OTHER DISORDERS OF ARTERIES AND ARTERIOLES
CHRONIC RENAL FAILURE
DISORDERS OF MINERAL METABOLISM
CEREBRAL LACERATION AND CONTUSION
MALIGNANT NEOPLASM OF BRAIN
MALIGNANT NEOPLASM OF PANCREAS
ACUTE MYOCARDIAL INFARCTION
MALIGNANT NEOPLASM OF LYMPH NODES
MALIGNANT NEOPLASM OF STOMACH
MALIGNANT NEOPLASM OF BRAIN AND SPINE
AFFECTIVE PSYCHOSES
CENTRAL PAIN
OTHER DISORDERS OF CERVICAL REGION
FUNCTIONAL DIGESTIVE DISORDERS
OSTEOARTHROSIS AND ALLIED DISORDERS
OTHER DISEASES OF ENDOCARDIUM
MALIGNANT NEOPLASM OF TRACHEA, BRONCHUS, AND LUNG
ARTERIAL EMBOLISM AND THROMBOSIS
MALIGNANT NEOPLASM OF LYMPH NODES
MALIGNANT NEOPLASM OF FEMALE BREAST
DISORDERS OF LIPOID METABOLISM
CARDIAC DYSRHYTHMIAS
CHRONIC ISCHEMIC HEART DISEASE
MALIGNANT NEOPLASM OF BRAIN
Paid Claims
$775,747.43
$708,701.01
$266,306.49
$242,628.18
$236,329.76
$210,036.83
$183,831.19
$182,897.52
$181,024.03
$157,044.64
$154,258.70
$142,792.28
$139,542.56
$138,883.39
$138,819.40
$132,686.86
$125,481.93
$124,653.31
$116,565.26
$116,125.79
$112,789.38
$111,811.18
$106,322.15
$102,889.28
$101,017.53
6
Claimants over $100k – FY12 (July 2011 - December 2011)
Claimant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Diagnosis
DISORDERS OF AMINO-ACID TRANSPORT AND METABOLISM
CHRONIC RENAL FAILURE
MALIGNANT NEOPLASM OF OROPHARYNX
MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE
MIGRAINE
OTHER FORMS OF CHRONIC ISCHEMIC HEART DISEASE
MALIGNANT NEOPLASM OF COLON
CHRONIC RENAL FAILURE
OSTEOARTHROSIS AND ALLIED DISORDERS
MALIGNANT NEOPLASM OF COLON
COMPLICATIONS DUE TO OTHER VASCULAR DEVICE
MALIGNANT NEOPLASM OF BREAST
MALIGNANT NEOPLASM OF COLON
CARDIAC DYSRHYTHMIAS
OSTEOARTHROSIS AND ALLIED DISORDERS
OCCLUSION OF CEREBRAL ARTERIES
OTHER CONGENITAL ANOMALIES OF HEART
SPONDYLOSIS AND ALLIED DISORDERS
Paid Claims
$324,581.38
$324,576.30
$219,738.91
$202,620.07
$159,413.31
$155,248.36
$150,135.29
$147,686.68
$143,447.84
$139,784.15
$138,929.50
$136,633.08
$130,755.26
$114,176.90
$109,581.57
$109,185.46
$104,406.96
$102,718.81
7
Major Diagnostic Category
Major Diagnosis Category
Health Status & Services
Musculoskeletal System
Circulatory System
Neoplasms
Injury and Poisoning
Ill-Defined Conditions
Digestive System
Nervous System
Genitourinary System
Pregnancy and Related
Mental Disorders
Endocrine, Metabolic and Immunity
Respiratory System
Skin and Tissue
Congenital Anomalies
Infectious and Parasitic
Perinatal
Blood
Other
Injury and Poisoning External Causes
Total
7/1/2011 - 12/31/2011
Percentage of
Paid PMPM
Total Paid Claims
Overall Total
$41.95
$2,427,510.33
12.31%
$63.87
$3,695,920.32
18.74%
$21.94
$1,269,596.04
6.44%
$34.81
$2,014,518.87
10.21%
$17.15
$992,344.46
5.03%
$25.77
$1,491,031.13
7.56%
$22.19
$1,284,029.11
6.51%
$22.50
$1,302,170.37
6.60%
$23.00
$1,330,973.93
6.75%
$11.30
$653,795.95
3.31%
$14.66
$848,541.90
4.30%
$14.64
$847,162.54
4.30%
$13.61
$787,818.30
3.99%
$5.11
$295,694.23
1.50%
$3.49
$201,805.44
1.02%
$2.59
$150,058.73
0.76%
$0.57
$33,038.18
0.17%
$1.64
$94,633.58
0.48%
$0.03
$1,975.36
0.01%
$0.01
$531.20
0.00%
$340.82
$19,723,149.97
100.00%
7/1/2012 - 12/31/2012
Percentage of
Paid PMPM
Total Paid Claims
Overall Total
$62.54
$3,378,515.99
16.58%
$53.24
$2,876,311.64
14.11%
$38.18
$2,062,514.82
10.12%
$37.83
