University of Alaska
July 2010 - June 2012
Demographics
Demographics - Overview
 The University of Alaska has fewer men than the norm with a greater male and
female concentration from ages 40 – 59 (36% compared to norm of 31%)
 Overall age/gender factor of 1.13 and based on age/gender mix we would anticipate
the University to be 13% more costly
 Employee age/gender factor of 1.37 compared to the norm of 1.17, and increased from
the previous Fiscal Year
 Spouse age/gender factor of 1.42 compared to the norm of 1.34, and increased from the
previous Fiscal Year
 Employees drove 45% of the plan costs and were 43% of the population
 Spouses drove 40% of the plan costs and were 25% of the population
 Dependents drove 15% of the plan costs and were 32% of the population
 10% of the University’s population has 3 or more chronic conditions with the
norm at 8%
 University’s PMPY cost for these members is $17,331 compared to norm of $14,558
 Approximately 69% of the current members have been enrolled in the medical
plan for 3 or more years and 80% more than 2 years
2
Demographics – Total Members
Length of Enrollment (For Current Members)
Members by Gender
100%
866
9%
1,071
11%
75%
12 - 23 months
1,068
11%
6,579
69%
47.4%
47.6%
51.3%
52.6%
52.4%
48.7%
2010-2011
2011-2012
Norm
Less than 12 months
50%
24 - 35 months
36 months
25%
0%
Female
Norm from Lockton InfoLock Book of Business.
Male
3
Demographics - Total Members
Member Percentage by Relationship
100%
PMPY Paid by Relationship
$9,000
30%
32%
$8,000
35%
75%
$7,000
$6,000
26%
50%
25%
20%
$5,000
$4,000
$2,098
$5,640
$4,178
$1,000
$2,049
$2,000
$5,774
45%
$6,493
43%
$2,849
44%
$7,125
25%
$8,441
$3,000
$-
0%
2010-2011
Employee
2011-2012
Norm
Spouse
Dependent
2010-2011
Employee
Norm from Lockton InfoLock Book of Business.
2011-2012
Spouse
Norm
Dependent
4
Health Cost Analysis
Medical Financial Analysis Overview
 Inpatient average allowed per admission decreased 19.4% from $30,111 to
$24,263 and the average length of stay decreased from 6.6 days to 4.4 days
 Decrease in the severity of inpatient claims due to shorter stays
 Preventive office visits per 1,000 decreased 10.5% from 454 to 406
 Emergency Room visits per 1,000 decreased from 176 to 172 and the cost per
visit decreased
 Non-emergent like condition ER visits increased from 7% to 14%
 Members with 3 plus ER visits accounted for 10.3% of all ER visits. This was
7.4% in the last InfoLock report from 7/10-6/11.
 28 members with 4 ER visits (38% on weekends)
 46 members with 5+ ER visits (30% on weekends)
6
Utilization Summary
Apr 10 Mar 11
Apr 11 Mar 12
% Change
Norm
Inpatient
IP Days/1000
353
221
-37.4%
305
53
50
-6.7%
69
$30,111
$24,263
-19.4%
$18,303
6.6
4.4
-32.9%
4.4
$4,549
$5,459
20.0%
$4,158
176
172
-2.4%
232
$2,622
$2,429
-7.4%
$1,751
4,391
3,812
-13.2%
4,000
Behavior Health Visits/1000
669
606
-9.3%
402
Preventive Visits/1000
454
406
-10.5%
470
$461
$471
2.1%
$263
9,372
7,900
-15.7%
9,786
$211
$258
22.3%
$245
$31
$38
21.5%
$29
65%
69%
5.8%
74%
MRIs/1000
74
72
-1.9%
71
CT Scans/1000
69
46
-33.6%
67
Admissions/1000
Average Allowed per Admission
Average Length of Stay
Average Allowed per Day
Outpatient
ER Visits/1000
Average Allowed per ER Visit
All Office Visits/1000
Average Allowed per Office Visit (includes ancillary)
Prescription Drugs
Prescriptions/1000
Average Allowed per Brand Script
Average Allowed per Generic Script
% Generic Scripts
Imaging
Utilization is provided on an incurred basis and lagged three months.
Norm from Lockton InfoLock Book of Business.
7
Claim Expense Distribution
Jul 10 - Jun 11
Paid Amount Range
Members
Count
%
Jul 11 - Jun 12
Plan Payment
Amount
%
Members
Count
%
Norm
Plan Payment
Amount
Plan
Members Payment
%
%
%
$0 or less
1,915
17.7%
-$90,078
-0.1%
2,740
25.0%
-$50,734
-0.1%
29.7%
-0.3%
$1 - $1,999
4,996
46.1%
$3,426,502
5.4%
4,760
43.4%
$3,220,703
6.1%
49.2%
10.3%
$2,000 - $4,999
1,683
15.5%
$5,378,886
8.5%
1,481
13.5%
$4,881,353
9.2%
10.5%
12.4%
$5,000 - $24,999
1,741
16.1%
$19,319,663
30.7%
1,551
14.1%
$16,337,449
31.0%
8.8%
33.5%
$25,000 - $49,999
321
3.0%
$10,881,166
17.3%
262
2.4%
$9,034,638
17.1%
1.1%
13.7%
$50,000 - $74,999
84
0.8%
$5,196,828
8.3%
82
0.7%
$5,011,974
9.5%
0.3%
7.1%
$75,000 - $99,999
36
0.3%
$3,082,142
4.9%
31
0.3%
$2,623,947
5.0%
0.1%
4.5%
$100,000 - $149,999
28
0.3%
$3,318,058
5.3%
36
0.3%
$4,482,502
8.5%
0.1%
5.7%
$150,000 +
39
0.4%
$12,430,278
19.7%
32
0.3%
$7,236,342
13.7%
0.1%
13.1%
187
1.7%
$24,027,305
38.2%
181
1.6%
$19,354,765
36.7%
0.7%
30.4%
Members > $50,000
All Members
10,843 100.0%
$62,943,445 100.0% 10,975 100.0%
$52,778,174 100.0% 100.0% 100.0%
Includes members who were enrolled or had a claim paid during the time period.
 0.3% of members drove 13.7% of the University’s costs
 1.6% of members (181) drove 36.7% of the University’s costs
Norm from Lockton InfoLock Book of Business.
8
Emergency Room Demographics
ER Visits by Number of Visits
2010-2011
Visits per
Member
# of
Members
% on
Weekends
2011-2012
%
# of
% on
%
Dependents Members Weekends Dependents
1
1,086
32%
31%
977
31%
36%
2
275
29%
31%
226
33%
34%
3
83
33%
16%
64
25%
25%
4
23
46%
39%
28
38%
36%
5+
37
31%
22%
46
30%
22%
ER Visits by Relationship
100%
28%
33%
28%
26%
44%
41%
2010-2011
2011-2012
75%
50%
25%
0%
Employees
Spouses
Dependents
9
Emergency Room Utilization
Emergency Room Visit by Top 20 Diagnosis Groups
Jul 11 - Jun 12
ER Visits by Type
Primary Diagnosis Group
20%
14%
Headache
99
$216,144
Chest Pain
77
$184,965
2
$170,380
Respiratory Failure
Potential Non Emergent
Neurotic and Personality Disorders
21
$165,578
Other
Pain, not elsewhere classified
79
$165,577
Abdominal Pain
115
$163,550
Misc Wounds and Injuries
197
$123,246
Misc Symptoms
193
$105,846
Depression
24
$104,638
Limb Fractures
63
$93,519
Stroke and TIA
7
$89,243
Musculoskeletal Disorders
99
$83,557
Nausea and Vomiting
44
$83,368
132
$78,286
Urinary Stones
27
$71,713
Pregnancy Complications
62
$70,405
Complicated Limb Fractures
11
$69,010
Dysrhythmias
19
$66,024
Gall Bladder Diseases
11
$63,799
9
$62,081
912
2,203
$1,222,076
$3,453,006
Injury and Potential Non Emergent Visits per 1000 by Service Date
80
70
60
50
40
30
20
10
0
ENT and Upper Resp Disorders
12/1/2011
11/1/2011
10/1/2011
9/1/2011
8/1/2011
7/1/2011
6/1/2011
5/1/2011
4/1/2011
3/1/2011
2/1/2011
1/1/2011
12/1/2010
11/1/2010
10/1/2010
9/1/2010
8/1/2010
7/1/2010
6/1/2010
5/1/2010
Affective Disorders except Depression
4/1/2010
Paid Amount
Injury
66%
ER Visits per 1000
Visits
All Others
Total
Service Date
Injury
Non-Emergent
10
Prescription Drug
Analysis
Pharmacy Financial Analysis Overview
 Generic usage increased from 65% to 69%

Estimated savings of $300,000 to $370,000

For each 1% increase in generic usage the pharmacy plan costs should decrease 1%
 Nexium per script usage decreased from 1,101 to 680 with Omeprazole scripts
decreasing from 1,023 to 987
 Lipitor per script usage decreased from 2,257 to 913 with Simvastatin scripts
decreasing from 1,269 to 1,037 and Atorvastatin Calcium at 863

Crestor decreased from 855 to 642
 Potential savings of $95,313, if 50% of cholesterol scripts moved to Simvastatin
 Potential savings of $80,221, if 50% of PPI scripts moved to Omeprazole
 Humira’s total Rx spend was $249,762 (3% of total University pharmacy spend)
and Enbrel’s total Rx spend was $101,716 (1% of total University pharmacy
spend)
12
Brand versus Generic Analysis
Brand and Generic Drugs by Scripts and Plan Paid
100%
21.4%
80%
60%
65.3%
69.1%
40%
20%
78.6%
34.7%
21.2%
24.5%
74.5%
78.8%
75.5%
30.9%
25.5%
0%
Scripts
Plan Paid
Jul 10 - Jun 11
Scripts
Plan Paid
Scripts
Jul 11 - Jun 12
Brand
Plan Paid
Norm
Generic
Cost per Script
$300
$250
$258
$245
$211
$200
$150
$100
$50
$31
$38
$29
$0
Jul 10 - Jun 11
Average Allowed per Brand Script
Jul 11 - Jun 12
Norm
Average Allowed per Generic Script
Norm from Lockton InfoLock Book of Business.
