UNIVERSITY OF ALASKA · Report Specifications . All reporting is based on the paid date with the...

L O C K T O N C O M P A N I E S

EXECUTIVE SUMMARY

UNIVERSITY OF ALASKA

1

Report Specifications

All reporting is based on the paid date with the exception of the Utilization metrics. These are monitored on an incurred basis thus analysis is lagged three months to account for the incomplete current period.

Reporting Period

Year 2 is based on claims paid from July 1, 2012 to June 30, 2013

Year 1 is based on claims paid from July 1, 2011 to June 30, 2012

Comparison to Normative Values

Normative values are based on Lockton’s InfoLock book of business, containing more than 1.6 million member lives, for the 12 months of paid claims ending 6/30/2013.

Normative values have not been adjusted for geography or industry

Risk Assignment

Risk determined using a concurrent DxCG model. 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 RRS of 1.00 means that the person’s risk burden (and predicted cost) is equal to the mean (average) in the development sample.

Compliance

Compliance is determined using the Care Gap Index. A Relative Care Gap Index (RCGI is a measure of compliance to standards of care, relative to an average person).

2 Norm from Lockton InfoLock® Book of Business 2

MEMBERS BY RELATIONSHIP

Demographics

MEMBERS BY GENDER LENGTH OF ENROLLMENT

45% 45%

24% 20%

32% 35%

Year 2 Norm

Employee Spouse Dependent

52.9% 48.7%

47.1% 51.3%

Year 2 Norm

Female Male

Enrolled membership has decreased 7.1% from Year 1

Average age is 36.9 (norm 33.9)

Age gender factor is 1.12, which means that costs are expected to be 12.0% higher than the normative group based upon age and gender alone.

Member-to-employee ratio is 2.25 (norm is 2.22)

81% of current members have been enrolled for 2+ years.

< 12 months

9% 12-23 months

10%

24-35 months

12%36 months

69%


Population Risk & Compliance

GOAL INTERVENTIONHigh Cost

235 members$77,037 PMPY

High Risk180 members

Noncompliant $13,576 PMPY343 members$10,379 PMPY Moderate Risk

163 membersPopulation $6,851 PMPY

8,577 members$5,306 PMPY High Risk

643 membersCompliant $12,816 PMPY

1,557 members$8,926 PMPY Moderate Risk


Low Risk6,442 members$1,454 PMPY

Manage risk factors Health Promotion

PR

IOR

ITY

Manage high costsHelp members navigate system

Case Management

Manage risk factorsReinforce and monitor compliance rates

Health Promotion

Close gaps in careSteerage

Disease ManagementandHealth Promotion

Your overall population’s RRS is 1.10 (norm 1.00)

Your overall population’s RCGI is 1.18 (norm 1.00)

The priority segment of the population represents high risk and moderate risk, noncompliant members. This represents 4.0% of your population

High risk and moderate risk noncompliant members cost 16.4% more than compliant members (norm 33.5%)


Illness Burden

PLAN PAID PMPY BY NUMBER OF CHRONIC CONDITIONS NUMBER OF CHRONIC CONDITIONS PER MEMBER

56%

20%13% 11%

63%

19%

10% 9%

0 conditions 1 condition 2 conditions 3 or more conditions

Actual Norm

$1,878

$5,668 $7,247

$19,077

$1,333

$4,269$6,518

$14,833


Actual Norm

43.9% (norm 37.1) of the population has one or more key chronic conditions and represents 80.5% (norm 77.6%) of plan costs

The top five chronic conditions based on prevalence are back pain, neck pain, hypertension, depression and hyperlipidemia

The goal for an effective disease management and comprehensive health promotion program is to prevent the natural progression towards comorbid chronic conditions

Having multiple chronic conditions increases cost significantly

5 Norm from Lockton InfoLock® Book of Business

Disease Management/Personal Health Support

Norms are in italics

Red lights indicate 2% greater than the Norm. Yellow lights indicate within 2% of the Norm. Green lights indicate 2% lower than the Norm.

*Costs include co-morbidities and exclude high cost claimants

Condition Notes

Asthma 3.2% 3.2% 34.1% 35.3% $6,720 $4,597

Back Pain 23.0% 13.0% 14.0% 15.5% $5,998 $5,116

CAD 1.0% 1.7% 63.3% 57.6% $9,749 $9,101

COPD 0.3% 0.7% 81.5% 74.3% $12,547 $9,096

Depression 7.3% 4.2% 14.6% 16.5% $6,500 $5,562

Diabetes 4.0% 4.7% 80.1% 75.4% $8,211 $6,960

Hyperlipidemia 7.1% 9.7% 21.5% 24.3% $6,269 $5,009

Hypertension 8.7% 10.9% 27.5% 31.5% $5,828 $5,240

Neck Pain 12.5% 5.7% 14.6% 14.7% $6,742 $5,321

Osteoarthritis 4.7% 3.5% 28.0% 30.6% $9,068 $8,684

Prevalence Noncompliance Paid PMPY*

Alaska adjusted norm is $6,482










DEMOGRAPHICS


Demographics – Total Members

AGE GENDER FACTOR Year 1 Year 2 Norm

Average Number of Members 9,610 8,927 -

Total Number of Members 10,587 9,936 -

Member Months 115,314 107,118 -

Employee Months 49,469 47,489 -

Age Gender Factor 1.10 1.12 1.00

Employee Age Gender Factor 1.34 1.35 1.16

Spouse Age Gender Factor 1.38 1.40 1.34

Dependent Age Gender Factor 0.57 0.58 0.62

Member-to-Employee Ratio 2.32 2.25 2.22

Average Age 36.3 36.7 33.9

% Female of Total Population 53% 53% 49%

% of Female Population in Childbearing Years 42% 43% 43%

A member’s complete medical profile, including risk, chronic conditions, and gaps in care, is considered valid after the member has been enrolled for 24 months.

LENGTH OF ENROLLMENT

Age Gender Factor is 1.12, which means that costs are expected to be 12.0% higher than the normative population based on age and gender alone.


PLAN PAID PMPM BY RELATIONSHIP MEMBER PERCENTAGE BY RELATIONSHIP

Overview by Relationship

43% 45% 45%

24% 24% 20%

33% 32% 35%

Year 1 Year 2 Norm


$615

$596

$358

$544

$551

$487

$184

$254

$184

Year 1

Year 2

Norm


RELATIVE RISK SCORE (RRS) RELATIVE CARE GAP INDEX (RCGI)

EmployeesEmployee

NormSpouses

SpouseNorm

DependentsDependent

NormOverall

Population

Overall Population

NormAverage Age 47 45 48 46 14 13 37 34

% Female 56% 40% 51% 73% 50% 49% 53% 49%

Average RRS 1.33 1.15 1.42 1.53 0.56 0.52 1.10 1.00

Average RCGI 1.37 1.17 1.61 1.37 0.60 0.59 1.18 1.00

A Relative Risk Score (RRS) is a measure of healthcare resource use, in total cost or count of outcomes events, relative to an average person (please see Glossary for more information). Your overall population RRS of 1.10 indicates that your population is predicted to spend/use 10.4% more in healthcare resources compared to the book of business normative population.

A Relative Care Gap Index (RCGI) is a measure of compliance with recommended healthcare management guidelines, normalized to the book of business (please see Glossary for more information). Your overall population RCGI of 1.18 indicates that your population is 18.3% less compliant than the book of business normative population.

9 9

Dependent Age Split by Paid Amount

There is a increase in cost for those dependents between 19 to 26 compared to those less than age 18

FY 11 (July 10 to June 11) Age Group Dependent Count Paid Claims PDPY

0-18 1882 5,637,619.05$ 2,870.36$

19-26 814 2,378,958.67$ 2,924.35$


0-18 1918 4,112,018.09$ 2,045.86$

19-26 902 2,778,253.63$ 2,508.96$


0-18 1880 5,524,935.79$ 2,893.02$

19-26 834 3,139,607.49$ 3,353.39$

FINANCIAL & UTILIZATION ANALYSIS


YEAR 2 INCURRED % MEMBER PAID (OF ALLOWED) BY POS YEAR 2 INCURRED % OF ALLOWED BY POS

Utilization Summary – Place of Service (POS)

Inpatient Hospital

25%

Outpatient Hospital

28%

Office35%

Emergency Room8%

Other4%

11%

17%

29%

19% 18%

Inpatient Hospital

Outpatient Hospital

Office Emergency Room

Other

Incurred indicates that dates are lagged three months and claims are being reported by service date.


Claim Expense Distribution

Exhibit includes all members who were enrolled or had a claim paid during the time period.