$2,043,874.86
10.03%
$28.59
$1,544,462.70
7.58%
$27.71
$1,496,924.62
7.34%
$21.52
$1,162,418.96
5.70%
$20.70
$1,118,267.81
5.49%
$18.35
$991,234.47
4.86%
$16.21
$875,802.70
4.30%
$15.19
$820,642.18
4.03%
$12.29
$663,930.70
3.26%
$10.53
$568,930.82
2.79%
$4.64
$250,434.99
1.23%
$3.20
$172,980.78
0.85%
$2.96
$159,903.24
0.78%
$1.98
$106,927.46
0.52%
$1.57
$84,612.72
0.42%
$0.06
$3,251.93
0.02%
$0.01
$635.76
0.00%
$377.31
$20,382,579.15
100.00%
Health Status and Services jumped from #2 to #1
Musculoskeletal system dropped from #1 to #2
Circulatory Systems (Heart) jumped from #8 to #3
8
Member Responsibility
Allowed Charges
Employee Out of Pocket
Deductible
Copays
Coinsurance
Member Responsibility
Member Cost Share
(% of Allowed Charges)
Allowed Charges
Employee Out of Pocket
Deductible
Copays
Coinsurance
Member Responsibility
Member Cost Share
(% of Allowed Charges)
FY12
$35,363,153
$3,300,349
$671,580
$3,343,266
$7,315,195
20.7%
FY13
$35,238,880
$3,220,594
$601,399
$3,567,779
$7,389,772
21.0%
9
Caremark - Pharmacy
Pharmacy Observations
 The total gross costs decreased $187,127 for 2nd Quarter FY12 to FY13
from $4,253,408 to $4,066,281
 The percent of mail order scripts/claims decreased from 20.0% to
18.8% for 2nd Qtr FY13
 The generic dispensing rate increased from 68.7% to 75.3%, a 9.6%
increase
 Specialty drug gross costs increased 29.8% from $659,867 to $856,288
 0.7% of membership utilize the specialty drugs accounting for 21.1% of
pharmacy spend
11
Pharmacy FY 12 to FY13 Comparison
Eligibility
Average Eligible Members per Month
Average Monthly Utilizers as % of Members
Jul - Dec 11 Jul - Dec 12 % Change
9,879
26.7%
11,431
22.6%
15.7%
-15.4%
$4,253,408
$3,615,538
$72
$61
15.0%
$4,066,281
$3,498,713
$59
$51
14.0%
-4.4%
-3.2%
-18.3%
-16.4%
-6.7%
29.1%
2.2%
68.7%
96.9%
22.2%
2.4%
75.3%
96.9%
-23.7%
9.1%
9.6%
0.0%
40,454
80.0%
20.0%
25
39,076
81.2%
18.8%
20
-3.4%
1.5%
-6.0%
-20.0%
$659,867
0.8%
$11
15.5%
1.0%
$856,288
0.7%
$12
21.1%
1.1%
29.8%
-12.5%
13.3%
36.1%
10.0%
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
Specialty
Specialty
Specialty
Specialty
Total Gross Cost
Utilizers as % of Members
Gross Cost PMPM
% of Total Gross Cost
% of Total Prescriptions
12
Top 25 Drugs by Gross Cost
Book of
Business
Rank
1
6
2
5
394
4
8
7
64
9
27
10
3
14
16
13
11
157
47
22
32
62
12
18
34
Prior
Rank
Current
Rank
Drug Name
2
5
3
7
0
9
72
8
0
10
13
70
12
14
0
27
0
35
21
42
16
25
24
29
33
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
Humira
Copaxone
Nexium
Cymbalta
Kuvan
Crestor
Atorvastatin Calcium
Advair Diskus
Incivek
Abilify
One Touch Ultra Test
Novolog
Enbrel
Celebrex
Escitalopram Oxalate
Lantus Solostar
Montelukast Sodium
Temodar
Valacyclovir
Lyrica
Lovaza
Restasis
Januvia
Oxycontin
Victoza 3-Pak
Dispense
Type
Specialty
Specialty
Brand
Brand
Specialty
Brand
Generic
Brand
Specialty
Brand
Brand
Brand
Specialty
Brand
Generic
Brand
Generic
Specialty
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Total
Total
Launch Gross Cost
Utilizers
Rxs
Date
Analgesics- Anti-Inflammatory
NA
$148,350
19
66
Psychotherapeuctic And Neurological Agents- Misc. Q3-2015
$100,568
6
24
Ulcer Drugs
Q2-2014
$100,538
123
276
Antidepressants
Q4-2013
$78,065
78
221
Endocrine And Metabolic Agents - Misc.