13
Prescription Drugs - Top 20 Drugs by Paid Amount
Jul 10 - Jun 11
Drug Name
HUMIRA
SINGULAIR
NEXIUM
COPAXONE
LIPITOR
CYMBALTA
ADVAIR DISKUS
ABILIFY
CRESTOR
ATORVASTATIN CALCIUM
ENBREL
ONE TOUCH ULTRA TEST
LEXAPRO
REBIF
CELEBREX
GLEEVEC
LOVAZA
VALACYCLOVIR
RESTASIS
ZYTIGA
Top 20 Drugs
All Others
Total
Brand/
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Brand
Brand
Therapeutic Class
Disease-modifying Antirheumatic Agents
Leukotriene Modifiers
Proton-pump Inhibitors
Biologic Response Modifiers
HMG-CoA Reductase Inhibitors
Selective Serotonin- and Norepinephrine-reuptake
Selective beta-2-Adrenergic Agonists
Atypical Antipsychotics
HMG-CoA Reductase Inhibitors
HMG-CoA Reductase Inhibitors
Disease-modifying Antirheumatic Agents
Diabetes Mellitus
Selective Serotonin-reuptake Inhibitors
Biologic Response Modifiers
Cyclooxygenase-2 (COX-2) Inhibitors
Antineoplastic Agents
Antilipemic Agents, Miscellaneous
Nucleosides and Nucleotides
EENT Anti-inflammatory Agents, Misc
Antineoplastic Agents
Paid
Paid
PMPM
Scripts
Jul 11 - Jun 12
Cost
per
Script
Paid
Paid
PMPM
Scripts
Cost
per
Script
$229,096
$153,735
$256,901
$158,976
$337,401
$111,428
$133,035
$104,055
$122,322
$0
$109,285
$86,265
$120,110
$112,457
$71,843
$0
$68,526
$73,449
$54,534
$0
$2,303,416
$1.96
$1.32
$2.20
$1.36
$2.89
$0.96
$1.14
$0.89
$1.05
$0.00
$0.94
$0.74
$1.03
$0.96
$0.62
$0.00
$0.59
$0.63
$0.47
$0.00
$19.74
117
1,012
1,101
48
2,257
634
579
176
855
64
479
1,083
41
442
349
645
178
10,060
$1,958
$152
$233
$3,312
$149
$176
$230
$591
$143
$0
$1,708
$180
$111
$2,743
$163
$0
$196
$114
$306
$0
$229
$249,762
$194,131
$179,464
$177,683
$162,725
$131,313
$127,163
$119,003
$116,811
$102,893
$101,716
$90,468
$83,810
$83,366
$77,044
$70,024
$65,967
$65,937
$64,469
$63,960
$2,327,709
$1.94
$1.51
$1.39
$1.38
$1.26
$1.02
$0.99
$0.92
$0.91
$0.80
$0.79
$0.70
$0.65
$0.65
$0.60
$0.54
$0.51
$0.51
$0.50
$0.50
$18.08
125
979
680
47
913
535
452
177
642
863
55
451
664
26
388
13
265
644
187
12
8,118
$1,998
$198
$264
$3,780
$178
$245
$281
$672
$182
$119
$1,849
$201
$126
$3,206
$199
$5,386
$249
$102
$345
$5,330
$287
$5,100,551
$43.71
81,555
$63
$5,191,329
$40.32
73,999
$70
$7,403,967
$63.46
91,615
$81
$7,519,038
$58.40
82,117
$92
14
Prescription Drugs - Top 20 Drugs by Script Count
Jul 10 - Jun 11
Drug Name
HYDROCODONE-ACETAMINOPHEN
LISINOPRIL
SYNTHROID
LEVOTHYROXINE SODIUM
ZOLPIDEM TARTRATE
HYDROCHLOROTHIAZIDE
SIMVASTATIN
OMEPRAZOLE
SINGULAIR
AZITHROMYCIN
LIPITOR
METFORMIN HCL
ATORVASTATIN CALCIUM
AMOXICILLIN
BUPROPION XL
SERTRALINE HCL
ALPRAZOLAM
FLUOXETINE HCL
AMLODIPINE BESYLATE
NEXIUM
Top 20 Drugs
All Others
Total
Brand/
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Therapeutic Class
Opiate Agonists
Angiotensin-Converting Enzyme Inhibitors
Thyroid Agents
Thyroid Agents
Anxiolytics, Sedatives, & Hypnotics Misc
Thiazide Diuretics
HMG-CoA Reductase Inhibitors
Proton-pump Inhibitors
Leukotriene Modifiers
Other Macrolides
HMG-CoA Reductase Inhibitors
Biguanides
HMG-CoA Reductase Inhibitors
Aminopenicillins
Miscellaneous Antidepressants
Selective Serotonin-reuptake Inhibitors
Benzodiazepines
Selective Serotonin-reuptake Inhibitors
Dihydropyridines
Proton-pump Inhibitors
Paid
Paid
PMPM
Scripts
Jul 11 - Jun 12
Cost
per
Script
Paid
Paid
PMPM
Scripts
Cost
per
Script
$10,356
$9,888
$1,940
$665
$23,734
$786
$40,661
$43,143
$153,735
$20,978
$337,401
$11,179
$0
$1,679
$60,589
$16,587
$1,166
$8,864
$12,747
$256,901
$1,012,997
$0.09
$0.08
$0.02
$0.01
$0.20
$0.01
$0.35
$0.37
$1.32
$0.18
$2.89
$0.10
$0.00
$0.01
$0.52
$0.14
$0.01
$0.08
$0.11
$2.20
$8.68
2,416
2,029
1,301
1,280
1,162
1,308
1,269
1,023
1,012
1,234
2,257
964
943
926
818
709
721
807
1,101
23,280
$4
$5
$1
$1
$20
$1
$32
$42
$152
$17
$149
$12
$0
$2
$65
$20
$2
$12
$16
$233
$44
$12,418
$13,221
$1,738
$669
$25,410
$1,128
$46,316
$51,952
$194,131
$16,080
$162,725
$14,541
$102,893
$1,348
$52,155
$14,686
$2,051
$11,686
$11,489
$179,464
$916,099
$0.10
$0.10
$0.01
$0.01
$0.20
$0.01
$0.36
$0.40
$1.51
$0.12
$1.26
$0.11
$0.80
$0.01
$0.41
$0.11
$0.02
$0.09
$0.09
$1.39
$7.12
2,150
1,917
1,275
1,094
1,078
1,069
1,037
987
979
957
913
887
863
848
846
834
738
732
705
680
20,589
$6
$7
$1
$1
$24
$1
$45
$53
$198
$17
$178
$16
$119
$2
$62
$18
$3
$16
$16
$264
$44
$6,390,969
$54.77
68,335
$94
$6,602,939
$51.29
61,528
$107
$7,403,967
$63.46
91,615
$81
$7,519,038
$58.40
82,117
$92
15
Current Member Chronic
Condition Analysis
•
•
Members included in this section were active plan participants
as of the last month of the reporting cycle and enrolled for
more than three months. Retirees and COBRA members are
excluded from this section.
Each individual member is assigned a relative risk score
indicating disease burden and a care gap score quantifying
appropriate medical care. Depending upon the prevalence of
disease and the extent of gaps in medical care, the population
is stratified into low, moderate, and high risk for disease
burden, and compliant or non-compliant for disease
management.
Chronic Conditions per Member
Chronic Conditions per Member
65%
70%
60%
Paid Amount by Number of Chronic Conditions
57%
16%
50%
40%
30%
20%
20%
18%
13%
10%
9%
10%
8%
0%
Members with 0
conditions
Members with 1
condition
Actual
Members with 2 Members with 3 or
conditions
more conditions
Norm
84%
No Chronic Conditions
PMPY by Number of Chronic Conditions
$20,000
$18,000
$16,000
$14,000
$12,000
$10,000
$8,000
$6,000
$4,000
$2,000
$-
1 or more condition
$17,331
$14,558
$7,306 $6,649
$5,984
$4,217
$1,364 $1,326
Members with 0 Members with 1 Members with 2 Members with 3
conditions
condition
conditions
or more
conditions
Actual
Norm
17
Top 5 Chronic Conditions
Chronic Conditions per Member
Back Pain
1302
Neck Pain
656
305
Hypertension
380
186
187
71
Depression
384
195
176
59
Hyperlipidemia
318
0
177
153
500
255
524
440
139
87
Low Risk
Moderate Risk
High Risk
High Cost Claimant
49
1000
1500
2000
2500
3000
18
Cost of Non-Compliance
PMPY Costs by Chronic Conditions
555 198
$10,305
$8,878
$5,385
528 120
$4,904
$7,104
$7,316
$8,114
59 334
$5,471
$5,271
$7,907
$8,347
$7,491
$5,674
$5,007
$6,021
$6,000
$6,432
$8,501
$8,000
$8,951
$10,000
$9,262
$11,286
$11,538
Prevent heart
attack
$12,000
$4,000
Prevent
Chronic Renal
Failure
$8,044
$14,000
$2,000
198 96
1,999 267
1,089 127
4
21
29
49
664 91
263 90
3,411 667
$-
Compliant
Non-Compliant
This exhibit excludes high cost claimants. PMPY costs include co morbidities. Only members with
at least one chronic condition are included.
19
Cost Adjustment
 1In the ACCRA Cost of Living Index, health care costs in
Alaska’s cities (Fairbanks, Anchorage and Juneau ranged
from 39.4% to 49.8% more costly than the average U.S.
city in 2011
 The Norm has not been adjusted for the higher costs in
Alaska
 Analysis Summary will compare UA costs to adjusted norm of norm
plus 42.0%
1http://labor.alaska.gov/research/col/col.pdf
20
Asthma Summary & Observations
 Asthma
 Prevalence is above the norm with UA costs of $6,161 per member per year (pmpy)
compared to the adjusted norm of $6,552 pmpy
 67% of the members with asthma are compliant in medication and doctor visits,
decreased from 80% in the InfoLock report for 7/10 to 6/11
 Patients with more than one asthma-related emergency room visit is higher than the
norm
 20.5% of members with Asthma are without inhaled corticosteroids or leukotriene
inhibitors compared to the norm of 29.5% without inhalers
 Recommendation:
 Alere send communications and out-reach to members with emergency room visits for
Asthma

Provide information on free generic program if actively engaged in Alere DM Asthma program
21
COPD Summary & Observations
 COPD (Chronic Obstructive Pulmonary Disease)
 Prevalence is below the norm with UA costs of $8,202 pmpy compared to the
adjusted norm of $13,127 pmpy
 80% of the members with COPD are non-compliant due to lack of doctor visits and
increased ER visits
 43% have three or more co-morbidities
 The percentage of hospitalizations due to COPD increased from 2.8% to 10.0%
 The number of members with COPD with an ER visit was above the norm
 The most common cause of COPD is smoking. The condition is associated with
significant lost work time and high health costs. It is progressive and remains
the fourth leading cause of death in the U.S. and there is no cure. Treatment is
aimed at managing exacerbations of the disease. The most important step in
treatment is to encourage those who are still smoking to stop. This can be
aided by implementing a smoking cessation program that combines behavioral
modification with medication.