Members Plan Paid

$0 or less 2,399 22.7% -$50,911 -0.1% 2,262 22.8% -$55,499 -0.1% 29.6% -0.3%

$1 - $1,999 4,722 44.6% $3,229,398 6.1% 4,404 44.3% $3,024,069 5.9% 49.2% 9.8%

$2,000 - $4,999 1,468 13.9% $4,866,199 9.2% 1,414 14.2% $4,667,746 9.2% 10.5% 11.9%

$5,000 - $24,999 1,554 14.7% $16,331,733 30.9% 1,490 15.0% $16,205,882 31.8% 8.8% 32.5%

$25,000 - $49,999 262 2.5% $8,985,930 17.0% 205 2.1% $7,141,636 14.0% 1.1% 13.9%

$50,000 - $74,999 83 0.8% $5,065,062 9.6% 56 0.6% $3,485,196 6.8% 0.4% 7.5%

$75,000 - $99,999 31 0.3% $2,631,050 5.0% 44 0.4% $3,833,930 7.5% 0.2% 4.6%

$100,000 - $149,999 36 0.3% $4,483,371 8.5% 26 0.3% $3,175,898 6.2% 0.1% 5.8%

$150,000 + 32 0.3% $7,236,342 13.7% 35 0.4% $9,533,261 18.7% 0.1% 14.5%

High Cost Claimants > $50,000 182 1.7% $19,415,825 36.8% 161 1.6% $20,028,286 39.3% 0.8% 32.3%

ALL MEMBERS 10,587 100.0% $52,778,174 100.0% 9,936 100.0% $51,012,121 100.0% 100.0% 100.0%

Year 1 Year 2 Norm

Members Plan Paid Members Plan Paid

DistributionDistributionDistributionDistributionDistributionPaid Amount Range

KEY OBSERVATIONS

22.8% of members have $0 or less in paid claims, compared to the norm of 29.6%. These members may be care avoiders or young and healthy dependents.

18.7% of members have more than $5,000 in paid claims per year (norm 10.7%) and account for 85.0% of costs (norm 78.6%).

The % of members exceeding $5,000 in paid claims does not take into account the higher claims cost in Alaska.


NUMBER OF CHRONIC CONDITIONS PER HCC

High Cost Claimants (HCC)

0 conditions5.0%

1 condition22.8%

2 conditions19.5%

3 or more conditions

52.6%

High Cost Claimants Year 1 Year 2 % Change Norm

Number of Members 182 163 -10.4% -

% Medical Paid 40.2% 42.6% 5.9% 37.2%

% Rx Paid 16.2% 19.2% 19.0% 16.9%

Medical Paid $18,200,617 $18,634,881 2.4% -

Rx Paid $1,215,208 $1,393,404 14.7% -

Total Paid $19,415,825 $20,028,286 3.2% -

Average Medical Paid $100,003 $114,324 14.3% $106,543

Average Rx Paid $6,677 $8,548 28.0% $11,113

Average Total Paid $106,680 $122,873 15.2% $117,655

Average RRS 8.9 12.8 43.3% 16.0

Average RCGI 2.9 2.8 -1.9% 4.1

HIGH COST CLAIMANTS (HCC)

High cost claimants are members who incurred $50,000 or more in claims expense in either Year 1 or Year 2.

HIGH COST CLAIMANTS (HCC)

There are 302 unique members who were high cost claimants in Year 1 or Year 2. HCCs account for 42.6% of total plan paid medical costs (norm 37.2%). 95.0% of HCCs have at least one chronic condition, with 72.2% having comorbid conditions. Prevent future high cost claimants by managing chronic illness (please see Glossary for more information on chronic conditions).

Nine out of the top 20 HCC had over $100,000 in the prior year

14 14

YEAR 2 ER VISITS/1,000 BY AGE AND GENDER

ER VISITS BY RELATIONSHIP

41% 38%

26% 24%

33% 38%

Year 1 Year 2

Employees Spouses Dependents

Emergency Room Demographics

268.4 294.5

119.9159.9 151.0 163.6

417.9

240.5

161.897.2

187.3 165.9213.9

325.5

F M F M F M F M F M F M F M

0-2 3-12 13-18 19-26 27-39 40-60 60+

Visits per Member Members

% on Weekends

% Dependents

% of ER Plan Paid Members

% on Weekends

% Dependents

% of ER Plan Paid

1 981 30% 36% 36% 936 31% 36% 39%

2 228 32% 33% 24% 222 32% 29% 23%

3 63 25% 25% 8% 65 33% 26% 12%

4 29 37% 34% 5% 19 21% 32% 5%

5+ 46 30% 22% 27% 34 24% 41% 21%

Year 2Year 1

ER by Number of Visits

EMERGENCY ROOM HIGH UTILIZERS

9.2% of all members who visited the emergency room are considered 'ER high utilizers,' meaning that they visited the emergency room three or more times in Year 2 (norm 10.5%). These members account for 32.2% of all ER visits and 37.9% of ER paid amount (norms 30.2% and 31.0%, respectively).

15 15

ER HIGH UTILIZERS BY RISK CATEGORY (DxCG Model 18)

Low, 16

Moderate, 16

High, 52

HCC, 34

ER HIGH UTILIZERS BY NUMBER OF CHRONIC CONDITIONS

ER High Utilizers Claims-Based Risk & Number of Chronic Conditions

15

0 conditions26

127

218

3+47

16 16

ER HIGH UTILIZERS CHRONIC CONDITION PREVALENCE

ER High Utilizers - Chronic Condition Prevalence

16

8%

42%

3%

3%

20%

15%

8%

19%

19%

12%

Asthma

Back Pain

CAD

COPD

Depression

Diabetes

Hyperlipidemia

Hypertension

Neck Pain

Osteoarthritis

17 17

ER VISITS BY DAY OF WEEK ER HIGH UTILIZERS BY NUMBER OF VISITS

ER High Utilizers - Utilization Patterns

17

13%13%

15% 15%16% 15%

14%

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

65

19

12

3

6

2

1

10

3

4

5

6

7

8

9

10+

18 18

ER HIGH UTILIZER VISITS BY TYPE

ER High Utilizer - Utilization Categorization

18

18.4%

20.9%

9.3%

21.3%

8.2%

6.1%

15.7%

Potentially Non-Emergent

Primary Care Treatable

Preventable/ Avoidable

Not Preventable/ Avoidable

Injury

MHSA

Unclassified

Top 20 Primary Diagnosis Groups Visits Allowed Amount

Liver Diseases 2 $115,135

Abdominal Pain 70 $94,090

Limb Fractures 7 $90,473

Depression 10 $89,330

Neurotic and Personality Disorders 8 $68,998

Back Pain 8 $64,850

Paralytic States 1 $64,563

Nausea and Vomiting 32 $57,791

Intracranial Hemorrhage 1 $53,020

Chest Pain 20 $51,234

Misc Symptoms 75 $41,655

Diabetes Mellitus 42 $35,658

Misc Wounds and Injuries 21 $33,972

Metabolic Disorders 16 $33,089

Pain, not elsewhere classified 16 $32,142

Misc Skin Diseases 32 $30,811

Pregnancy Complications 22 $28,842

Neuropathies 2 $27,510

Pancreatic Diseases 5 $26,774

Syncope 5 $26,476

All Others 260 $457,175

TOTAL 655 $1,523,589

19 19

ER visits are classified using the 2000 New York University Emergency Department algorithm. This algorithm uses the ER discharge diagnosis (defined here as the diagnosis with the highest allowed amount) to assign a probability to the ER visit of being:

(1) Potentially Non-Emergent: immediate medical care (within 12 hours) was not likely required,

(2) Emergent, Primary Care Treatable: immediate medical care was required, but could have been provided in a primary care setting,

(3) Emergent, Preventable/Avoidable: immediate medical care was required, but the emergent nature of the condition was potentially preventable/avoidable if timely and effective ambulatory care had been delivered during the episode of illness, and/or

(4) Emergent, Not Preventable/Avoidable: immediate medical care was required and ambulatory care treatment could not have prevented the condition.

The model identifies Injury claims separately from the probabilities noted above.