NA
$72,637
1
5
Antihyperlipidemics
Q3-2016
$66,875
111
269
Antihyperlipidemics
$61,725
315
768
Antiasthmatic And Bronchodilator Agents
NA
$58,383
86
173
Antivirals
NA
$56,381
1
3
Antipsychotics/Antimanic Agents
Q2-2015
$55,620
25
62
Diagnostic Products
NA
$47,577
103
205
Antidiabetics
Q4-2014
$41,331
38
100
Analgesics- Anti-Inflammatory
NA
$40,895
5
20
Analgesics- Anti-Inflammatory
Q2-2014
$40,279
83
167
Antidepressants
$40,223
169
462
Antidiabetics
NA
$40,119
52
124
Antiasthmatic And Bronchodilator Agents
$38,828
154
313
Antineoplastics and Adjunctive Therapies
Q3-2013
$36,244
2
12
Antivirals
$35,613
181
308
Anticonvulsants
NA
$33,304
34
98
Antihyperlipidemics
Q2-2015
$32,581
60
114
Ophthalmic Agents
NA
$30,672
60
89
Antidiabetics
NA
$28,884
33
72
Analgesics - Opioid
NA
$27,848
17
62
Antidiabetics
NA
$27,241
16
46
Therapeutic Class
13
Top 25 Drugs by Script Count
Drug Name
Hydrocodone/Acetaminophen
Lisinopril
Atorvastatin Calcium
Levothyroxine Sodium
Synthroid
Azithromycin
Hydrochlorothiazide
Omeprazole
Zolpidem Tartrate
Escitalopram Oxalate
Simvastatin
Bupropion XL
Metformin HCL
Sertraline HCL
Amoxicillin
Amlodipine Besylate
Alprazolam
Ventolin HFA
Venlafaxine HCL ER
Lisinopril-Hydrochlorothiazide
Montelukast Sodium
Fluoxetine HCL
Valacyclovir
Metroprolol Succinate
Citalopram HBR
Therapeutic Class
Non-Narcotic Analgesic
Antihypertensive
Antihyperlipidemics
Thyroid Agents
Thyroid Agents
Macrolide Antibiotic
Diuretics
Ulcer Drugs
Hypnotics
Antidepressants
Antihyperlipidemics
Antidepressants
Antidiabetics
Antidepressants
Penicillin
Calcium Channel Blockers
Anti-anxiety
Antiasthmatic And Bronchodilator Agents
Antidepressants
Antihypertensive Agent
Antiasthmatic And Bronchodilator Agents
Antidepressants
Antivirals
Beta Blockers
Antidepressants
Total Rxs
951
947
768
651
621
575
546
498
488
462
456
396
395
390
389
350
341
336
317
315
313
310
308
307
288
Amount
Paid
$5,078
$4,794
$54,705
$264
$276
$4,367
$573
$21,726
$7,578
$36,173
$17,838
$19,812
$6,518
$6,368
$611
$3,663
$704
$8,421
$19,643
$1,887
$36,938
$5,948
$33,908
$6,509
$2,113
14
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
16
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)
17