22
CAD Summary & Observations
 CAD (Coronary Artery Disease)
 Prevalence is below the norm with UA costs of $9,073 pmpy compared to the
adjusted norm of $13,801 pmpy
 High Risk members make up 34% of the group
 High Cost Claimants make up 26% of the group
 40% have 3 or more co-morbidities
 Patients with obesity are above the norm
 There was significant non-compliance with only 35% of members being compliant
 CAD can be minimized or ameliorated by implementing healthy lifestyle habits
that include regular exercise, a healthy diet, and successful work-life balance.
Medications also play a significant role, so compliance with a medication
regimen is important
23
Depression Summary & Observations
 Depression
 Prevalence is significantly above the norm and UA costs are $5,957 pmpy compared
to the adjusted norm of $7,932 pmpy
 Employees make up 57% of the depressed population
 Back and Neck pain are the top two co-morbidities
 There is a high compliance rate of 87%
 Lower than the norm for hospitalization and depression-related ER visits
 Patients without an office visit in the last 12 months is above the norm
 Several studies indicate that regular sleep and exercise, combined with a strong
social network can reduce the incidence and severity of depression and also
reduce the need for medication.
24
Diabetes Summary & Observations
 Diabetes
 Prevalence is above the norm with UA costs of $8,542 pmpy compared to the
adjusted norm of $9,895 pmpy
 84% of the population is non-compliant
 There is significant non-compliance in this population with 57% in the moderate and high
risk category and 11% are High Cost Claimants
 There were no patients with a diabetes-related ER visit
 Obesity is an issue within the University as the percent of the diabetic population
that is obese is greater than the norm (4.3% to 2.0%)
 Continue to promote Disease Management, IHP and vision exams
 Promote biometric screenings to keep pre-diabetic from becoming diabetic
25
Hyperlipidemia Summary & Observations
 Hyperlipidemia (High Cholesterol)
 Lower prevalence to the norm with UA costs of $5,808 pmpy compared to the
adjusted norm of $7,235
 64% of the population are employees
 22% of the population is high risk but has a significant compliance rate of 80%
26
Hypertension Summary & Observations
 Hypertension
 Prevalence is lower the norm and UA costs of $5,910 pmpy compared to the
adjusted norm of $7,542 pmpy
 23% of the population is high risk but with a high compliance rate of 72%
 Hypertension related ER visits are in line with the norm
27
Cancer & Screenings Summary & Observations
 Malignant Neoplasms & Cancer Screenings
 Cancer screenings (e.g. colonoscopy) are better than the norm
 56% of the cancers as a percentage of total paid for cancer are early-identifiable
cancers such as breast and colon
 Recommendation:
 Continue communication to all members that there is no cost for preventive
care and screenings
28
Malignant Neoplasms/ Cancer Screenings
Top 5 Malignant Neoplasms Diagnoses by Paid Amount
Jul 11 - Jun 12
Cancer Screenings
60%
50%
33%
24%
Breast Cancer
9%
10%
37%
34%
30%
20%
Misc Cancers
9%
50%
44% 45%
40%
Colorectal Cancer
15%
54%
Secondary Malignancy
10%
0%
Prostate Cancer
Women >49 y/o with
mammogram in last 12
months
All Others
Women>20 y/o with
Patients >49 y/o with
pap smear in the last
any colorectal cancer
two years
screening in the analysis
period
Actual
Norm
Early-Identifiable Cancers as a % of Total
Paid
15%
44%
56%
5%
24%
9%
3%
Non-Early Identifiable
Colorectal Cancer
Prostate Cancer
Breast Cancer
Female Genital Organ Cancer
Skin Cancer
Norm from Lockton InfoLock Book of Business.
29
Back & Neck Pain Summary & Observations
 Back & Neck Pain
 57% of the members with back pain were employees
 18% of the members with back pain are categorized as high risk
 Approximately 53% of back pain members had associated neck pain
 Significantly higher utilization of chiropractic and physical therapy care compared to
the norm
 Chiropractic visits/1,000 are 633 compared to the norm of 383
 Physical Therapy visits/1,000 are 790 compared to the norm of 341
 MRI Scans and CT Scans are below the norm on visits/1,000
 Paid per visit for CT Scans are at the adjusted norm
 Paid per visit for MRI Scans are significantly above the norm
30
Musculoskeletal
Back Pain, Neck Pain, and Intervertebral Disc Disorders Utilization
Primary Procedure Group
Visits
Physical Therapy
Neurosurgery
MRI Scan
Orthopedic Surgery, exclude endoscopic
Chiropractic
Neurology
Other Anesthesia
Office Visit - Established Patient
Durable Medical Equipment
Rehab
X-ray
Other Procedures
All Others
Total
6,274
19
162
5
4,411
76
66
914
45
580
259
341
493
13,645
$888,929
$403,229
$264,689
$219,657
$176,070
$140,148
$117,780
$109,436
$109,374
$69,186
$49,157
$42,375
$184,756
2,774,786
Jul 11 - Jun 12
Category
Chiropractic
Physical Therapy
CT Scan
MRI Scan
Avg Paid
Per Visit
Paid
Visits/1000
Paid/Visit
633.0
790.1
2.0
15.5
$38
$95
$793
$1,526
Norm from Lockton InfoLock Book of Business.
$142
$21,223
$1,634
$43,931
$40
$1,844
$1,785
$120
$2,431
$119
$190
$124
$375
$203
Norm
Visits/1000 Paid/Visit
383.3
340.9
4.7
29.1
$17
$34
$566
$752
31
Osteoarthritis Summary & Observations
 Osteoarthritis
 Prevalence is above the norm and UA costs of $9,253 pmpy compared to the
adjusted norm of $12,573 pmpy
 60% of the members with osteoarthritis were employees
 33% of the members with osteoarthritis are categorized as high risk
 21% of the members with osteoarthritis
 73% of the members are compliant
32
Pregnancy & Neonates Summary & Observations
 Pregnancy
 Per capita pregnancy inpatient costs increased 6.1% from $10,939 to $11,612
 Pregnant women delivering with fewer than 6 prenatal visits is significantly worse
than the norm
 83.7% of the pregnant women in the UA population had less than 6 prenatal visits
 20.8% of pregnant women had a pregnancy related ER visit which is above the
norm
 Neonates
 Per capita inpatient neonate costs decreased 5% from $4,329 to $4,158
33
Recommendations
 Medical
 Emergency Room - Specific communication on using alternative care setting for
non-emergent care
 Depression – communication campaign on how to reduce depression and use of
EAP services
 Neonates – provide communication on importance of prenatal vitamins and visits
 Communicate to employees no cost preventive care and screenings
 Explore patient advocacy and transparency vendor to assist members in choosing
the lowest cost service provider/facility
 Pharmacy
 Covering generic only PPIs – was not supported by JHCC for FY 2012
 Continue generic usage communication to members and enrollment in disease
management programs
34
Current Member Risk Analysis
•
•
Members included in this section were active plan participants
as of the last month of the reporting cycle and enrolled for
more than three months. Retirees and COBRA members are
excluded from this section.
Each individual member is assigned a relative risk score
indicating disease burden and a care gap score quantifying
appropriate medical care. Depending upon the prevalence of
disease and the extent of gaps in medical care, the population
is stratified into low, moderate, and high risk for disease
burden, and compliant or non-compliant for disease
management.
Population Risk
 High Risk members made up 9.3% (878) of the population and accounted for
25.1% of the costs
 High Risk - Non-Compliant members on average cost $838* more per year than
Compliant members
 Moderate Risk members made up 12.5% (1176) of the population and accounted
for 15.7% of the costs
 Moderate Risk - Non-Compliant members on average cost $439* more per year than
Compliant members
 Low Risk members made up 75.4% of the population and accounted for 19.4% of
the costs
 Top 5 Chronic conditions are back pain, neck pain, hypertension, depression, and
hyperliperdemia
*Norm from the Lockton InfoLock Book of Business.
36
Claims Based Population Stratification
High Cost
Non-Compliant
367 members
$10,092 PMPY
PRIORITY
269 members
$62,017 PMPY
Goal
Intervention
Manage high costs
Help members
navigate system
Case Management
Close gaps in care
Steerage
Disease Management
and
Health Promotion
High Risk
197 members
$13,027 PMPY
Moderate Risk
170 members
$6,691 PMPY
Population
9,440 members
$5,144 PMPY
High Risk
Compliant
1,687 members
$8,648 PMPY
681 members
$12,189 PMPY
Moderate Risk
1,006 members
$6,252 PMPY
Low Risk
7,117 members
$1,356 PMPY
DxCG Risk Model 18
Manage risk factors
Reinforce and
monitor compliance
rates
Manage risk factors
Health Promotion
Health Promotion
37
Utilization Metrics by Claims Based Population Risk
Current Year Metrics
Number of members
Low Risk
Moderate Risk
High Risk
7,117
1,176
878
% of members with no claims
20.3%
0.6%
0.0%
% of members with no medical claims
23.4%
0.6%
0.1%
% of members with no Rx claims
49.4%
17.7%
13.3%
82
257
493
Office Visits/1000
3,548
11,894
14,955
Prescriptions/1000
4,251
14,097
19,997
Adult Preventive Exam
27.7%
38.9%
35.7%
Well Child Exam
44.3%
64.8%
58.8%
Mammogram
41.8%
47.7%
57.1%
Pap Smear
50.1%
58.8%
59.0%
Colorectal Screening
27.8%
46.6%
45.4%
Utilization Metrics
ER Visits/1000
Preventive Care
38
Appendix
Demographics – Total Members
Jul 10 Jun 11
Average Number of Members
Total Number of Members
Member Months
Employee Months
Age Gender Factor
Employee Age Gender Factor
Spouse Age Gender Factor
Dependent Age Gender Factor
Member to Employee Ratio
Average Age
% Female
% Female in child bearing years
9,723
10,594
116,678
51,902
1.14
1.36
1.40
0.56
2.27
36.7
52.6%
38.3%
Norm from Lockton InfoLock Book of Business.
Jul 11 Jun 12
9,341
10,975
112,099
56,242
1.13
1.37
1.42
0.56
2.32
36.4
52.4%
41.1%
Norm
1.01
1.17
1.34
0.61
2.23
33.4
50%
43%
40
Demographics - Total Members
Employees
Average Age
% Female
Average RRS
Average RCGI
47
56%
1.27
1.54
Employee
Norm
44
40%
1.16
1.17
Spouses
48
49%
1.31
1.74
Spouse
Norm
46
72%
1.55
1.36
Dependent
Norm
Dependents
14
50%
0.50
0.61
13
49%
0.51
0.59
Overall
Overall Population
Population
Norm
36
52%
1.03
1.29
33
50%
1.00
1.00
 Routine Care Gap Index- RCGI
 Relative Risk Score- RRS
Norm from Lockton InfoLock Book of Business.
