UNIVERSITY OF ALASKA EXECUTIVE SUMMARY L O

UNIVERSITY OF ALASKA
EXECUTIVE SUMMARY
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Report Specifications
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).
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.
1
Demographics

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.
LENGTH OF ENROLLMENT
MEMBERS BY RELATIONSHIP
< 12
months
9%
36 months
69%
12-23
months
10%
24-35
months
12%
32%
MEMBERS BY GENDER
35%
24%
20%
45%
45%
Year 2
Norm
Employee
Spouse
Dependent
Norm from Lockton InfoLock® Book of Business
47.1%
51.3%
52.9%
48.7%
Year 2
Norm
Female
Male
2
Population Risk & Compliance

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%)
High Cost
235 members
$77,037 PMPY
Noncompliant
343 members
$10,379 PMPY
Population
8,577 members
PRIORITY

GOAL
INTERVENTION
Manage high costs
Help members
navigate system
Case Management
Close gaps in care
Steerage
Disease
Management
and
Health Promotion
Manage risk factors
Reinforce and
monitor compliance
rates
Health Promotion
Manage risk factors
Health Promotion
High Risk
180 members
$13,576 PMPY
Moderate Risk
163 members
$6,851 PMPY
High Risk
643 members
$5,306 PMPY
Compliant
1,557 members
$8,926 PMPY
$12,816 PMPY
Moderate Risk
914 members
$6,176 PMPY
Low Risk
6,442 members
$1,454 PMPY
Norm from Lockton InfoLock® Book of Business
3
Illness Burden

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
NUMBER OF CHRONIC CONDITIONS PER MEMBER
56%
PLAN PAID PMPY BY NUMBER OF CHRONIC CONDITIONS
63%
$19,077
$14,833
20%
0 conditions
19%
1 condition
Actual
13%
10%
2 conditions
11%
$5,668
9%
3 or more conditions
$4,269
$7,247 $6,518
$1,878 $1,333
0 conditions
1 condition
Actual
Norm
Norm from Lockton InfoLock® Book of Business
2 conditions
3 or more
conditions
Norm
4
Disease Management/Personal Health Support
Condition
Asthma
Back Pain
Prevalence
3.2%
23.0%
Noncompliance
Paid PMPY*
Notes
3.2%
34.1%
35.3%
$6,720
$4,597
Alaska adjusted norm is $6,482
13.0%
14.0%
15.5%
$5,998
$5,116
Alaska adjusted norm is $7,214
CAD
1.0%
1.7%
63.3%
57.6%
$9,749
$9,101
Alaska adjusted norm is $12,832
COPD
0.3%
0.7%
81.5%
74.3%
$12,547
$9,096
Alaska adjusted norm is $12,825
Depression
7.3%
4.2%
14.6%
16.5%
$6,500
$5,562
Alaska adjusted norm is $7,842
Diabetes
4.0%
4.7%
80.1%
75.4%
$8,211
$6,960
Alaska adjusted norm is $9,814
Hyperlipidemia
7.1%
9.7%
21.5%
24.3%
$6,269
$5,009
Alaska adjusted norm is $7,063
Hypertension
8.7%
10.9%
27.5%
31.5%
$5,828
$5,240
Alaska adjusted norm is $7,388
12.5%
5.7%
14.6%
14.7%
$6,742
$5,321
Alaska adjusted norm is $7,503
4.7%
3.5%
28.0%
30.6%
$9,068
$8,684
Alaska adjusted norm is $12,244
Neck Pain
Osteoarthritis
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
Norm from Lockton InfoLock® Book of Business
5
DEMOGRAPHICS
Demographics – Total Members
Year 1
Year 2
AGE GENDER FACTOR
Norm
9,610
8,927
-
10,587
9,936
-
115,314
107,118
-
49,469
47,489
-
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%
Average Number of Members
Total Number of Members
Member Months
Employee Months
Age Gender Factor
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.
LENGTH OF ENROLLMENT
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.
Norm from Lockton InfoLock® Book of Business
7
Overview by Relationship
Employees
Average Age
Employee
Norm
Spouses
Spouse
Norm
Dependents
Dependent
Norm
Overall
Population
Norm
Overall
Population
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
RELATIVE RISK SCORE (RRS)
RELATIVE CARE GAP INDEX (RCGI)
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.