Mental health-, drug-, and alcohol-related claims are also classified separately. These are being grouped as Mental Health and Substance Abuse (MHSA) claims. Source: Wagner NYU webpage. ED Algorithm back-ground. http://wagner.nyu.edu/faculty/billings/nyued-background. (Accessed September 2013)

In Focus: ER Visit Classification

ER VISITS BY TYPE

Emergency Room Utilization

17.5%

19.0%

6.0%

19.1%

20.4%

3.7%

14.3%

18.3%

21.4%

4.9%

16.2%

23.0%

2.7%

13.6%

Potentially Non-Emergent

Primary Care Treatable

Preventable/ Avoidable

Not Preventable/ Avoidable

Injury

MHSA

Unclassified

Year 2 Norm

Difference fromYear 1 to Year 2

-3.2%

1.3%

1.6%

0.8%

0.2%

0.2%

-0.7%

20 20

ER VISITS PER 1,000 BY INCURRED (SERVICE) DATE WITHIN QUARTER

Emergency Room Utilization

0

10

20

30

40

50

60

70

Injury Potentially Non-Emergent

Primary Diagnosis Group Visits Allowed Amount

Misc Wounds and Injuries 175 $239,687

Chest Pain 95 $252,713

Abdominal Pain 132 $216,755

Limb Fractures 55 $150,088

Urinary Stones 44 $131,643

Depression 18 $115,407

Head Injuries 30 $111,271

Pregnancy Complications 57 $100,397

ENT and Upper Resp Disorders 105 $75,385

Liver Diseases 2 $115,135

Neurotic and Personality Disorders 25 $101,153

Appendicitis 8 $93,857

Misc Symptoms 159 $91,020

Musculoskeletal Disorders 86 $69,204

Fracture of Neck and Trunk 5 $98,439

Nausea and Vomiting 54 $87,277

Pain, not elsewhere classified 48 $73,213

Back Pain 31 $86,584

Headache 41 $70,529

Misc Skin Diseases 85 $64,502

All Others 780 $2,171,713

TOTAL 2,035 $4,515,972

Emergency Room Visits by Top 20 Diagnosis GroupsYear 2

FY 14 implemented new Nurseline to redirect to appropriate care

PRESCRIPTION DRUG ANALYSIS

22 22

If 50% of brand name antihyperlipidemic scripts (statins) filled last year had been switched to a generic in the same class, plan paid amount would have been reduced by approximately

In Focus: Potential Savings by Switching to Generics

Antihyperlipidemics Generic Analysis

Potential savings calculation is based on moving 50% of scripts for Lipitor, Crestor, and Lescol XL to Simvastatin.

Selected Statins Brand/ Generic

Script Count

Rx Plan PaidPMPM

Script Count

Rx Plan PaidPMPM

% Change in Paid PMPM

Lipitor Brand 913 $1.41 23 $0.04 -97.5%

Crestor Brand 642 $1.01 568 $1.10 9.0%

Lescol XL Brand - $0.00 4 $0.01 0.0%

Simvastatin Generic 1,037 $0.40 897 $0.30 -24.9%

Lovastatin Generic 75 $0.02 43 $0.01 -25.6%

Pravastatin Sodium Generic 410 $0.10 411 $0.09 -9.8%

Atorvastatin Calcium Generic 926 $0.97 1,607 $1.05 9.2%

1,080 $1.87 587 $1.64 -12.3% 5,083 $5.78 4,140 $4.25 -26.6%

Year 1 Year 2

All Other Antihyperlipidemics

ALL ANTIHYPERLIPIDEMICS

$48,755

23 23

If 50% of brand name peptic ulcer scripts (PPIs) filled last year had been switched to a generic in the same class, plan paid amount would have been reduced by approximately

In Focus: Potential Savings by Switching to Generics

Peptic Ulcer Generic Analysis

$73,225

Potential savings calculation is based on moving 50% of scripts for Prevacid, Nexium, Aciphex, Protonix, Kapidex, Prilosec, Axid, and Zantac to Omeprazole.

Selected Peptic Ulcer Drugs

Brand/ Generic

Script Count

Rx Plan PaidPMPM

Script Count

Rx Plan PaidPMPM

% Change in Paid PMPM

Prevacid Brand 11 $0.02 16 $0.04 86.8%

Nexium Brand 680 $1.56 540 $1.45 -7.0%

Aciphex Brand 30 $0.09 29 $0.09 9.3%

Protonix Brand 0 $0.00 0 $0.00 0.0%

Kapidex Brand 0 $0.00 0 $0.00 0.0%

Prilosec Brand 0 $0.00 0 $0.00 0.0%

Axid Brand 0 $0.00 0 $0.00 0.0%

Zantac Brand 0 $0.00 0 $0.00 0.0%

Pantoprazole Sodium Generic 378 $0.23 318 $0.15 -33.6%

Lansoprazole Generic 391 $0.35 308 $0.27 -24.5%

Omeprazole Generic 987 $0.45 1,017 $0.42 -7.7%

Ranitidine HCL Generic 193 $0.02 274 $0.02 30.6%

Cimetidine Generic 9 $0.00 15 $0.00 18.2%

Famotidine Generic 60 $0.05 19 $0.01 -68.6%

All Other Ulcer Drugs 297 $0.20 260 $0.20 -3.7%

ALL ULCER DRUGS 3,036 $2.96 2,796 $2.65 -10.5%

Year 1 Year 2


AVERAGE PLAN PAID PER PILL/UNIT FOR HIGH COST SCRIPTS

PMPM PAID FOR HIGH COST SCRIPTS NUMBER OF HIGH COST SCRIPTS

Prescription Drugs - High Cost Scripts (>$1,000)

640 675

Year 1 Year 2

$13.14

$17.59 $17.01

Year 1 Year 2 Norm

$6.71

$12.01

Year 1 Year 2

Specialty drugs will account for the majority of new drug approvals in the coming years, and they will consume approximately 40% of a health plan's drug spending by 2020. Source: URAC/Specialty Pharmacy white paper, “The Patient-Centered Outgrowth of Specialty Pharmacy”

There is no common industry indicator for specialty drugs, however, high cost scripts (drugs costing $1,000 or more) are a good approximation for evaluating specialty drugs.

In Focus: Specialty Drug Trend


MEDICAL ALLOWED AMOUNT - TOP 10 MEDICAL PHARMACY DRUGS

Medical Pharmacy

Year 1 Year 2 % Change Norm

Medical Plan Paid PMPM $19.23 $25.14 31% $12.39

Rx Plan Paid PMPM $6.62 $8.68 31% $7.87

Total Plan Paid PMPM $25.85 $33.82 31% $20.26

Medical Pharmacy drugs are those drugs that can be provided in a medical setting or obtained through a pharmacy benefit manager (PBM). Codes for drugs payable in either setting are provided by the Centers for Medicare & Medicaid Services (CMS).

These drugs can be billed through either the medical plan or the PBM. Drugs billed through the medical plan are not regulated for cost, and can be marked up at the doctor’s office. Your PBM may have negotiated discount rates for these drugs.

If the medical allowed amount for these drugs is higher than the norm, consider engaging Pharmacy Analytics.

MEDICAL PHARMACY DRUGS

Average Allowed Amount per Procedure Norm

$39,922 $19,315

$3,537 $2,091

$6,252 $3,627

$6,323 $2,973

$3,619 $9,709

$7,182 $3,372

$3,182 $3,276

$6,438 $3,203

$6,250 $2,231

$9,186 $4,608

$359,302

$275,857

$250,072

$208,675

$199,038

$179,549

$152,719

$135,189

$93,747

$82,673

Injection, eculizumab, 10 mg

Bevacizumab Injection

Injection, Pegfilgrastim, 6 Mg

Injection, Oxaliplatin, 0.5 Mg

INJECTION, IMIGLUCERASE, 10 UN

Injection, natalizumab, 1 mg

Infliximab Injection

Trastuzumab

Injection, immune globulin, (f

Rituximab Cancer Treatment

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 noncompliant for disease management.

27 27

Claims-Based Population Stratification

PMPY amounts are plan paid.

GOAL INTERVENTIONHigh Cost


High Risk180 members

Noncompliant $13,576 PMPY343 members$10,379 PMPY Moderate Risk

163 membersPopulation $6,851 PMPY

8,577 members$5,306 PMPY High Risk

643 membersCompliant $12,816 PMPY

1,557 members$8,926 PMPY Moderate Risk


Low Risk6,442 members$1,454 PMPY

Manage risk factors Health Promotion

PR

IOR

ITY

Manage high costsHelp members navigate system

Case Management

Manage risk factorsReinforce and monitor compliance rates

Health Promotion

Close gaps in careSteerage

Disease ManagementandHealth Promotion

28 Norm from Lockton InfoLock® Book of Business

Claims-Based Population Risk

Distribution arrows indicate 2% or greater variance from the norm.

PMPY arrows indicate 5% or greater variance from the norm.

KEY FACT

Risk CategoryCompliance Stratification

Number of Members

Member Distribution

Norm

Paid PMPY Norm

Plan Paid Distribution

NormAvg Age

Compliant 6,156 71.8% 75.3% $1,397 $1,057 18.8% 21.5%Noncompliant 286 3.3% 3.4% $2,644 $2,252 1.7% 2.2%

Low Risk Sub-Total 6,442 75.1% 78.7% $1,454 $1,112 20.5% 23.8%

Compliant 914 10.7% 9.5% $6,176 $4,922 12.6% 13.2%

Noncompliant 163 1.9% 2.0% $6,851 $5,585 2.5% 3.2%

Moderate Risk Sub-Total 1,077 12.6% 11.5% $6,279 $5,037 15.1% 16.4%

Compliant 643 7.5% 6.6% $12,816 $10,889 18.4% 20.3%

Noncompliant 180 2.1% 2.3% $13,576 $13,373 5.5% 9.0%

High Risk Sub-Total 823 9.6% 8.9% $12,984 $11,550 24.0% 29.3%

High Cost Claimant 235 2.7% 0.9% $77,037 $116,135 40.5% 30.6% 49.5

TOTAL 8,577 100% 100% $5,306 $3,648 100% 100%

High Risk

33.7

47.3

46.6

Year 2 PaidPMPY

Member Distribution

Plan Paid Distribution

Low Risk

Moderate Risk

Moderate risk, high risk, and high cost members account for 21.3% of members and 79.5% of costs.