41
Demographics – Current Year Total Members
Age
Category
0-1
0-1
2-19
2-19
20-29
20-29
30-39
30-39
40-49
40-49
50-59
50-59
60-64
60-64
65+
65+
Total
Gender
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
# of
Members
# of
Employees
# of
Spouses
# of
Deps
% of
Norm % of
Members Members
111
116
1,202
1,233
835
702
932
733
1,000
832
1,135
953
356
393
185
257
1
2
272
188
602
469
645
524
773
546
239
213
131
119
110
71
329
264
355
307
362
407
117
180
54
138
111
116
1,201
1,231
453
443
1
1
-
1%
1%
11%
11%
8%
6%
8%
7%
9%
8%
10%
9%
3%
4%
2%
2%
1%
1%
13%
14%
8%
8%
8%
8%
8%
8%
7%
8%
2%
2%
1%
2%
10,975
4,724
2,694
3,557
100%
100%
Norm from Lockton InfoLock Book of Business.
42
Financial Summary
Jul 10 - Jun 11
Jul 11 - Jun 12
% Change
Norm
Allowed Amount
$60,584,676
$56,218,526
-7.2%
Plan Paid
$55,539,478
$45,259,136
-18.5%
Plan Paid PMPM
$476.01
$351.55
-26.1%
$255.98
Plan Paid PEPM
$1,070.08
$804.72
-24.8%
$569.85
Allowed Amount
$8,568,068
$8,691,083
1.4%
Plan Paid
$7,403,967
$7,519,038
1.6%
Plan Paid PMPM
$63.46
$58.40
-8.0%
$55.89
Plan Paid PEPM
$142.65
$133.69
-6.3%
$124.42
$69,152,744
$64,909,609
-6.1%
$6,162,889
$12,081,381
96.0%
$62,943,445
$52,778,174
-16.1%
Plan Paid PMPM
$539.46
$409.95
-24.0%
$311.87
Plan Paid PEPM
$1,212.74
$938.41
-22.6%
$694.27
$197.26
$141.01
-28.5%
$88.96
$8.67
$9.33
7.6%
$7.79
% Pharmacy of Total Paid
Medical Costs
2010-2011
11.8%
2011-2012
14.2%
Rx Costs
Norm
0.0%
Employee Paid
Plan Paid
10.0%
20.0%
% Employee Paid
Total Costs
Allowed Amount
17.9%
2010-2011
8.9%
2011-2012
18.6%
High Cost Claimants (>50,000 in claims)
Medical PMPM
Rx PMPM
Norm
0.0%
Norm from Lockton InfoLock Book of Business.
16.5%
10.0%
20.0%
43
Utilization Summary
Apr 10 Mar 11
Place of Service Allowed PMPM
Apr 11 Mar 12
% Change
Norm
Inpatient Hospital
$134.04
$103.17
-23.0%
$90.55
Outpatient Hospital
$145.93
$135.89
-6.9%
$94.99
Office
$169.16
$153.60
-9.2%
$71.98
$38.58
$35.71
-7.4%
$28.17
$0.21
$0.13
-37.4%
$13.64
Inpatient Hospital
$131.16
$92.67
-29.3%
$83.97
Outpatient Hospital
$136.80
$116.60
-14.8%
$80.82
Office
$143.86
$113.23
-21.3%
$55.34
$35.30
$29.62
-16.1%
$22.00
$0.16
$0.09
-47.3%
$11.15
Emergency Room
Other
Place of Service Paid PMPM
Emergency Room
Other
Current Incurred Year Allowed by Place of Service
8%
0%
Current Incurred Year Employee Paid by Place of Service
35%
24%
36%
30%
Inpatient Hospital
25%
Outpatient Hospital
20%
Office
15%
Emergency Room
Other
32%
32%
26%
17%
14%
10%
10%
5%
0%
Inpatient
Hospital
Outpatient
Hospital
Office
Emergency
Room
Other
44
Emergency Room Demographics
Current Year ER Visits by Age and Gender
400
342
339
350
278
300
250
212
200
150
101
100
100
50
32
34
F
M
159
132
74
63
F
M
97
90
0
0-2
F
M
3-12
13-18
F
M
19-26
F
M
27-39
F
M
40-60
F
M
60+
45
Prescription Drug Changes
Top 20 Drugs with Script Count Decreases
LIPITOR
1344
FEXOFENADINE HCL
508
NEXIUM
421
LEXAPRO
419
Top 20 Drugs with Script Count Increases
-60%
ATORVASTATIN CALCIUM
-92%
ESCITALOPRAM OXALATE
-38%
LEVOFLOXACIN
205
4100%
-39%
VIAGRA
175
875%
863
NA
287
NA
LEVAQUIN
278
-99%
METHYLPHENIDATE ER
150
1154%
AZITHROMYCIN
277
-22%
CIALIS
128
2560%
HYDROCODONE-…
265
-11%
LATANOPROST
108
300%
HYDROCHLOROTHIAZIDE
239
-18%
LOSARTAN POTASSIUM
102
20%
SIMVASTATIN
232
-18%
ZOLPIDEM TARTRATE ER
91
47%
CRESTOR
213
-25%
PORTIA
88
4400%
LEVOTHYROXINE SODIUM
186
-15%
CITALOPRAM HBR
86
21%
EFFEXOR XR
186
-93%
AVIANE
79
46%
AMBIEN CR
176
-97%
FLUORIDE
74
NA
AVAPRO
140
-63%
DEXTROAMPHETAMINE- … 69
37%
CONCERTA
134
-89%
NOVOLOG
65
86%
LISINOPRIL-…
130
-17%
PREDNISONE
62
12%
SULFAMETHOXAZOLE-…
127
-24%
METHYLPHENIDATE HCL
61
469%
ADVAIR DISKUS
127
-22%
FLUVIRIN 2011-2012
56
NA
NASACORT AQ
127
-97%
JUNEL
55
344%
AVALIDE
125
-99%
AMPHETAMINE SALT COMBO
54
31%
-1500
Brand
-1000
Generic
-500
0
0
Brand
200
400
600
800 1000
Generic
46
Prescription Drugs - Top 20 Therapeutic Classes
Current Year Top 20 Therapeutic Classes by Plan Paid Amount
HMG-CoA Reductase Inhibitors
$468,613
Disease-modifying Antirheumatic Agents
$388,986
Biologic Response Modifiers
$377,059
Proton-pump Inhibitors
$326,666
Insulins
$256,683
Antineoplastic Agents
$248,186
Atypical Antipsychotics
$224,020
Selective beta-2-Adrenergic Agonists
$204,167
Selective Serotonin- and Norepinephrine-…
$203,045
Leukotriene Modifiers
$194,218
Adrenals
$193,974
Skin and Mucous Membrane Agents, Misc
$188,014
Angiotensin II Receptor Antagonists
$181,301
Selective Serotonin-reuptake Inhibitors
$166,085
Opiate Agonists
$149,111
Anticonvulsants, Miscellaneous
$145,021
Anti-inflammatory Agents
$134,425
Contraceptives
$130,387
Amphetamines
$121,624
Nucleosides and Nucleotides
$118,602
$0
Brand
$100,000
$200,000
$300,000
$400,000
$500,000
Generic
47
Prescription Drugs - Top 20 Therapeutic Classes
Jul 10 - Jun 11
Therapeutic Class
HMG-CoA Reductase Inhibitors
Disease-modifying Antirheumatic Agents
Biologic Response Modifiers
Proton-pump Inhibitors
Insulins
Antineoplastic Agents
Atypical Antipsychotics
Selective beta-2-Adrenergic Agonists
Selective Serotonin- and Norepinephrine-reuptake Inhibitors
Leukotriene Modifiers
Adrenals
Skin and Mucous Membrane Agents, Misc
Angiotensin II Receptor Antagonists
Selective Serotonin-reuptake Inhibitors
Opiate Agonists
Anticonvulsants, Miscellaneous
Anti-inflammatory Agents
Contraceptives
Amphetamines
Nucleosides and Nucleotides
Top 20 Therapeutic Classes
All Others
Total
Paid
$529,125
$397,596
$401,481
$426,119
$234,829
$122,321
$198,498
$211,190
$224,390
$153,735
$163,146
$145,546
$187,590
$165,589
$140,868
$150,968
$97,084
$139,410
$65,657
$120,795
$4,275,935
$3,128,031
$7,403,967
Paid
PMPM
$4.53
$3.41
$3.44
$3.65
$2.01
$1.05
$1.70
$1.81
$1.92
$1.32
$1.40
$1.25
$1.61
$1.42
$1.21
$1.29
$0.83
$1.19
$0.56
$1.04
$36.65
$26.81
$63.46
Scripts
5,048
211
134
3,273
800
503
569
2,134
1,506
1,012
1,646
588
2,195
3,437
5,216
1,516
1,165
4,288
561
973
36,775
54,840
91,615
Jul 11 - Jun 12
Cost
per
Script
$105
$1,884
$2,996
$130
$294
$243
$349
$99
$149
$152
$99
$248
$85
$48
$27
$100
$83
$33
$117
$124
$116
$57
$81
Paid
$468,613
$388,986
$377,059
$326,666
$256,683
$248,186
$224,020
$204,167
$203,045
$194,218
$193,974
$188,014
$181,301
$166,085
$149,111
$145,021
$134,425
$130,387
$121,624
$118,602
$4,420,189
$3,098,850
$7,519,038
Paid
PMPM
$3.64
$3.02
$2.93
$2.54
$1.99
$1.93
$1.74
$1.59
$1.58
$1.51
$1.51
$1.46
$1.41
$1.29
$1.16
$1.13
$1.04
$1.01
$0.94
$0.92
$34.33
$24.07
$58.40
Scripts
4,087
200
107
2,576
818
546
577
1,911
1,257
980
1,597
603
1,883
3,400
4,730
1,405
1,142
4,034
765
932
33,550
48,567
82,117
Cost
per
Script
$115
$1,945
$3,524
$127
$314
$455
$388
$107
$162
$198
$121
$312
$96
$49
$32
$103
$118
$32
$159
$127
$132
$64
$92
% Change
in Paid
PMPM
-19.7%
-11.3%
-14.9%
-30.5%
-0.9%
83.9%
2.3%
-12.4%
-18.0%
14.5%
7.8%
17.1%
-12.4%
-9.1%
-4.1%
-12.9%
25.5%
-15.2%
67.9%
-11.0%
-6.3%
-10.2%
-8.0%
48
Top 10 Medical Pharmacy
Rx Spend - Top 10 Medical Pharmacy Drugs
HUMIRA
$249,762
ENBREL
$101,716
NOVOLOG
$46,673
AVONEX
$46,446
HUMALOG
$38,559
TEMODAR
$37,120
AVONEX …
$32,978
PULMOZYME
$25,812
REMICADE
$21,683
XELODA
$12,850
$0
$100,000
$200,000
$300,000
49
Prescription Drugs - High Cost Scripts (>$1,000)
Number of High Cost Scripts
800
700
692
PMPM Paid for High Cost Scripts
$14
640
600
$12
$11.39
$11.77
2010-2011
2011-2012
$10
500
$8
400
$6
300
200
$4
100
$2
0
$0
2010-2011
2011-2012
Year 1 Rx PMPM Paid
Year 2 Rx PMPM Paid
$11.39
18%
$46.63
80%
$52.07
82%
High Cost Scripts PMPM
$11.77
20%
All Other PMPM
High Cost Scripts PMPM
All Other PMPM
50
Anti-Hyperlipidemics Generic Analysis
HMG-CoA
Reductase
Inhibitors
Jul 10 - Jun 11
Plan Paid PMPM
Statins
Lipitor
Crestor
Lescol XL
Simvastatin
Lovastatin
Pravastatin Sodium
Jul 11 - Jun 12 % Change
$4.53
$3.64
Jul 10 - Jun 11
Script
Rx
Count PMPM
2,257
855
1,269
81
437
$2.89
$1.05
$0.00
$0.35
$0.01
$0.09
-19.7%
Jul 11 - Jun 12
Script
Rx
% Change
Count PMPM
913
642
1,037
75
410
$1.26
$0.91
$0.00
$0.36
$0.01
$0.09
-56.3%
-13.5%
0.0%
3.2%
60.4%
1.3%
Potential Savings
If 50% of scripts for:
Lipitor,
Crestor,
and Lescol XL
moved to
Simvastatin last year
costs would have
been reduced by
approximately:
$95,313
51
Peptic Ulcer Generic Analysis
75% of members with a Proton-Pump inhibitor script had no peptic ulcer claims in the current
year compared to a norm of 76%.