MEMBER PERCENTAGE BY RELATIONSHIP
PLAN PAID PMPM BY RELATIONSHIP
$615
32%
33%
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.
35%
Year 1
$544
$184
24%
24%
$596
20%
Year 2
$551
$254
45%
45%
43%
$358
Norm
Year 1
Year 2
Employee
Spouse
Norm
$487
$184
Employee
Dependent
Norm from Lockton InfoLock® Book of Business
Spouse
Dependent
8
Dependent Age Split by Paid Amount
FY 11 (July 10 to June 11)
Age Group Dependent Count
Paid Claims
0-18
1882 $
5,637,619.05
$ 2,870.36
19-26
814 $
2,378,958.67
$ 2,924.35
FY 12 (July 11 to June 12) Age Group Dependent Count
FY 13 (July 12 to June 13)
Paid Claims
PDPY
PDPY
0-18
1918 $
4,112,018.09
$ 2,045.86
19-26
902 $
2,778,253.63
$ 2,508.96
Age Group Dependent Count
Paid Claims
PDPY
0-18
1880 $
5,524,935.79
$ 2,893.02
19-26
834 $
3,139,607.49
$ 3,353.39
There is a increase in cost for those dependents between 19 to 26 compared to those less than age 18
9
FINANCIAL &
UTILIZATION ANALYSIS
Utilization Summary – Place of Service (POS)
YEAR 2 INCURRED % OF ALLOWED BY POS
Emergency
Room
8%
Office
35%
YEAR 2 INCURRED % MEMBER PAID (OF ALLOWED) BY POS
Other
4%
Inpatient
Hospital
25%
Outpatient
Hospital
28%
29%
17%
19%
18%
Emergency
Room
Other
11%
Inpatient
Hospital
Outpatient
Hospital
Office
Incurred indicates that dates are lagged three months and claims are being reported by service date.
Norm from Lockton InfoLock® Book of Business
11
Claim Expense Distribution
Year 1
Members
Paid Amount Range
Year 2
Plan Paid
Distribution
Members
Distribution
Norm
Plan Paid
Distribution
Members
Distribution
Plan Paid
Distribution
$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
ALL MEMBERS
182
1.7%
$19,415,825
36.8%
161
1.6%
$20,028,286
39.3%
0.8%
32.3%
10,587
100.0%
$52,778,174
100.0%
9,936
100.0%
$51,012,121
100.0%
100.0%
100.0%
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.
Exhibit includes all members who were enrolled or had a claim paid during the time period.
Norm from Lockton InfoLock® Book of Business
12
High Cost Claimants (HCC)
HIGH COST CLAIMANTS (HCC)
High Cost Claimants
Year 1
Number of Members
High cost claimants are members who
incurred $50,000 or more in claims
expense in either Year 1 or Year 2.
% Medical Paid
% Rx Paid
Medical Paid
Rx Paid
Total Paid
Average Medical Paid
Norm
182
163
-10.4%
-
40.2%
42.6%
5.9%
37.2%
16.2%
19.2%
19.0%
16.9%
$18,634,881
2.4%
-
$1,215,208
$1,393,404
14.7%
-
$19,415,825
$20,028,286
3.2%
-
$100,003
$114,324
14.3%
$106,543
$6,677
$8,548
28.0%
$11,113
$117,655
$106,680
$122,873
15.2%
Average RRS
8.9
12.8
43.3%
16.0
Average RCGI
2.9
2.8
-1.9%
4.1
NUMBER OF CHRONIC CONDITIONS PER HCC
HIGH COST CLAIMANTS (HCC)
0 conditions
5.0%
1 condition
22.8%
3 or more
conditions
52.6%
% Change
$18,200,617
Average Rx Paid
Average Total Paid
Year 2
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
2 conditions
19.5%
Norm from Lockton InfoLock® Book of Business
13
Emergency Room Demographics
ER VISITS BY RELATIONSHIP
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).