The average Relative Risk Score (RRS) for the current, active population is 1.06, and the average Relative Care Gap Index (RCGI) for the current, active population is 1.29.


MEMBERSHIP DISTRIBUTION PLAN PAID PMPY BY RISK CATEGORY

Claims-Based Population Risk

Low, 75.1%

Low, 78.7%

Moderate, 12.6%

Moderate, 11.5%

High, 9.6% High, 8.9%HCC, 2.7% HCC, 0.9%

Year 2 Norm

$1,454

$6,279

$12,984

$1,112

$5,037

$11,550

Low Risk Moderate High Risk

Year 2 Norm

30 30

Utilization Metrics by Claims-Based Population Risk

Low Risk Compliant Noncompliant

Number of Members 6,442 1,557 343

% of Members with No Claims 19.2% 0.2% 0.0%

% of Members with No Medical Claims 22.5% 0.4% 0.3%

% of Members with No Rx Claims 47.9% 16.5% 14.0%

ER Visits/1,000 81 358 615

Office Visits/1,000 2,006 7,092 8,183

Prescriptions/1,000 4,337 14,550 30,710

Adult Preventive Exam 24.7% 37.0% 26.8%

Well-Child Exam 41.7% 41.9% 50.0%

Mammogram 39.7% 60.8% 30.6%

Pap Smear 44.9% 60.0% 39.5%

Colorectal Screening 26.5% 47.0% 39.0%

Utilization Metrics

Preventive Care

Current Year Metrics

POTENTIAL CARE AVOIDANCE

19.2% of low risk members had $0 in paid claims in Year 2, and only 24.7% had an adult preventive exam. These members could be artificially classified as low risk due to lack of claims data. Biometric screening or HRA data could be a better indicator of potential risk.

Care Avoiders

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 noncompliant for disease management.

CURRENT MEMBER CHRONIC CONDITION ANALYSIS


PREVALENCE AND YEAR 2 PLAN PAID PMPY COMPARED TO BENCHMARK

Chronic Conditions by Prevalence and Cost

Size of bubble is based on number of members with each chronic condition. Details in the Appendix

0

0.5

1

1.5

2

0 0.5 1 1.5 2 2.5 3

Plan

Pai

d PM

PY R

elat

ive

to B

ench

mar

k

Prevalence Relative to Benchmark

Back Pain Hyperlipidemia Diabetes Hypertension Depression Asthma COPD Neck Pain CAD Osteoarthritis

QUADRANT I

Conditions in this quadrant have a higher cost and prevalence as compared to the normative population.

QUADRANT III

Conditions in this quadrant have a lower cost and prevalence as compared to the normative population.

Depression Back Pain

Neck Pain

Osteoarthritis

33 33

The overall cost for a noncompliant member is $7,251 versus $5,251 for a compliant member. Compliance is determined by a member’s Relative Care Gap Index (RCGI). Members with high RCGI scores are considered noncompliant.

PLAN PAID PMPY BY CHRONIC CONDITIONS AND COMPLIANCE

Cost of Noncompliance

This exhibit excludes high cost claimants. PMPY costs include comorbidities. Only members with at least one chronic condition are included.

$6,072

$5,563

$6,400

$16,034

$12,083

$6,149

$8,832

$5,662

$5,337

$8,562

$7,964

$9,021

$9,093

$11,772

$8,379

$8,789

$8,062

$8,710

$7,211

$10,499

Asthma

Back Pain

Neck Pain

COPD

CAD

Depression

Diabetes

Hyperlipidemia

Hypertension

Osteoarthritis

Compliant Noncompliant

COMPLIANCE

34 34

Cost Adjustment

1In the ACCRA Cost of Living Index, health care costs in Alaska’s cities (Fairbanks, Anchorage and Juneau ranged from 35.3% to 46.9% more costly than the average U.S. city in 2012

The Norm has not been adjusted for the higher costs in Alaska Analysis Summary will compare UA costs to adjusted norm of norm

plus 41.0%

1http://labor.alaska.gov/research/col/col.pdf

35 35

Asthma Summary & Observations

Asthma

Prevalence is at the the norm with UA costs of $6,720 per member per year (pmpy) compared to the adjusted norm of $6,482 pmpy

66% of the members with asthma are compliant in medication and doctor visits

Patients with more than one asthma-related emergency room visit is higher than the norm

19.9% of members with Asthma are without inhaled corticosteroids or leukotriene inhibitors compared to the norm of 31.6% without inhalers

Recommendation:

Premera send communications and out-reach to members with emergency room visits for Asthma

Provide information on free generic program if actively engaged in Premera DM Asthma program

36 36

COPD Summary & Observations

COPD (Chronic Obstructive Pulmonary Disease)

Prevalence is below the norm with UA costs of $12,547 pmpy compared to the adjusted norm of $12,825 pmpy

81% of the members with COPD are non-compliant due to lack of doctor visits and increased ER visits

44% have three or more co-morbidities

The percentage of hospitalizations due to COPD was 25.9% compared to 17.9%

The number of members with COPD with an ER visit was above the norm 22.2% compared to 12.6%

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.

37 37

CAD Summary & Observations

CAD (Coronary Artery Disease)

Prevalence is below the norm with UA costs of $9,749 pmpy compared to the adjusted norm of $12,832 pmpy

High Risk members make up 37% of the group

High Cost Claimants make up 26% of the group

52% have 3 or more co-morbidities

Patients with obesity are above the norm

There was significant non-compliance with only 37% 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

38 38

Depression Summary & Observations

Depression

Prevalence is significantly above the norm and UA costs are $6,500 pmpy compared to the adjusted norm of $7,842 pmpy

Employees make up 55% of the depressed population

Back and Neck pain are the top two co-morbidities

There is a high compliance rate of 85%

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.

39 39

Diabetes Summary & Observations

Diabetes

Prevalence is above the norm with UA costs of $8,211 pmpy compared to the adjusted norm of $9,814 pmpy

80% of the population is non-compliant

There is significant non-compliance in this population with 56% in the moderate and high risk category and 11% are High Cost Claimants

There were 5% of the diabetic members 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 (3.8% to 2.4%)

Continue to promote Disease Management, On-Campus wellness visits and vision exams

Promote biometric screenings to keep pre-diabetic from becoming diabetic

40 40

Hyperlipidemia Summary & Observations

Hyperlipidemia (High Cholesterol)

Lower prevalence to the norm with UA costs of $6,269 pmpy compared to the adjusted norm of $7,063

65% of the population are employees

22% of the population is high risk but has a high compliance rate of 78%

8% of the population are high cost claimants

16.4% did not have lab tests in the last 12 months

41 41

Hypertension Summary & Observations

Hypertension (High Blood Pressure)

Prevalence is lower the norm and UA costs of $5,828 pmpy compared to the adjusted norm of $7,388 pmpy

21% of the population is high risk but with a high compliance rate of 72%

25% of members have 3+ comorbidities

Hypertension related ER visits are in line with the norm

6.1% of the population did not have an office visit in the last 12 months compared to the norm at 4.8%

42 42

Back & Neck Pain Summary & Observations

Back & Neck Pain

56% of the members with back pain were employees

19% of the members with back pain are categorized as high risk

Approximately 52% 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 623 compared to the norm of 389

Physical Therapy visits/1,000 are 774 compared to the norm of 349

MRI Scans and CT Scans are below the norm on visits/1,000

Paid per visit for CT Scans are above the adjusted norm cost

Paid per visit for MRI Scans are significantly above the adjusted norm cost (almost double)


Focus Area – Back Pain, Neck Pain, and Intervertebral Disc Disorders

Primary Procedure Group Visits Plan PaidAvg Paid/

Visit

Physical Therapy 5,277 $767,298 $145

MRI Scan 135 $210,388 $1,558

Neurosurgery 11 $178,565 $16,233

Orthopedic Surgery; exclude endoscopic 6 $163,023 $27,171

Chiropractic 3,471 $152,603 $44

Other Anesthesia 55 $80,997 $1,473

Office Visit - Established Patient 697 $78,382 $112

Neurology 43 $66,983 $1,558

Rehab 456 $59,551 $131

Other Procedures 479 $56,860 $119

Ambulance 2 $55,799 $27,899

X-ray 216 $47,932 $222

All Others 426 $159,841 $375

TOTAL 11,274 $2,078,223 $184

Top 10 Primary Procedure Groups for Back Pain, Neck Pain, and Disc Disorders in Year 2

Utilization

CategoryProcedures/

1,000Allowed/

ProcedureProcedures/

1,000Allowed/

Procedure

Chiropractic 623 $72 389 $38

Physical Therapy 774 $143 349 $53

CT Scan 1.6 $1,167 4.3 $732

MRI Scan 15 $1,802 29 $988

Year 2 Norm

This page includes all current members with a paid claim for back pain, neck pain, or disc disorder (not limited to those who have been diagnosed with chronic back pain).