Proton-pump
Inhibitors
Jul 10 - Jun 11
Plan Paid PMPM
Peptic Ulcer
Prevacid
Nexium
Aciphex
Protonix
Kapidex
Prilosec
Axid
Zantac
Pantoprazole Sodium
Lansoprazole
Omeprazole
Ranitidine HCL
Cimetidine
Famotidine
Jul 11 - Jun 12 % Change
$3.65
$2.54
Jul 10 - Jun 11
Script
Rx
Count
PMPM
21
1101
53
2
0
2
0
0
501
450
1023
224
28
59
$0.05
$2.20
$0.12
$0.00
$0.00
$0.00
$0.00
$0.00
$0.36
$0.39
$0.37
$0.02
$0.00
$0.03
-30.5%
Jul 11 - Jun 12
Script
Rx
% Change
Count PMPM
11
680
30
0
0
0
0
0
378
391
987
193
9
60
$0.02
$1.39
$0.08
$0.00
$0.00
$0.00
$0.00
$0.00
$0.20
$0.32
$0.40
$0.01
$0.00
$0.04
-55.2%
-36.7%
-35.8%
0.0%
0.0%
-100.0%
0.0%
0.0%
-44.0%
-18.3%
9.1%
-19.9%
-31.9%
52.5%
Potential Savings
If 50% of scripts for:
Prevacid, Nexium,
Aciphex, Protonix,
Kapidex, Prilosec,
Axid, and Zantac
moved to
Omeprazole last year
costs would have
been reduced
by approximately:
$80,221
52
Asthma
Members by Relationship
45%
Member by Risk Category
21%
34%
56%
Members by Compliance
20%
20%
67%
Number of Comorbidities
42%
Asthma Prevalence
Employees
Low Risk
3%
33%
20%
22%
Spouses
Moderate Risk
Compliant
Top 5 Co morbidities by Number of Members
High Risk
HCC
Non-Compliant
Asthma Only
2 comorbidities
16%
Dependents
1 comorbidity
3+ comorbidities
Asthma Members Annual Cost
Excludes High Cost Claimants
300
2.5%
250
2.0%
200
1.5%
150
1.0%
100
0.5%
50
303
0.0%
0
Prevalence
114
Neck Pain
59
Depression
32
Hypertension
30
Hyperlipidemia
26
Norm
0
20
40
60
80
100 120
Norm from the Lockton InfoLock Book of Business.
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
$8,498
$7,904
$5,803
$4,614
2.8%
3.0%
Back Pain
$6,161
350
3.2%
$7,512
3.5%
2010-2011 2011-2012
Norm
PMPY
PMPY
Plan Paid
Employee Paid
53
Asthma Quality and Risk Measures
Risk Measures
Criteria
#
Description
Actual %
Norm % Variance
Asthma
303
Patients with more than one asthma-related ER visit in the analysis period
4.3%
3.0%
1.3%
Asthma
303
Patients with more than one asthma-related hospitalization in the analysis period
0.3%
0.4%
-0.1%
Asthma
303
Patients with asthma-related ER visit in the analysis period
10.6%
11.8%
-1.3%
Asthma
303
Patients with asthma-related hospitalization in the analysis period
3.0%
2.9%
0.1%
Quality Care Measures
Criteria
Asthma-related ER visit
Asthma-related admission
Asthma
#
Description
Actual %
Norm % Variance
40
Patients without office visit in the analysis period
0.0%
3.2%
-3.2%
9
Patients without office visit in the analysis period
0.0%
1.4%
-1.4%
20.5%
29.5%
-9.0%
303
Patients without inhaled corticosteroids or leukotriene inhibitors in the analysis period
Norm from the Lockton InfoLock Book of Business.
54
COPD
Members by Relationship
43%
Member by Risk Category
30%
Members by Compliance
53%
13%
40%
20%
Number of Comorbidities 3%
3%
Low Risk
17%
80%
27%
Spouses
Moderate Risk
Compliant
27%
Dependents
High Risk
HCC
Non-Compliant
COPD Only
2 comorbidities
43%
Top 5 Co morbidities by Number of Members
COPD Prevalence
Employees
1 comorbidity
3+ comorbidities
COPD Members Annual Cost
Excludes High Cost Claimants
0.6%
30
0.5%
25
0.4%
20
0.3%
0.3%
15
0.2%
10
0.1%
5
30
0.0%
0
Prevalence
Back Pain
12
Diabetes
10
Hypertension
10
Neck Pain
9
Congestive Heart Failure
6
Norm
0
5
10
15
Norm from the Lockton InfoLock Book of Business.
$18,000
$16,000
$14,000
$12,000
$10,000
$8,000
$6,000
$4,000
$2,000
$0
$15,390
$10,265
$11,284
$9,244
35
$8,202
0.6%
$13,983
0.7%
2010-2011 2011-2012
Norm
PMPY
PMPY
Plan Paid
Employee Paid
55
COPD Quality and Risk Measures
Risk Measures
Criteria
COPD
COPD
COPD
COPD
#
30
30
30
30
Description
Patients
Patients
Patients
Patients
Actual %
with COPD-related ER visit in the analysis period
with more than one hospitalization in the analysis period
with more than one COPD-related ER visit in the analysis period
with COPD-related hospitalization in the analysis period
20.0%
20.0%
6.7%
10.0%
Norm % Variance
12.4%
19.5%
3.7%
9.3%
7.6%
0.5%
3.0%
0.7%
Quality Care Measures
Criteria
COPD-related ER visit
COPD-related admission
COPD
#
13
3
30
Description
Actual %
Patients without office visit in the analysis period
Patients without office visit in the analysis period
COPD without Office visit in last 12 months
Norm from the Lockton InfoLock Book of Business.
0.0%
0.0%
10.0%
Norm % Variance
1.1%
0.9%
4.7%
-1.1%
-0.9%
5.3%
56
CAD
Members by Relationship
Member by Risk Category
55%
25%
Members by Compliance
Number of Comorbidities
45%
15%
34%
35%
14%
Employees
Low Risk
26%
65%
21%
CAD Prevalence
Spouses
Moderate Risk
Compliant
25%
Top 5 Co morbidities by Number of Members
High Risk
HCC
Non-Compliant
CAD Only
2 comorbidities
40%
Dependents
1 comorbidity
3+ comorbidities
CAD Members Annual Cost
Excludes High Cost Claimants
1.4%
1.2%
1.1%
80
1.0%
$14,000
39
Back Pain
$12,000
29
20
Diabetes
$4,000
26
$2,000
106
0.0%
0
Prevalence
$11,757
$6,000
40
0.4%
$11,141
$8,000
Hyperlipidemia
0.6%
$11,459
$10,000
37
60
0.8%
0.2%
Hypertension
Neck Pain
$0
17
Norm
0
10
20
$9,719
100
$9,073
1.6%
1.6%
120
$10,222
1.8%
30
40
50
Norm from the Lockton InfoLock Book of Business.
2010-2011 2011-2012
Norm
PMPY
PMPY
Plan Paid
Employee Paid
57
CAD Quality and Risk Measures
Risk Measures
Criteria
CAD
CAD
CAD
CAD
CAD
CAD
CAD
CAD
CAD
CAD
CAD
CAD
#
106
106
106
106
106
106
106
106
106
106
106
106
Description
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Actual %
with cardiac catheterization in the analysis period
with CABG in the analysis period
with cerebrovascular disease (CVD)
with MI-related hospitalization in the analysis period
with peripheral vascular disease (PVD)
with CAD-related ER visit in the analysis period
with depression
with CAD-related hospitalization in the analysis period
with obesity
with more than one hospitalization in the analysis period
with cardiac stenting in the analysis period
with hyperlipidemia
43.4%
5.7%
9.4%
4.7%
3.8%
8.5%
7.5%
25.5%
1.9%
17.0%
21.7%
27.4%
Norm % Variance
40.8%
5.0%
8.9%
5.5%
5.1%
16.1%
5.3%
20.1%
1.3%
16.1%
17.2%
52.6%
2.6%
0.7%
0.5%
-0.8%
-1.3%
-7.6%
2.2%
5.4%
0.6%
0.9%
4.5%
-25.3%
Quality Care Measures
Criteria
CAD and Hypertension
CAD-related ER visit
CAD-related admission
CAD
#
39
12
27
106
Description
Patients
Patients
Patients
Patients
Actual %
without antihypertensive
without office visit in the
without office visit in the
without office visit in the
drugs in the analysis period
analysis period
analysis period
last 12 months
Norm from Lockton InfoLock Book of Business.