33%
ER by Number of Visits
Year 1
Visits per
Member
Members
% on
Weekends
26%
Year 2
%
Dependents
% of ER
Plan Paid
Members
38%
% 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%
24%
41%
38%
Year 1
Year 2
Employees
Spouses
Dependents
YEAR 2 ER VISITS/1,000 BY AGE AND GENDER
417.9
325.5
294.5
268.4
240.5
159.9
119.9
F
M
0-2
F
M
3-12
151.0
163.6
F
M
13-18
161.8
187.3
165.9
F
M
213.9
97.2
F
M
19-26
F
M
27-39
40-60
F
M
60+
14
ER High Utilizers Claims-Based Risk & Number of
Chronic Conditions
ER HIGH UTILIZERS BY RISK CATEGORY (DxCG Model 18)
ER HIGH UTILIZERS BY NUMBER OF CHRONIC CONDITIONS
Low, 16
HCC, 34
Moderate,
16
0 conditions
26
3+
47
1
27
High, 52
2
18
15
15
ER High Utilizers - Chronic Condition Prevalence
ER HIGH UTILIZERS CHRONIC CONDITION PREVALENCE
Asthma
8%
Back Pain
42%
CAD
3%
COPD
3%
Depression
20%
Diabetes
Hyperlipidemia
15%
8%
Hypertension
19%
Neck Pain
19%
Osteoarthritis
12%
16
16
ER High Utilizers - Utilization Patterns
ER VISITS BY DAY OF WEEK
ER HIGH UTILIZERS BY NUMBER OF VISITS
3
15%
13%
15%
16%
15%
14%
13%
65
4
19
5
12
6
3
7
Sunday
Monday
Tuesday Wednesday Thursday
Friday
6
8
2
9
1
Saturday
10+
10
17
17
ER High Utilizer - Utilization Categorization
ER HIGH UTILIZER VISITS BY TYPE
Potentially NonEmergent
Top 20 Primary Diagnosis Groups
18.4%
20.9%
2
$115,135
Abdominal Pain
70
$94,090
Limb Fractures
7
$90,473
10
$89,330
Neurotic and Personality Disorders
8
$68,998
Back Pain
8
$64,850
Paralytic States
1
$64,563
32
$57,791
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
Nausea and Vomiting
Preventable/
Avoidable
Intracranial Hemorrhage
9.3%
Not Preventable/
Avoidable
Injury
MHSA
Unclassified
21.3%
8.2%
6.1%
15.7%
Allowed Amount
Liver Diseases
Depression
Primary Care
Treatable
Visits
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
18
18
Emergency Room Utilization
ER VISITS BY TYPE
Difference from
Year 1 to Year 2
17.5%
Potentially NonEmergent
18.3%
19.0%
Primary Care
Treatable
Preventable/
Avoidable
6.0%
Year 2
(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
0.2%
(4)
Emergent, Not Preventable/Avoidable: immediate medical
care was required and ambulatory care treatment could not
have prevented the condition.
0.2%
The model identifies Injury claims separately from the probabilities
noted above.
1.3%
1.6%
4.9%
19.1%
16.2%
0.8%
20.4%
Injury
Unclassified
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:
21.4%
Not Preventable/
Avoidable
MHSA
-3.2%
In Focus: ER Visit
Classification
23.0%
3.7%
2.7%
14.3%
13.6%
Norm
-0.7%
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)
19
Emergency Room Utilization
ER VISITS PER 1,000 BY INCURRED (SERVICE) DATE WITHIN QUARTER
Emergency Room Visits by Top 20 Diagnosis Groups
Year 2
Primary Diagnosis Group
70
Misc Wounds and Injuries
Chest Pain
60
Visits
Allowed Amount
175
$239,687
95
$252,713
Abdominal Pain
132
$216,755
Limb Fractures
55
$150,088
Urinary Stones
44
$131,643
40
Depression
18
$115,407
Head Injuries
30
$111,271
30
Pregnancy Complications
57
$100,397
105
$75,385
50
ENT and Upper Resp Disorders
Liver Diseases
20
Neurotic and Personality Disorders
Appendicitis
10
Misc Symptoms
Musculoskeletal Disorders
0
Potentially Non-Emergent
$115,135
$101,153
8
$93,857
159
$91,020
86
$69,204
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
780
$2,171,713
2,035
$4,515,972
Fracture of Neck and Trunk
Injury
2
25
All Others
TOTAL
FY 14 implemented new Nurseline to redirect to appropriate care
20
PRESCRIPTION DRUG
ANALYSIS
Antihyperlipidemics Generic Analysis
In Focus: Potential Savings
by Switching to Generics
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
Year 1
Selected Statins
Brand/
Generic
Script
Count
Year 2
Rx Plan Paid
PMPM
Script
Count
Rx Plan Paid
PMPM
% 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%
All Other Antihyperlipidemics
1,080
$1.87
587
$1.64
-12.3%
ALL ANTIHYPERLIPIDEMICS
5,083
$5.78
4,140
$4.25
-26.6%
$48,755
Potential savings calculation is based on moving 50% of scripts for Lipitor, Crestor, and Lescol XL to Simvastatin.