The primary procedure is based on the highest paid procedure on the day of the visit. The cost is based on all procedures incurred on the day of the visit.

Costs represented on this page reflect only those claims with a diagnosis related to back pain.

In Focus: How are Members Treating Back Pain?

44 44

Osteoarthritis Summary & Observations

Osteoarthritis

Prevalence is above the norm and UA costs of $9,068 pmpy compared to the adjusted norm of $12,244 pmpy

58% of the members with osteoarthritis were employees

35% of the members with osteoarthritis are categorized as high risk

17% of the members with osteoarthritis are high cost claimants

72% of the members are compliant

45 45

Cancer & Screenings Summary & Observations

Malignant Neoplasms & Cancer Screenings

Cancer screenings (e.g. colonoscopy) are at or better than the norm

44% 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


EARLY-IDENTIFIABLE CANCERS AS PERCENT OF CANCER-RELATED PLAN PAID

CANCER SCREENINGS

TOP 10 MALIGNANT NEOPLASM DIAGNOSES BY YEAR 2 PLAN PAID

Malignant Neoplasms/Cancer Screenings

$440,910

$297,061

$266,848

$258,026

$159,893

$138,139

$130,359

$122,348

$118,367

$117,174

$231,759

Breast Cancer

Misc Cancers

Pancreatic Cancer

Prostate Cancer

Upper GI Cancer

Secondary Malignancy

Lung Cancer

Colorectal Cancer

Urinary Tract Cancers

Female Genital Organ Cancer

All Others

Non-Early Identifiable56% Breast

19%

Colorectal6%

Female Genital Organ5%

Prostate11%

Skin3%

Other44%

46%50%

36%45%

50%

34%

Women >49 y/o with mammogram in last 12

months

Women>20 y/o with pap smear in the last two

years

Patients >49 y/o with any colorectal cancer

screening in the analysis period

Actual Norm

47 47

Recommendations

Medical

Communicate to employees no cost preventive care and screenings

Emergency Room - Specific communication on using alternative care setting for non-emergent care

Monitor ER usage with introduction of Nurseline FY 14

Work with Premera Personal Health Support to ensure that individuals with 3+ ER visits are contacted

Depression – Communication campaign on how to reduce depression and use of EAP services

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 and should be revisited for FY 2015 (Nexium comes off patent 2Q 2014)

Continue generic Rx usage communication to members and enrollment in Personal Health Support programs

APPENDIX

49 49

Prescription Drugs – Top 20 Drugs by Plan Paid Amount

Drug NameBrand/ Generic Therapeutic Class Paid PMPM

PMPM Norm Scripts

Paid per Pill/Unit

HUMIRA Brand ANALGESICS - ANTI-INFLAMMATORY $3.12 $2.09 143 $1,071.28

COPAXONE Brand PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - $1.81 $1.15 44 $4,395.44

NEXIUM Brand ULCER DRUGS $1.45 $1.07 540 $4.61

CYMBALTA Brand ANTIDEPRESSANTS $1.40 $1.09 460 $5.35

KUVAN Brand ENDOCRINE AND METABOLIC AGENTS - MISC. $1.35 $0.04 10 $32.23

CRESTOR Brand ANTIHYPERLIPIDEMICS $1.10 $1.13 568 $4.14

ABILIFY Brand ANTIPSYCHOTICS/ANTIMANIC AGENTS $1.08 $0.91 137 $19.14

ATORVASTATIN CALCIUM Generic ANTIHYPERLIPIDEMICS $1.05 $0.41 1,607 $1.31

ADVAIR DISKUS Brand ANTIASTHMATIC AND BRONCHODILATOR AGENTS $0.96 $0.81 335 $3.26

NOVOLOG Brand ANTIDIABETICS $0.79 $0.59 198 $13.67

LANTUS SOLOSTAR Brand ANTIDIABETICS $0.78 $0.57 258 $13.60

ONE TOUCH ULTRA TEST STRIPS Brand DIAGNOSTIC PRODUCTS $0.78 $0.42 422 $0.90

REBIF Brand PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - $0.76 $0.47 20 $687.11

ENBREL Brand ANALGESICS - ANTI-INFLAMMATORY $0.74 $1.61 38 $519.73

MONTELUKAST SODIUM Generic ANTIASTHMATIC AND BRONCHODILATOR AGENTS $0.69 $0.33 745 $2.05

VALACYCLOVIR Generic ANTIVIRALS $0.64 $0.30 607 $3.57

CELEBREX Brand ANALGESICS - ANTI-INFLAMMATORY $0.63 $0.37 290 $2.49

LOVAZA Brand ANTIHYPERLIPIDEMICS $0.60 $0.24 229 $1.31

TEMODAR Brand ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES $0.59 $0.09 17 $85.71