5.1%
0.0%
0.0%
12.3%
Norm % Variance
5.0%
0.6%
0.5%
3.8%
0.1%
-0.6%
-0.5%
8.5%
58
Depression
Members by Relationship
57%
Member by Risk Category
25%
47%
Members by Compliance
18%
24%
22%
7%
87%
Number of Comorbidities
34%
13%
27%
Depression Prevalence
Employees
21%
Low Risk
Spouses
Moderate Risk
Compliant
Top 5 Co morbidities by Number of Members
High Risk
HCC
Non-Compliant
Depression Only
2 comorbidities
19%
Dependents
1 comorbidity
3+ comorbidities
Depression Members Annual Cost
Excludes High Cost Claimants
800
Back Pain
349
700
600
Neck Pain
212
500
3.9%
400
Hypertension
79
Headache
78
300
200
100
814
0
Prevalence
Osteoarthritis
67
Norm
0
100
200
300
400
Norm from Lockton InfoLock Book of Business.
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
$8,436
$7,665
$7,007
$5,586
8.6%
$5,957
900
$7,505
10.0%
9.0%
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
2010-2011 2011-2012
Norm
PMPY
PMPY
Plan Paid
Employee Paid
59
Depression Quality and Risk Measures
Risk Measures
Criteria
Depression
Depression
#
814
814
Description
Actual %
Patients with more than one hospitalization in the analysis period
Patients with depression-related ER visit in the analysis period
4.3%
3.3%
Norm % Variance
7.0%
5.1%
-2.7%
-1.7%
Quality Care Measures
Criteria
Depression
Depression-related
admission
#
814
25
Description
Actual %
Patients without office visit in the last 12 months
Patients without mental health office visit within 14 days of discharge
Norm from Lockton InfoLock Book of Business.
Norm % Variance
9.0%
4.3%
4.7%
24.0%
22.2%
1.8%
60
Diabetes
Members by Relationship
58%
Member by Risk Category
Members by Compliance
33%
37%
30%
27%
16%
Number of Comorbidities
5%
11%
84%
32%
21%
Diabetes Prevalence
Employees
Low Risk
Spouses
Moderate Risk
Compliant
20%
Top 5 Co morbidities by Number of Members
High Risk
HCC
Non-Compliant
Diabetes Only
2 comorbidities
28%
Dependents
1 comorbidity
3+ comorbidities
Diabetes Members Annual Cost
Excludes High Cost Claimants
440
Prevalence
Back Pain
163
$14,000
$12,000
Hypertension
119
Neck Pain
82
Hyperlipidemia
81
$6,000
$4,000
$0
Norm
50
$8,572
$8,000
55
0
$10,522
$10,000
$2,000
Osteoarthritis
$11,628
$6,968
4.5%
500
450
400
350
300
250
200
150
100
50
0
$8,542
4.7%
$10,385
5.0%
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
100
150
200
Norm from Lockton InfoLock Book of Business.
2010-2011 2011-2012
Norm
PMPY
PMPY
Plan Paid
Employee Paid
61
Diabetes Quality and Risk Measures
Risk Measures
Criteria
Diabetes-related admission
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes-related ER visit
Diabetes
Diabetes
Diabetes
#
8
440
440
440
440
440
440
440
440
440
20
440
440
440
Description
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Patients
Actual %
without diabetes-related office visit in the analysis period
with dialysis in the analysis period
with diabetes-related hospitalization in the analysis period
with ulcer or open wound
with CAD
with obesity
with hyperlipidemia
with hypertension or taking antihypertensive drugs
with peripheral vascular disease (PVD)
with retinopathy
without office visit in the analysis period
with diabetes-related ER visit in the analysis period
with renal failure
with more than one hospitalization in the analysis period
0.0%
0.9%
1.8%
9.5%
5.9%
4.3%
18.4%
64.8%
0.9%
2.0%
0.0%
3.9%
3.9%
5.5%
Norm % Variance
7.5%
2.1%
2.3%
8.1%
10.5%
2.0%
35.1%
73.8%
1.8%
2.8%
1.3%
4.4%
4.0%
7.5%
-7.5%
-1.2%
-0.5%
1.4%
-4.6%
2.3%
-16.7%
-9.0%
-0.8%
-0.7%
-1.3%
-0.6%
-0.2%
-2.0%
Quality Care Measures
Criteria
#
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
440
440
392
392
440
440
440
392
Description
Actual %
Patients without micro or macroalbumin screening test in the last 12 months
Patients without semiannual HbA1c test
Diabetes without Office Visit in Analysis Period
Diabetes without Lab Test in Analysis Period
Patients without HbA1c test in the last 12 months
Patients without claims for home glucose testing supplies in the last 12 months
Patients without retinal eye exam in the last 12 months
Diabetes without Lab Test in Last 12 Months
Norm from Lockton InfoLock Book of Business.
45.5%
87.7%
0.3%
1.3%
28.6%
54.5%
83.0%
16.3%
Norm % Variance
40.8%
87.8%
0.8%
1.8%
25.3%
48.9%
75.3%
9.2%
4.6%
-0.1%
-0.5%
-0.6%
3.3%
5.6%
7.7%
7.1%
62
Hyperlipidemia
Members by Relationship
64%
Member by Risk Category
35%
46%
Members by Compliance
25%
22%
80%
Number of Comorbidities
26%
22%
Employees
Low Risk
7%
20%
29%
Hyperlipidemia Prevalence
1%
Spouses
Moderate Risk
Compliant
Top 5 Co morbidities by Number of Members
High Risk
HCC
Non-Compliant
Hyperlipidemia Only
2 comorbidities
23%
Dependents
1 comorbidity
3+ comorbidities
Hyperlipidemia Members Annual Cost
Excludes High Cost Claimants
Back Pain
277
600
500
Hypertension
190
400
300
Neck Pain
155
200
100
697
Osteoarthritis
84
Diabetes
81
0
Prevalence
Norm
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
$7,952
$6,366
2010-2011 2011-2012
PMPY
PMPY
Plan Paid
0
100
$7,514
200
$5,095
7.4%
700
$5,808
8.6%
800
$6,927
10.0%
9.0%
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
Norm
Employee Paid
300
Norm from Lockton InfoLock Book of Business.
63
Hypertension
Members by Relationship
63%
Member by Risk Category
36%
46%
Members by Compliance
23%
23%
72%
Number of Comorbidities
32%
18%
Employees
Low Risk
9%
28%
26%
Hypertension Prevalence
1%
Compliant
Spouses
Moderate Risk
Top 5 Co morbidities by Number of Members
High Risk
HCC
Non-Compliant
Hypertension Only
2 comorbidities
24%
Dependents
1 comorbidity
3+ comorbidities
Hypertension Members Annual Cost
Excludes High Cost Claimants
8.7%
Back Pain
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
299
700
8.0%
600
Hyperlipidemia
190
500
6.0%
400
4.0%
2.0%
800
Neck Pain
152
300
200
825
100
824
0.0%
0
Prevalence
Norm
Osteoarthritis
121
Diabetes
119
0
100
200
$8,111
$7,602
$6,637
2010-2011 2011-2012
PMPY
PMPY
300
400
Norm from Lockton InfoLock Book of Business.
Plan Paid
$5,311
9.9%
$5,910
10.0%
900
$7,111
12.0%
Norm
Employee Paid
64
Hypertension Quality and Risk Measures
Risk Measures
Criteria
Hypertension
Hypertension
Hypertension
#
825
825
825
Description
Actual %
Hypertension Related ER Visit in Analysis Period
Hypertension Related Hospitalization
Patients with more than one hospitalization in the analysis period
33.5%
0.1%
3.3%
Norm % Variance
37.6%
0.6%
5.8%
-4.2%
-0.5%
-2.5%
Quality Care Measures
Criteria
Hypertension-related ER
visit
Hypertension-related
admission
Hypertension
Hypertension
#
Description
Actual %
Norm % Variance
21
Patients without office visit in the analysis period
0.0%
2.2%
-2.2%
1
825
825
Patients without office visit in the analysis period
Patients without office visit in the last 12 months
Patients without office visit in the analysis period
0.0%
8.8%
0.2%
1.0%
4.8%
0.6%
-1.0%
4.0%
-0.3%
Norm from Lockton InfoLock Book of Business.
65
Musculoskeletal
Back Pain
Members by Relationship
57%
Member by Risk Category
31%
54%
Members by Compliance
22%
12%
18%
87%
Number of Comorbidities
24%
38%
Back Pain Prevalence
22%
6%
Employees
Low Risk
Spouses
Moderate Risk
13%
Compliant
16%
Back Pain Only
2 comorbidities
Top 5 Co morbidities by Number of Members
Dependents
High Risk
HCC
Non-Compliant
1 comorbidity
3+ comorbidities
Back Pain Members Annual Cost
Excludes High Cost Claimants
2500
20.0%
2000
15.0%
1500
11.9%
10.0%
1000
5.0%
500
2405
0.0%
Neck Pain
1263
Depression
349
Hypertension
299
Hyperlipidemia
277
Osteoarthritis
249
0
Prevalence
Norm
0
500
1000
1500
Norm from the Lockton InfoLock Book of Business.
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
$7,885
$7,085
$6,457
$5,141
25.5%
25.0%
$5,443
3000
$6,975
30.0%
2010-2011 2011-2012
Norm
PMPY
PMPY
Plan Paid
Employee Paid
66
Musculoskeletal
Back Pain Quality and Risk Measures
Risk Measures
Criteria
Back Pain
Back Pain
Back Pain
#
2,405
2,405
2,405
Description
Actual %
Back Pain Related Hospitalization in Analysis Period
Back Pain Related ER Visit in Analysis Period
Back Pain with >1 Hospitalizations in Analysis Period
0.6%
31.9%
1.9%
Norm % Variance
1.1%
39.8%
4.3%
-0.5%
-8.0%
-2.5%
Quality Care Measures
Criteria
Back Pain-related ER visit
#
122
Description
Actual %
Patients without office visit in the analysis period
Norm from the Lockton InfoLock Book of Business.
3.3%
Norm % Variance
4.7%
-1.4%
67
Musculoskeletal
Neck Pain
Members by Relationship
58%
Member by Risk Category
30%
50%
Members by Compliance
23%
12%
20%
87%
Number of Comorbidities 1%
13%
46%
Neck Pain Prevalence
7%
29%
Employees
Low Risk
Spouses
Moderate Risk
Compliant
Top 5 Co morbidities by Number of Members
High Risk
HCC
Non-Compliant
Neck Pain Only
2 comorbidities
23%
Dependents
1 comorbidity
3+ comorbidities
Neck Pain Members Annual Cost
Excludes High Cost Claimants
1200
12.0%
1000
10.0%
Back Pain
1263
Depression
212
800
8.0%
5.3%
6.0%
600
4.0%
400
2.0%
200
1303
0.0%
0
Prevalence
Hyperlipidemia
155
Hypertension
152
Osteoarthritis
135
Norm
0
500
1000
1500
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
$8,541
$6,613
2010-2011 2011-2012
PMPY
PMPY
Plan Paid
Norm from the Lockton InfoLock Book of Business.