LYRICA Brand ANTICONVULSANTS $0.58 $0.33 207 $2.84

Top 20 Drugs $20.90 6,875 $4.68

All Others $46.75 71,746 $1.11

TOTAL $67.65 78,621 $1.45

Year 2

50 50

Prescription Drugs – Top 20 Drugs by Script Count

Drug NameBrand/ Generic Therapeutic Class Paid PMPM

Paid PMPM Norm Scripts

Paid per Pill/Unit

LISINOPRIL Generic ANTIHYPERTENSIVES $0.09 $0.05 1,918 $0.11

ACETAMINOPHEN Generic ANALGESICS - OPIOID $0.10 $0.17 1,909 $0.12

ATORVASTATIN CALCIUM Generic ANTIHYPERLIPIDEMICS $1.05 $0.41 1,607 $1.31

SYNTHROID Brand THYROID AGENTS $0.02 $0.03 1,278 $0.02

LEVOTHYROXINE SODIUM Generic THYROID AGENTS $0.01 $0.03 1,269 $0.02

HYDROCHLOROTHIAZIDE Generic DIURETICS $0.01 $0.01 1,090 $0.03

AZITHROMYCIN Generic MACROLIDES $0.08 $0.08 1,050 $0.97

OMEPRAZOLE Generic ULCER DRUGS $0.42 $0.22 1,017 $0.80

ZOLPIDEM TARTRATE Generic HYPNOTICS $0.12 $0.03 965 $0.40

ESCITALOPRAM OXALATE Generic ANTIDEPRESSANTS $0.55 $0.31 913 $1.40

SIMVASTATIN Generic ANTIHYPERLIPIDEMICS $0.30 $0.15 897 $0.72

METFORMIN HCL Generic ANTIDIABETICS $0.11 $0.05 823 $0.14

BUPROPION XL Generic ANTIDEPRESSANTS $0.34 $0.20 798 $1.04

AMOXICILLIN Generic PENICILLINS $0.01 $0.02 786 $0.02

SERTRALINE HCL Generic ANTIDEPRESSANTS $0.11 $0.06 777 $0.31

MONTELUKAST SODIUM Generic ANTIASTHMATIC AND BRONCHODILATOR $0.69 $0.33 745 $2.05

AMLODIPINE BESYLATE Generic CALCIUM CHANNEL BLOCKERS $0.07 $0.05 723 $0.24

ALPRAZOLAM Generic ANTIANXIETY AGENTS $0.01 $0.02 700 $0.04

FLUOXETINE HCL Generic ANTIDEPRESSANTS $0.09 $0.04 626 $0.31

LISINOPRIL-HYDROCHLOROTHIAZ Generic ANTIHYPERTENSIVES $0.04 $0.02 622 $0.12

Top 20 Drugs $4.24 20,513 $0.46

All Others $63.42 58,108 $1.70

TOTAL $67.65 78,621 $1.45

Year 2

51 51

TOP TEN CHRONIC CONDITIONS BY PREVALENCE NUMBER OF CHRONIC CONDITIONS PER MEMBER

Low Risk Members – Chronic Conditions

0 conditions

68%

118%

210%

3+4%

16.2%

8.1%

5.6%

4.7%

4.3%

2.5%

1.8%

1.8%

1.6%

1.0%

Back Pain

Neck Pain

Hypertension

Depression

Hyperlipidemia

Asthma

Diabetes

Headache

Osteoarthritis

Congenital Anomalies

52 52


MEMBERS BY AGE GROUP LENGTH OF ENROLLMENT

MEMBERS BY GENDER

Employee57%

Spouse29%

Dependent14%

Female63%

Male37%

Moderate and High Risk Compliant Members – Demographics

2%

7%9%

16%

21%

26%

12%

8%

0-1 2-19 20-29 30-39 40-49 50-59 60-64 65+

< 12 months

4%

12-23 months

10%

24-35 months

10%

36 months76%

53 53



MEMBERS BY GENDER

Employee40%

Spouse22%

Dependent38%

Low Risk Members – Demographics

Female49%Male

51%

2%

27%

15% 16% 16% 17%

5%2%

0-1 2-19 20-29 30-39 40-49 50-59 60-64 65+

Less than 12 months

9% 12 - 23 months

10%

24 - 35 months

13%36 months68%

54 54


Moderate and High Risk Compliant Members – Chronic Conditions

0 conditions

26%

126%

225%

3+23%

42.1%

25.2%

14.3%

13.9%

13.3%

10.5%

6.2%

6.2%

3.9%

3.2%

Back Pain

Neck Pain

Depression

Hypertension

Hyperlipidemia

Osteoarthritis

Headache

Cancer

Asthma

Bipolar Disorder

55 55



MEMBERS BY GENDER

Employee57%

Spouse39%

Dependent4%

Moderate and High Risk Noncompliant Members – Demographics

Female64%

Male36%

0%2% 2%

5%

15%

35%

21%19%

0-1 2-19 20-29 30-39 40-49 50-59 60-64 65+

< 12 months

0%

12-23 months

6% 24-35 months

7%

36 months87%

56 56


Moderate and High Risk Noncompliant Members – Chronic Conditions

0 conditions

3%

119%

221%

3+57%

47.5%

44.3%

34.1%

26.2%

22.2%

19.8%

15.2%

14.6%

10.8%

9.3%

Back Pain

Diabetes

Hypertension

Neck Pain

Hyperlipidemia

Osteoarthritis

Depression

Asthma

Headache

CAD

57 57



MEMBERS BY GENDER

Employee56%

Spouse30%

Dependent14%

High Cost Claimants – Demographics

Female53%

Male47%

3%6% 5%

9%

19%

28%

14%

17%

0-1 2-19 20-29 30-39 40-49 50-59 60-64 65+

< 12 months

3%

12-23 months

8% 24-35 months

10%

36 months79%

58 58


High Cost Claimants – Chronic Conditions

0 conditions

4%

121%

219%

3+56%

47.2%

29.4%

28.9%

24.3%

22.6%

19.6%

19.6%

15.3%

11.5%

9.8%

Back Pain

Osteoarthritis

Neck Pain

Hypertension

Depression

Cancer

Hyperlipidemia

Diabetes

Headache

CAD

59 59

Moderate and High Risk Noncompliant Members – Top Noncompliance Issues

Stoplights are yellow within 0.5% of the norm. The analysis period is the most recent 36 months of paid claims loaded in InfoLock®

88.8% of the 152 members with diabetes did not have a semiannual HbA1c test (norm 86.2%).

86.2% of the 152 members with diabetes did not have a retinal eye exam in the last 12 months (norm 75.0%).

44.7% of the 152 members with diabetes did not have any claims for home glucose testing supplies in the last 12 months (norm 48.8%).

41.4% of the 152 members with diabetes did not have a micro or macroalbumin screening test in the last 12 months (norm 38.9%).

31.3% of the 32 members with CAD (current members only) have taken only two of these agents: Beta-blockers, ACE/ARB, or Statins in the last 12 months (norm 32.0%).

21.9% of the 32 members with CAD (current members only) have not taken Beta-blockers, ACE/ARB, or Statins in the last 12 months (norm 15.4%).

20.0% of the 50 members with asthma did not have inhaled corticosteroids or leukotriene inhibitors in the analysis period (norm 31.6%).

18.9% of the 74 members with diabetes (current members >18 y/o only), taking at least 2 prescriptions of ACE-I/ARBS in the last 12 months, had a MPR for ACE-I/ARBS of < 80% (norm 27.9%).

18.8% of the 32 members with CAD (current members only) have taken only one of these agents: Beta-blockers, ACE/ARB, or Statins in the last 12 months (norm 19.6%).

18.4% of the 152 members with diabetes did not have a HbA1c test in the last 12 months (norm 22.7%).

Most Prevalent Gaps in Quality Care among Priority Segment of Population


PLAN PAID PMPY BY NUMBER OF CHRONIC CONDITIONS

NUMBER OF CHRONIC CONDITIONS PER MEMBER % OF PLAN PAID BY NUMBER OF CHRONIC CONDITIONS

Chronic Conditions per Member

56%

20%13% 11%

63%

19%

10% 9%


Actual Norm

$1,878

$5,668 $7,247

$19,077

$1,333

$4,269$6,518

$14,833


Actual Norm

20% 22%

80% 78%

Actual Norm

No Chronic Conditions 1 or more condition

CHRONIC CONDITIONS

43.9% (norm 37.1%) of the population has one or more key chronic conditions and represents 80.5% (norm 77.6%) of plan costs.

POTENTIAL CARE AVOIDANCE

5.6% of members identified as having one or more key chronic conditions had $0 in paid claims in Year 2.

61 61

TOP 5 CHRONIC CONDITIONS BY CLAIMS-BASED RISK CATEGORIES

Top 5 Chronic Conditions

1,044

519

358

300

280

655

392

217

223

207

163

90

117

52

76

111

68

57

53

46

0 500 1,000 1,500 2,000 2,500

Back Pain

Neck Pain

Hypertension

Depression

Hyperlipidemia

Low Risk Moderate Risk High Risk High Cost Claimant


ASTHMA MEMBERS ALLOWED PMPY

$6,8

04

$6,7

20

$4,5

97

$8,742 $8,807

$5,800

Year 1 Year 2 Norm

Plan Paid Employee Paid

TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS ASTHMA PREVALENCE

Compliant66%

Noncompliant34%

3.2% 3.2%

2760

50

100

150

200

250

300

0%

1%

1%

2%

2%

3%

3%

4%

Prevalence Norm24

30

31

54

102

Headache

Depression

Hypertension

Neck Pain

Back Pain

Asthma

Low Risk59%

Moderate Risk21%

High Risk19%

HCC1%

Employees47%

Spouses21%

Dependents32%

Asthma Only40%

1 comorbidity25%

215%

3+20%

0-1724%

18-3925%

40-6447%

65+5%

Excludes high cost claimants

Members by Relationship

Members by Age Group

Number of Comorbidities

Members by Risk Category

Members by Compliance


Asthma Quality and Risk Measures

9.4% of the 276 members with asthma had an asthma-related ER visit in the analysis period (norm 11.0%).

2.5% of the 276 members with asthma had an asthma-related hospitalization in the analysis period (norm 2.4%).

3.3% of the 276 members with asthma had more than one asthma-related ER visit in the analysis period (norm 2.9%).

0.0% of the 276 members with asthma had more than one asthma-related hospitalization in the analysis period (norm 0.3%).

2.9% of the 35 members with an asthma-related ER visit did not have an office visit in the analysis period (norm 2.8%).

0.0% of the 7 members with an asthma-related admission did not have an office visit in the analysis period (norm 1.1%).

19.9% of the 276 members with asthma did not have inhaled corticosteroids or leukotriene inhibitors in the analysis period (norm 31.6%).

Asthma-Related Risk Measures

Asthma-Related Quality Care Gap Measures



COPD MEMBERS ALLOWED PMPY COPD PREVALENCE

0.3%

0.7%

270

5

10

15

20

25

30

0%

0%

0%

0%

0%

1%

1%

1%

1%

Prevalence Norm

Chronic Obstructive Pulmonary Disease (COPD)

Low Risk19%

Moderate Risk22%

High Risk41%

HCC19%

COPD Only0%

1 comorbidity33%

222%

3+44%

Compliant19%

Noncompliant81%

$10,

214

$12,

547

$9,0

96

$12,914

$16,079

$11,158

Year 1 Year 2 Norm


Employees48%

Spouses48%

Dependents4%

6

6

8

9

10

Osteoarthritis

Depression

Hypertension

Diabetes

Back Pain

0-174%

40-6452%

65+44%


TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS







COPD Quality and Risk Measures

22.2% of the 27 members with COPD had a COPD-related ER visit in the analysis period (norm 12.6%).

11.1% of the 27 members with COPD had a COPD-related hospitalization in the analysis period (norm 8.8%).

3.7% of the 27 members with COPD had more than one COPD-related ER visit in the analysis period (norm 3.6%).

25.9% of the 27 members with COPD had more than one hospitalization in the analysis period (norm 17.9%).

7.4% of the 27 members with COPD had a claim for sleep apnea in the analysis period (norm 14.0%).

7.4% of the 27 members with COPD had a claim for tobacco use disorder in the analysis period (norm 8.1%).

3.7% of the 27 members with COPD did not have an office visit in the analysis period (norm 0.5%).

0.0% of the 9 members with a COPD-related ER visit did not have an office visit in the analysis period (norm 0.9%).

0.0% of the 3 members with a COPD-related admission did not have an office visit in the analysis period (norm 1.0%).

COPD-Related Quality Care Gap Measures

COPD-Related Risk Measures



CAD MEMBERS ALLOWED PMPY TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS CAD PREVALENCE

Coronary Artery Disease (CAD)

Low Risk18%

Moderate Risk20%

High Risk37%

HCC26%

CAD Only11%

1 comorbidity19%

218%

3+52%

Compliant37%

Noncompliant63%

1.0%

1.7%

900102030405060708090100

0%

0%

0%

1%

1%

1%

1%

1%

2%

2%

Prevalence Norm

$12,

146

$9,7

49

$9,1

01

$14,768

$12,254 $11,087

Year 1 Year 2 Norm


Employees60%

Spouses40%

Dependents0%

21

26

33

34

36

Osteoarthritis

Diabetes

Hypertension

Hyperlipidemia

Back Pain






18-391%

40-6461%

65+38%



CAD Quality and Risk Measures

6.7% of the 90 members with CAD had a CAD-related ER visit in the analysis period (norm 15.3%).

25.6% of the 90 members with CAD had a CAD-related hospitalization in the analysis period (norm 17.9%).

3.3% of the 90 members with CAD had a MI-related hospitalization in the analysis period (norm 5.9%).

13.3% of the 90 members with CAD had more than one hospitalization in the analysis period (norm 14.9%).

45.6% of the 90 members with CAD had a cardiac catheterization in the analysis period (norm 37.5%).

18.9% of the 90 members with CAD had a cardiac stenting in the analysis period (norm 15.3%).

8.9% of the 90 members with CAD had a coronary artery bypass graft (CABG) in the analysis period (norm 4.8%).

7.8% of the 90 members with CAD have cerebrovascular disease (CVD) (norm 9.2%).

10.0% of the 90 members with CAD have depression (norm 5.5%).

37.8% of the 90 members with CAD have hyperlipidemia (norm 55.7%).

3.3% of the 90 members with CAD have obesity (norm 1.7%).

2.2% of the 90 members with CAD have peripheral vascular disease (PVD) (norm 4.8%).

6.7% of the 90 members with CAD did not have an office visit in the last 12 months (norm 3.6%).

0.0% of the 10 members with a CAD-related ER visit did not have an office visit in the analysis period (norm 0.8%).

0.0% of the 23 members with a CAD-related admission did not have an office visit in the analysis period (norm 0.6%).

6.1% of the 33 members with CAD and hypertension did not have antihypertensive drugs in the analysis period (norm 6.0%).

18.0% of the 89 members with CAD (current members only) have not taken Beta-blockers, ACE/ARB, or Statins in the last 12 months (norm 15.4%).

20.2% of the 89 members with CAD (current members only) have taken only one of these agents: Beta-blockers, ACE/ARB, or Statins in the last 12 months (norm 19.6%).24.7% of the 89 members with CAD (current members only) have taken only two of these agents: Beta-blockers, ACE/ARB, or Statins in the last 12 months (norm 32.0%).14.5% of the 62 members with CAD (current members only), taking at least 2 prescriptions of statins in the last 12 months, had a MPR for statins of <80% (norm 18.7%).

CAD-Related Risk Measures

CAD-Related Quality Care Gap Measures



DEPRESSION MEMBERS ALLOWED PMPY TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS DEPRESSION PREVALENCE

Depression

Low Risk48%

Moderate Risk23%

High Risk21%

HCC8%

Depression Only31%

1 comorbidity26%

220%

3+24%

Compliant85%

Noncompliant15%

$6,7

39

$6,5

00

$5,5

62

$8,680 $8,611

$7,027

Year 1 Year 2 Norm


Employees55%

Spouses25%

Dependents20%

7.3%

4.2%

6280

100

200

300

400

500

600

700

0%

1%

2%

3%

4%

5%

6%

7%

8%

Prevalence Norm63

65

76

173

288

Headache

Hyperlipidemia

Hypertension

Neck Pain

Back Pain






0-177%

18-3935%

40-6455%

65+4%



Depression Quality and Risk Measures

3.8% of the 628 members with depression had a depression-related ER visit in the analysis period (norm 5.0%).

3.3% of the 628 members with depression had a depression-related hospitalization in the analysis period (norm 5.5%).

4.8% of the 628 members with depression had more than one hospitalization in the analysis period (norm 6.6%).

13.4% of the 628 members with depression have taken SSRI and bupropion in the analysis period (norm 12.9%).

6.8% of the 628 members with depression did not have an office visit in the last 12 months (norm 4.7%).

33.3% of the 21 members with a depression-related admission did not have a mental health office visit within 14 days of discharge (norm 24.5%).

6.0% of the 84 members with depression on SSRI and bupropion did not have an an office visit in the last six months (norm 11.5%).

28.6% of the 7 members with two or more depression related admissions (current members >=18 y/o only) did not have any antidepressants in the last 12 months (norm 17.9%).25.0% of the 20 members with a depression-related ER visit (current members only), taking at least 2 prescriptions of antidepressants in the last 12 months, had a MPR for antidepressants of < 80% (norm 24.0%).33.3% of the 15 members with a depression-related hospitalization (current members only), taking at least 2 prescriptions of antidepressants in the last 12 months, had a MPR for antidepressants of < 80% (norm 23.5%).0.0% of the 4 members with depression (pediatric patients on complex antidepressant therapy) did not have a visit with a psychiatrist or psychologist near the time of starting complex antidepressant therapy (norm 7.1%).

Depression-Related Risk Measures

Depression-Related Quality Care Gap Measures



DIABETES MEMBERS ALLOWED PMPY TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS DIABETES PREVALENCE

Diabetes

Diabetes Only31%

1 comorbidity20%

219%

3+30%

Compliant20%

Noncompliant80%

45

64

71

98

124

Osteoarthritis

Neck Pain

Hyperlipidemia

Hypertension

Back Pain

Employees60%

Spouses35%

Dependents5%

Low Risk34%

Moderate Risk28%

High Risk28%

HCC11%

4.0%

4.7%

3410

50

100

150

200

250

300

350

400

0%1%1%2%2%3%3%4%4%5%5%

Prevalence Norm

$9,2

80

$8,2

11

$6,9

60

$11,482 $10,400

$8,585

Year 1 Year 2 Norm







0-172%

18-3912%

40-6470%

65+16%



Diabetes Quality and Risk Measures

5.0% of the 341 members with diabetes had a diabetes-related ER visit in the analysis period (norm 4.5%).

2.9% of the 341 members with diabetes had a diabetes-related hospitalization in the analysis period (norm 2.3%).

6.5% of the 341 members with diabetes had more than one hospitalization in the analysis period (norm 6.9%).

0.6% of the 341 members with diabetes had a dialysis in the analysis period (norm 2.3%).

4.4% of the 341 members with diabetes had renal failure in the analysis period (norm 4.2%).

7.9% of the 341 members with diabetes had an ulcer or open wound in the analysis period (norm 7.9%).

7.6% of the 341 members with diabetes have CAD (norm 10.4%).

20.8% of the 341 members with diabetes have hyperlipidemia (norm 38.4%).

69.2% of the 341 members with diabetes have hypertension or are taking antihypertensive drugs (norm 75.1%).

3.8% of the 341 members with diabetes have obesity (norm 2.4%).

0.9% of the 341 members with diabetes have peripheral vascular disease (PVD) (norm 1.7%).

2.9% of the 341 members with diabetes have retinopathy (norm 3.0%).

0.0% of the 18 members with a diabetes-related ER visit did not have an office visit in the analysis period (norm 1.0%).

0.0% of the 10 members with a diabetes-related admission did not have a diabetes-related office visit in the analysis period (norm 7.9%).

85.6% of the 341 members with diabetes did not have a semiannual HbA1c test (norm 86.2%).

21.4% of the 341 members with diabetes did not have a HbA1c test in the last 12 months (norm 22.7%).

46.9% of the 341 members with diabetes did not have any claims for home glucose testing supplies in the last 12 months (norm 48.8%).

39.3% of the 341 members with diabetes did not have a micro or macroalbumin screening test in the last 12 months (norm 38.9%).

81.5% of the 341 members with diabetes did not have a retinal eye exam in the last 12 months (norm 75.0%).

14.7% of the 163 members with diabetes (current members >18 y/o only), taking at least 2 prescriptions of ACE-I/ARBS in the last 12 months, had a MPR for ACE-I/ARBS of < 80% (norm 27.9%).9.4% of the 139 members with diabetes (current members >18 y/o only), taking at least 2 prescriptions of statins in the last 12 months, had a MPR for statins of < 80% (norm 23.2%).