$7,766
$5,261
13.8%
$6,033
14.0%
1400
$7,574
16.0%
Norm
Employee Paid
68
Musculoskeletal
Osteoarthritis
Members by Relationship
60%
Member by Risk Category
25%
22%
Members by Compliance
18%
22%
Low Risk
21%
27%
28%
Employees
Spouses
Moderate Risk
Compliant
Top 5 Co morbidities by Number of Members
High Risk
HCC
Non-Compliant
Osteoarthritis Only
2 comorbidities
32%
Dependents
1 comorbidity
3+ comorbidities
Osteoarthritis Members Annual Cost
Excludes High Cost Claimants
445
Back Pain
249
$14,000
$12,088
$12,000
Neck Pain
$11,634
$10,741
$10,000
135
$8,000
Hypertension
121
Hyperlipidemia
$6,000
$4,000
84
$2,000
Depression
$0
67
Norm
0
100
$8,854
3.1%
500
450
400
350
300
250
200
150
100
50
0
$9,253
4.7%
Prevalence
33%
73%
Osteoarthritis Prevalence
5.0%
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
1%
$10,880
Number of Comorbidities
39%
200
300
Norm from Lockton InfoLock Book of Business.
2010-2011 2011-2012
Norm
PMPY
PMPY
Plan Paid
Employee Paid
69
Musculoskeletal
Osteoarthritis Quality and Risk Measures
Risk Measures
Criteria
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
#
445
445
445
445
Description
Actual %
Patients with continuous use of opiates across the last 12 months
Osteoarthritis Related ER Visit in Analysis Period
Osteoarthritis with >1 Hospitalizations in Analysis Period
Osteoarthritis Related Hospitalization in Analysis Period
8.1%
37.5%
5.8%
17.5%
Norm % Variance
12.4%
43.6%
9.8%
11.9%
-4.3%
-6.1%
-3.9%
5.6%
Quality Care Measures
Criteria
Osteoarthritis-related ER
visit
Osteoarthritis-related
admission
#
Description
Actual %
0
Patients without office visit in the analysis period
0.0%
1.0%
-1.0%
78
Patients without office visit in the analysis period
0.0%
0.1%
-0.1%
Norm from Lockton InfoLock Book of Business.
Norm % Variance
70
Pregnancy
Pregnancy Related Claimants of Total
Childbearing Aged Females
Pregnancy Related Cost
120
$1,400,000
2,151
Child Bearing Age - No Pregnancy Claims
80
$800,000
60
$600,000
31
$400,000
$68,431
31
20
$80,553
0
$2010-2011 2011-2012 2010-2011 2011-2012
Pregnancy Claimants - Spouse
52
40
$200,000
Pregnancy Claimants - Employee
99
100
$1,083,014
$1,000,000
94
108
$1,254,113
$1,200,000
137
Pregnancy Related Claimants
Pregnancy Claimants - Dependent
ER Cost
2010-2011 2011-2012 2010-2011 2011-2012
ER Claimants
Inpatient Cost
Risk Measures
Inpatient Claimants
Pregnancy as a % of Total Paid
Description
# Actual %
Pregnant women delivered with fewer than six prenatal visits
307
83.7%
Norm %Variance
28.8%
54.9%
Quality Care Measures
Description
# Actual %
Women with hospitalization for pregnancy-related diagnosis
other than delivery
Women with pregnancy-related ER visit in the analysis period
Actual
4.6%
Norm
4.7%
Norm %Variance
307
5.2%
5.2%
0.0%
307
20.8%
18.8%
2.0%
Norm from Lockton InfoLock Book of Business.
0%
50%
All Others
100%
71
Neonates
Neonates as a % of Total Paid
Neonates Related Cost
Neonates Related Claimants
120
Actual
1.8%
Norm
0.0%
4.1%
50.0%
All Others
Neonates
100.0%
$500,000
$450,000
$400,000
$350,000
$300,000
$250,000
$200,000
$150,000
$100,000
$50,000
$-
103
$450,985
93
100
$386,756
80
60
40
20
$2,216
$2,232
5
0
2010-2011 2011-2012 2010-2011 2011-2012
ER Cost
6
Inpatient Cost
2010-2011 2011-2012 2010-2011 2011-2012
ER Claimants
Inpatient Claimants
72
Low Risk Members Demographics
Members by Gender
Members by Relationship
38%
39%
50%
50%
Female
Employee
Male
Spouse
Dependent
23%
Members by Age Group
Length of Enrollment (For Current Members)
66%
70%
30%
28%
25%
60%
50%
20%
40%
15%
17%
17%
15%
30%
20%
10%
15%
9%
13%
10%
12%
5%
0%
Less than 12
months
12 - 23 months 24 - 35 months
36 months
5%
2%
2%
0%
0-1
2-19
20-29 30-39 40-49 50-59 60-64
65+
73
Low Risk Members Chronic Conditions
Number of Chronic Conditions per Member
3%
Top Ten Chronic Conditions by Prevalence
Back Pain
10%
18.3%
Neck Pain
9.2%
Depression
5.4%
Hypertension
5.3%
18%
Hyperlipidemia
4.5%
69%
Members with 0 conditions
Members with 1 condition
Asthma
2.4%
Diabetes
2.0%
Headache
1.8%
Osteoarthritis
1.5%
Congenital Anomalies
0.9%
Members with 2 conditions
Members with 3+ conditions
74
Moderate Risk Members Demographics
Members by Gender
Members by Relationship
14%
42%
Employee
Female
Spouse
Male
58%
56%
30%
Members by Age Group
Length of Enrollment (For Current Members)
35%
90%
80%
80%
70%
31%
30%
25%
60%
20%
20%
50%
40%
13%
15%
30%
20%
10%
Dependent
3%
7%
9%
5%
0%
Less than 12
months
12 - 23 months
24 - 35 months
9%
10%
36 months
7%
11%
6%
2%
0%
0-1
2-19 20-29 30-39 40-49 50-59 60-64 65+
75
Moderate Risk Members Chronic Conditions
Number of Chronic Conditions per Member
Top Ten Chronic Conditions by Prevalence
Back Pain
22%
25%
25%
Neck Pain
25.9%
Depression
16.6%
Hypertension
15.8%
Hyperlipidemia
15.1%
Diabetes
28%
44.6%
Osteoarthritis
Headache
11.1%
8.3%
6.6%
Members with 0 conditions
Members with 1 condition
Asthma
5.3%
Cancer
4.7%
Members with 2 conditions
Members with 3+ conditions
76
High Risk Members Demographics
Members by Gender
Members by Relationship
8%
36%
Employee
Female
Male
Spouse
35%
57%
Dependent
64%
Members by Age Group
Length of Enrollment (For Current Members)
90%
82%
30%
80%
26%
25%
70%
20%
60%
20%
50%
40%
16%
15%
13%
12%
30%
10%
8%
10%
20%
4%
8%
7%
5%
0%
Less than 12
months
12 - 23 months 24 - 35 months
36 months
4%
1%
0%
0-1
2-19 20-29 30-39 40-49 50-59 60-64
65+
77
High Risk Members Chronic Conditions
Number of Chronic Conditions per Member
Top Ten Chronic Conditions by Prevalence
Back Pain
50.1%
16%
Neck Pain
40%
29.0%
Hypertension
21.3%
Depression
20.0%
22%
22%
Members with 0 conditions
Members with 1 condition
Hyperlipidemia
17.4%
Osteoarthritis
16.5%
Diabetes
Headache
Cancer
13.6%
10.4%
9.8%
Members with 2 conditions
Members with 3+ conditions
Asthma
6.9%
78
High Cost Claimants Demographics
Members by Gender
Members by Relationship
10%
40%
Employee
Female
Male
Spouse
31%
60%
59%
Members by Age Group
Length of Enrollment (For Current Members)
84%
90%
80%
35%
60%
25%
50%
20%
40%
17%
16%
16%
15%
30%
10%
20%
10%
29%
30%
70%
Dependent
1%
5%
10%
9%
5%
0%
Less than 12
months
12 - 23 months
24 - 35 months
36 months
7%
1%
3%
0%
0-1
2-19 20-29 30-39 40-49 50-59 60-64
65+
79
High Cost Claimants Chronic Conditions
Number of Chronic Conditions per Member
Top Ten Chronic Conditions by Prevalence
Back Pain
51.7%
3%
Osteoarthritis
34.2%
23%
Neck Pain
32.3%
Hypertension
53%
26.4%
Cancer
23.0%
Depression
21.9%
21%
Members with 0 conditions
Members with 1 condition
Members with 2 conditions
Hyperlipidemia
18.2%
Diabetes
17.5%
Headache
11.2%
CAD
10.4%
Members with 3+ conditions
80
Claims Based Population Risk
Risk Category
Low Risk, Compliant
Number of
Members
2010-2011
PMPY
2011-2012
PMPY
Paid PMPY
Norm
Member
Average Average
Member
Distribution
RRS
RCGI
Distribution
Norm
6,850
$2,058
$1,291
$1,073
0.33
0.78
72.6%
76.2%
267
$5,303
$3,029
$2,343
0.60
5.46
2.8%
3.5%
1,006
$6,303
$6,252
$5,011
1.61
1.36
10.7%
9.2%
Moderate Risk, Non-Compliant
170
$9,454
$6,691
$5,866
1.59
5.54
1.8%
1.9%
High Risk, Compliant
681
$10,639
$12,189
$11,099
3.77
1.59
7.2%
6.1%
High Risk, Non-Compliant
197
$15,582
$13,027
$13,593
4.45
5.56
2.1%
2.3%
High Cost Claimant
269
$76,997
$62,017
$113,537
7.97
3.29
2.8%
0.9%
$6,213
$5,144
$3,515
1.05
1.27
100%
100%
Low Risk, Non-Compliant
Moderate Risk, Compliant
Total
9,440
Percent of Members compared to Percent of Cost
100%
Members and Cost Compared to Norm
Moderate Risk, High Risk, and High Cost members
account for 25% of members and 81% of costs.