Diabetes-Related Quality Care Gap Measures

Diabetes-Related Risk Measures



HYPERLIPIDEMIA MEMBERS ALLOWED PMPY TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS HYPERLIPIDEMIA PREVALENCE

Hyperlipidemia

Compliant78%

Noncompliant22%

Employees65%

Spouses34%

Dependents1%

$6,7

80

$6,2

69

$5,0

09

$8,670 $8,150

$6,281

Year 1 Year 2 Norm


7.1%

9.7%

6090

100

200

300

400

500

600

700

0%

2%

4%

6%

8%

10%

12%

Prevalence Norm

Low Risk46%

Moderate Risk25%

High Risk22%

HCC8%

Hyperlipidemia Only21%

1 comorbidity29%

221%

3+28%

71

104

134

196

246

Diabetes

Osteoarthritis

Neck Pain

Hypertension

Back Pain






18-396%

40-6478%

65+15%



Hyperlipidemia Quality and Risk Measures

11.1% of the 279 members with hyperlipidemia (current members >18 y/o only), taking at least 2 prescriptions of lipid lowering medications in the last 12 months, and at least a 60 day supply during the 6 months after the initial prescription fill, had a MPR for lipid lowering medications of < 80% (norm 23.4%).16.4% of the 827 members with antihyperlipidemic agents did not have any laboratory tests in the last 12 months (norm 16.4%).

Hyperlipidemia-Related Quality Care Gap Measures



HYPERTENSION MEMBERS ALLOWED PMPY TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS HYPERTENSION PREVALENCE

$6,1

53

$5,8

28

$5,2

40

$7,968 $7,651 $6,565

Year 1 Year 2 Norm


Hypertension

Compliant72%

Noncompliant28%

Employees64%

Spouses34%

Dependents1%

8.7%

10.9%

7490

100

200

300

400

500

600

700

800

0%

2%

4%

6%

8%

10%

12%

Prevalence Norm

Low Risk48%

Moderate Risk23%

High Risk21%

HCC8%

98

119

142

196

252

Diabetes

Osteoarthritis

Neck Pain

Hyperlipidemia

Back Pain

Hypertension Only32%

1 comorbidity26%

217%

3+25%






18-398%

40-6476%

65+16%



Hypertension Quality and Risk Measures

3.5% of the 749 members with hypertension had more than one hospitalization in the analysis period (norm 5.2%).

6.1% of the 749 members with hypertension did not have an office visit in the last 12 months (norm 4.8%).

0.4% of the 749 members with hypertension did not have an office visit in the analysis period (norm 0.6%).

0.0% of the 11 members with a hypertension-related ER visit did not have an office visit in the analysis period (norm 1.8%).

0.0% of the 1 members with a hypertension-related admission did not have an office visit in the analysis period (norm 0.8%).

Hypertension-Related Risk Measures

Hypertension-Related Quality Care Gap Measures



BACK PAIN MEMBERS ALLOWED PMPY TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS BACK PAIN PREVALENCE

0-176%

18-3928%

40-6461%

65+6%

Employees56%

Spouses30%

Dependents13%

Musculoskeletal – Back Pain

Low Risk53%

Moderate Risk22%

High Risk19%

HCC6%

Back Pain Only25%

1 comorbidity35%

222%

3+18%

Compliant86%

Noncompliant14%

$6,1

05

$5,9

98

$5,1

16

$7,931 $7,955

$6,468

Year 1 Year 2 Norm


23.0%

13.0%

1,9730

500

1,000

1,500

2,000

2,500

0%

5%

10%

15%

20%

25%

Prevalence Norm213

246

252

288

1035

Osteoarthritis

Hyperlipidemia

Hypertension

Depression

Neck Pain








Musculoskeletal – Back Pain Quality and Risk Measures

7.6% of the 1,138 members with low back pain have taken three or more narcotic prescriptions in a month (norm 11.3%).

4.1% of the 98 members with a back pain-related ER visit did not have office visit in the analysis period (norm 4.6%).

0.0% of the 11 members with a back pain-related admission did not have office visit in the analysis period (norm 0.1%).

6.1% of the 676 members with a new diagnosis of low back pain (current members only) had a CT or MRI within 6 weeks of initial diagnosis of low back pain (norm 12.6%).0.3% of the 676 members with a new diagnosis of low back pain (current members only) had lumbar spine surgery within 3 months of initial diagnosis of low back pain (norm 1.3%).

Back Pain-Related Risk Measures

Back Pain-Related Quality Care Gap Measures



NECK PAIN MEMBERS ALLOWED PMPY TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS NECK PAIN PREVALENCE

Musculoskeletal – Neck Pain

Low Risk49%

Moderate Risk25%

High Risk20%

HCC6%

Neck Pain Only1%

1 comorbidity44%

230%

3+25%

Compliant85%

Noncompliant15%

12.5%

5.7%

1,0690

200

400

600

800

1,000

1,200

0%

2%

4%

6%

8%

10%

12%

14%

Prevalence Norm

$6,8

11

$6,7

42

$5,3

21

$8,758 $8,879

$6,729

Year 1 Year 2 Norm


Employees58%

Spouses30%

Dependents12%

122

134

142

173

1035

Osteoarthritis

Hyperlipidemia

Hypertension

Depression

Back Pain






0-176%

18-3927%

40-6462%

65+5%



OSTEOARTHRITIS MEMBERS ALLOWED PMPY TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS OSTEOARTHRITIS PREVALENCE

Musculoskeletal – Osteoarthritis

Compliant72%

Noncompliant28%

Employees58%

Spouses41%

Dependents1%

Low Risk25%

Moderate Risk22%

High Risk35%

HCC17%

Osteoarthritis Only17%

1 comorbidity22%

225%

3+36%

$9,5

74

$9,0

68

$8,6

84

$12,107 $11,924 $10,575

Year 1 Year 2 Norm


4.7%

3.5%

4040

50

100

150

200

250

300

350

400

450

0%1%1%2%2%3%3%4%4%5%5%

Prevalence Norm57

104

119

122

213

Depression

Hyperlipidemia

Hypertension

Neck Pain

Back Pain






18-394%

40-6480%

65+16%



Musculoskeletal – Osteoarthritis Quality and Risk Measures

6.2% of the 404 members with osteoarthritis had continuous use of opiates across the last 12 months (norm 11.9%).

11.6% of the 404 members with osteoarthritis had hylan injections in the analysis period (norm 12.3%).

Osteoarthritis-Related Risk Measures


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.

Chronic Obstructive Pulmonary Disease (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.

Coronary Artery Disease (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 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

Age Gender Factor A comparison of population age and gender to the Lockton Book of Business Norm. The difference between the age gender factor and 1.00 (the norm) is the

expected difference in costs based on the population’s age and gender alone.

Allowed Amount Total cost, including 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

Comorbidities 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 copays, coinsurances, and deductibles paid by an enrollee, the spouses, and their dependents.

Employer Paid (Plan 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 nonemergent ER visits are visits that, 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.

84

Glossary (continued)

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.

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.

Noncompliant 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 12/31/2012 from Lockton’s Normative Database,

composed 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.

85


Outpatient Services that 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.

High Cost Script A prescription 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.

PMPY Per member per year.

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 is 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 divided by the Lockton Book of Business norm.

86


Relative Risk Score (RRS), DxCG Model 18 (concurrent) 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.

Relative Risk Score (RRS), DxCG Model 56 (prospective) 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 (AHFS). 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.

87

Methodology

Risk Assignment Risk is determined using a concurrent DxCG model. Concurrent models use base-period claims to predict expenditures incurred in the same time period. Sometimes called "profiling" models, they provide the most complete profile of the diagnoses treated and/or drug prescriptions filled within a population. Risk is distributed across all recorded conditions: chronic, traumatic, acute, and episodic conditions. Because these models capture the impact of all conditions, they are typically used for assessing plan performance.

The constant enrollment and disenrollment of members in populations is an expected occurrence. DxCG models account for this

effect in generating Relative Risk Scores (RRS) that reflect an entire year’s risk. Members eligible less than the full prediction

period have their observed risk systematically inflated. The models are weighted to statistically account for the inflation.

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.

Compliance The Care Gap Index (CGI) is used to determine compliance for care management. A numeric score assigned to each individual is

calculated by summing the weights assigned to each care gap present. Care gaps are derived from up to 36 months of claims

experience based on 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 divided by the Lockton InfoLock® Book of Business

norm.

Turnover and immature cycle periods can result in an understatement or overstatement of compliance.

88

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

www.lockton.com

© 2013 Lockton, Inc. All rights reserved. Images © 2013 Thinkstock. All rights reserved.

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

www.lockton.com

© 2012 Lockton, Inc. All rights reserved. Images © 2012 Thinkstock. All rights reserved.

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.

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