HCC, 2.8%
High, 9.3%
Moderate, 12.5%
75%
50%
HCC, 39.8%
High, 25.1%
Low, 75.4%
Moderate, 15.7%
25%
Risk Category
Member
Distribution
Member
Distribution
Norm
Cost
Distribution
Cost
Distribution
Norm
Low Risk
75%
80%
19%
25%
Moderate Risk
12%
11%
16%
17%
High Risk
9%
8%
25%
29%
High Cost
3%
1%
40%
29%
Low, 19.4%
0%
Membership
Cost
Norm from Lockton InfoLock Book of Business.
81
Chronic Condition Reference
Asthma
Asthma is quite common. It can be triggered by environmental triggers such as allergies to pets or pollens, infections, cold
temperatures, stress, and sometimes exercise. It is a common reason for emergency room visits and sometimes hospital admissions.
It is best managed by avoidance of triggers when possible and regular use of medication. The number one reason for poor asthma
control is lack of adherence to a medication regimen that includes an inhaled steroid in addition to a bronchodilator. Educating
patients about the triggers and the importance of medication compliance are key to controlling this condition.
Back Pain and Neck Pain
Back injury prevention programs and core strengthening programs are effective in preventing injury and getting individuals back to
work. In the workplace, attention to ergonomics of workstations is important in reducing back and neck pain. Monitoring the trend
in high cost radiology for back pain, and surgery for herniated discs is important to establish the need for low back pain condition
management programs and pre-certification programs in high cost radiology. Evaluation along with proper treatment of back
pain and neck pain should limit the early use of high cost radiology including MRI and CT scans and early back surgery for herniated
discs and other back ailments. Preventive practices in postural alignment, availability of therapeutic alternative treatments such as
PT, acupuncture, pain treatment, and steroid injections help promote lower cost, higher efficacy solutions.
COPD
The most common cause of COPD is smoking. Unfortunately about 23% of American adults still smoke. COPD commonly includes
chronic emphysema and bronchitis. The condition is associated with significant lost work time and high health costs. It is progressive
and remains the fourth leading cause of death in the U.S. There is no cure. Treatment is aimed at managing exacerbations of the
disease. The most important step in treatment is to encourage those who are still smoking to stop. This can be aided by
implementing a smoking cessation program that combines behavioral modification with medication.
CAD
This the most common type of chronic heart disease. It is caused by the build up of plaque in the arteries supplying oxygen and
nutrients to the heart muscle. Plaque consists of a number of substances, including cholesterol, other fats, and calcium. CAD can
result in chest pain (angina), heart attacks, abnormal heart rhythms, and congestive heart failure. It can be minimized or
ameliorated by implementing healthy lifestyle habits that include regular exercise, a healthy diet, and successful work-life balance.
Medications also play a significant role, so compliance with a medication regimen is important.
Depression
Depression is common, whether it is mild, moderate, or severe. It is often associated with other chronic conditions such as heart
disease, diabetes, and chronic pain. It is most commonly managed with medication. These drugs are expensive so employees should
be aware of several good generic antidepressants that are now available. Several studies indicate that regular sleep and exercise,
combined with a strong social network can reduce the incidence and severity of depression and also reduce the need for medication.
82
Chronic Condition Reference (continued)
Diabetes
Type 2 diabetes continues to increase in the U.S. The prevalence is a direct result of poor lifestyle choices including inactivity and
poor dietary choices that result in obesity and diabetes. This a particularly serious chronic disease because it affects so many
different body systems including the heart, the eyes, the kidneys, and the blood vessels. Poorly controlled diabetes results in
accelerated decline in these body systems, a decline in quality of life, and high health costs. Like many of the other chronic
conditions, it is best managed by implementing healthy lifestyle habits that include regular exercise, a healthy diet, and successful
work-life balance. For those with established type 2 diabetes, it is very important that regular monitoring of the condition is done in
order to avoid some of the serious complications.
Hyperlipidemia
An abnormally elevated lipid profile is a risk factor for heart disease. The lipid profile includes measurement of cholesterol,
triglycerides, and LDL and HLD cholesterol. There is a genetic component to lipid levels that can make it more challenging for some
individuals to control their lipid levels. But for most people lipid levels can be managed by implementing healthy lifestyle habits that
include regular exercise, a healthy diet, and successful work-life balance. But many people now are prescribed medication to help
control lipids. These medications are called “statins” and a variety of medication options are now available.
Hypertension
High blood pressure is very common. Sometimes there is an increased risk for an individual due to genetic makeup. For most people
blood pressure gradually rises with age. Hypertension is a significant risk factor for heart attack, stroke, impaired vision, kidney
damage, and congestive heart failure. Hypertension can be ameliorated by implementing healthy lifestyle habits that include regular
exercise, a healthy diet, and successful work-life balance. Also for many a diet low in sodium is helpful. There are many medications
that can help control blood pressure. As with any treatment for chronic disease, compliance is essential for effective management.
Osteoarthritis
About 21 million Americans have osteoarthritis. The incidence increases with age. It is associated with a breakdown of cartilage in
joints and can occur in almost any joint in the body. It most commonly occurs in the weight bearing joints of the hips, knees, and
spine. Factors associated with its onset include obesity, injury, joint overuse, and heredity. Osteoarthritis generates a lot of medical
expense due to the cost of pain medications, diagnostic imaging, and surgical procedures (especially of the hip and lower back).
Exercise and physical therapy are important restorative and preventive measures. Weight management and good nutrition are often
helpful as well.
83
Glossary
Allowed Amount
Total paid amount, this includes both the employee and employer paid amount.
Chronic Conditions
Chronic Conditions included are Asthma, Atrial Fibrillation, Back Pain, Bipolar Disorder, Cerebrovascular Disease, Chronic Obstructive Pulmonary Disease, Chronic
Pancreatitis, Chronic Renal Failure, Cirrhosis, Coagulopathy, Congenital Anomalies, Congestive Heart Failure, Coronary Artery Disease (incl. MI), Cystic Fibrosis,
Demyelinating Diseases, Depression, Diabetes, Eating Disorders, Headache, High Risk Pregnancy, Hyperlipidemia, Hypertension, Immune Disorders, Inflammatory Bowel
Diseases, Neck Pain, Osteoarthritis, Osteomyelitis, Osteoporosis, Parkinson's Disease, Rheumatoid Arthritis, Schizophrenia, Sickle Cell Anemia, Tuberculosis
Co-morbidities
A medical condition that exists simultaneously with and usually independently of another medical condition.
Compliant Members
Members with a Care Gap Index of 4 or less.
Current Members
Individuals who are eligible with the plan as of the end of the reporting period.
Employee Paid
Employee paid consists of co-pays, coinsurances, and deductibles paid by an enrollee, the spouses, and their dependents.
Employer Paid
Employer paid includes total paid by the plan for enrollee, the spouses, and their dependents.
Emergency Room Visit
Distinct service dates for members with claims that have HCFA (Health Care Financing Administration) Place of Service code of 23.
Emergency Room Visits, Potential Non Emergent – Potential non emergent ER visits are visits which based on the diagnoses potentially should have been treated
in a physician’s office. These include visits for general symptoms, sinusitis, influenza, general medical examinations, etc.
Full Cycle
Time period that corresponds to date range of data included in the data warehouse (typically 36 months).
High Cost Claimants (HCC)
Claimants with plan payment of $50,000 or more during either the current or previous 12 months.
High Risk Claimants
Claimants with plan payment of less than $50,000 during the most recent 12 months and Relative Risk Scores predicted costs greater than $10,000.
84
Glossary (continued)
Incurred Basis
Claim expenses reported based on the service date.
Inpatient
All claims paid for hospital inpatient services base on HCFA Place of Service code 21, 51, and 61.
Low Risk Claimants
Claimants with plan payment of less than $50,000 during the most recent 12 months and Relative Risk Scores predicted costs less than $5,000.
MDC
Major Diagnostic Category
Member Months
Total number of members eligible for the time period.
Moderate Risk Claimants
Claimants with plan payment of less than $50,000 during the most recent 12 months and Relative Risk Scores predicted costs between $5,000-$9,999.
Non-Compliant Members
Members with a Care Gap Index of 5 or more.
Norm
Norms from the Lockton InfoLock Book of Business are derived from claims paid for the 12 months ending 12/31/2011 from Lockton’s Normative Database comprised of
2 million member lives from self-insured, commercial plans.
Office Visit
Distinct service dates for members with claims that have HCFA Place of Service code of 11.
Outpatient
Services which take place outside of an inpatient place of service are defined as outpatient.
Paid Basis
Claim expenses reported based on the date the claim was paid.
PEPM
Per Employee per Month.
85
Glossary (continued)
High Cost Script
Script with a plan paid amount of $1,000 or more.
Homegrown Codes
Non-standard codes found in the dataset being reported
PMPM
Per Member per Month.
Plan Payment
Plan payment includes total paid by the plan for enrollee, the spouses, and their dependents. Also referred to as Employer Paid.
Quality and Risk Measures
The Quality and Risk measures are designed to identify potential gaps in care and care management opportunities.
Relative Care Gap Index (RCGI)
The Care Gap Index (CGI) is used to determine compliance for care management. A numeric score assigned to each individual calculated by summing the weights
assigned to each care gap present. Care gaps are derived from evidence-based guidelines, the primary medical literature, standard medical practice, and the Verisk
Health Medical Advisory Board. The Relative Care Gap Index is the Care Gap Index / the Lockton Book of Business norm.
Relative Risk Score (RRS)
A Relative Risk Score (RRS) is a measure of resource use, in total cost or count of outcomes events, relative to an average person. A relative risk score of 1.00 means
that the person's risk burden (and predicted cost) is equal to the mean (average) in the development sample. Predictions in the DxCG main output file are relative to an
average person in the datasets used to develop the models. For example, using a commercial risk adjustment model, a person with an RRS of 1.50 is predicted to spend
50% more in resources compared to the average person in the Thomson Reuters® MarketScan based benchmark sample. Similarly, an RRS of 1.50 in an event model
predicts the member will incur 50% more such events (such as hospitalizations) as the average. All DxCG risk models predict one year of risk.
Therapeutic Class
Grouping of drugs into categories defined by the American Hospital Formulary Service. The AHFS Pharmacologic-Therapeutic Classification was developed and is
maintained by the American Society of Health-System Pharmacists.
Total Members
Number of unique members in the time period.
Units per 1,000
The average number of units (days, members, emergency room visits, etc.) per 1,000 members per year.
86
Our Mission
To be the worldwide value and service leader in
insurance brokerage, employee benefits, and risk management
Our Goal
To be the best place to do business and to work
This document contains the proprietary work product of Lockton Companies, LLC, and is provided on a
confidential basis. Any reproduction, disclosure or distribution to any third party without first securing written
permission from Lockton Companies, LLC is expressly prohibited.
www.lockton.com
© 2012 Lockton, Inc. All rights reserved.
Images © 2012 Thinkstock. All rights reserved.
87