22
Peptic Ulcer Generic Analysis
In Focus: Potential Savings
by Switching to Generics
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
$73,225
Year 1
Selected Peptic Ulcer
Drugs
Brand/
Generic
Script
Count
Year 2
Rx Plan Paid
PMPM
Prevacid
Brand
11
Nexium
Brand
Aciphex
Brand
Protonix
Script
Count
Rx Plan Paid
PMPM
$0.02
16
680
$1.56
30
$0.09
Brand
0
Kapidex
Brand
Prilosec
Brand
Axid
% Change in
Paid PMPM
$0.04
86.8%
540
$1.45
-7.0%
29
$0.09
9.3%
$0.00
0
$0.00
0.0%
0
$0.00
0
$0.00
0.0%
0
$0.00
0
$0.00
0.0%
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%
297
$0.20
260
$0.20
-3.7%
3,036
$2.96
2,796
$2.65
-10.5%
All Other Ulcer Drugs
ALL ULCER DRUGS
Potential savings calculation is based on moving 50% of scripts for Prevacid, Nexium, Aciphex, Protonix, Kapidex, Prilosec, Axid, and Zantac to Omeprazole.
23
Prescription Drugs - High Cost Scripts (>$1,000)
NUMBER OF HIGH COST SCRIPTS
640
PMPM PAID FOR HIGH COST SCRIPTS
675
$17.59
$17.01
Year 2
Norm
$13.14
Year 1
Year 2
Year 1
AVERAGE PLAN PAID PER PILL/UNIT FOR HIGH COST SCRIPTS
In Focus: Specialty Drug
Trend
$12.01
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.
$6.71
Source: URAC/Specialty Pharmacy white paper, “The PatientCentered Outgrowth of Specialty Pharmacy”
Year 1
Year 2
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.
Norm from Lockton InfoLock® Book of Business
24
Medical Pharmacy
Year 1
Medical Plan Paid PMPM
Rx Plan Paid PMPM
Total Plan Paid PMPM
Year 2
% Change
MEDICAL PHARMACY DRUGS
Norm
$19.23
$25.14
31%
$12.39
$6.62
$8.68
31%
$7.87
$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).
MEDICAL ALLOWED AMOUNT - TOP 10 MEDICAL PHARMACY DRUGS
Average Allowed
Amount per
Procedure
Injection, eculizumab, 10 mg
Bevacizumab Injection
$208,675
INJECTION, IMIGLUCERASE, 10
UN
Infliximab Injection
Trastuzumab
Injection, immune globulin, (f
Rituximab Cancer Treatment
$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
$250,072
Injection, Oxaliplatin, 0.5 Mg
Injection, natalizumab, 1 mg
$359,302 $39,922
$275,857
Injection, Pegfilgrastim, 6 Mg
$199,038
$179,549
$152,719
$135,189
$93,747
$82,673
Norm
Norm from Lockton InfoLock® Book of Business
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.
25
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.
Claims-Based Population Stratification
High Cost
235 members
Noncompliant
343 members
$10,379 PMPY
Population
8,577 members
PRIORITY
$77,037 PMPY
GOAL
INTERVENTION
Manage high costs
Help members
navigate system
Case Management
Close gaps in care
Steerage
Disease
Management
and
Health Promotion
Manage risk factors
Reinforce and
monitor compliance
rates
Health Promotion
Manage risk factors
Health Promotion
High Risk
180 members
$13,576 PMPY
Moderate Risk
163 members
$6,851 PMPY
High Risk
643 members
$5,306 PMPY
Compliant
1,557 members
$8,926 PMPY
$12,816 PMPY
Moderate Risk
914 members
$6,176 PMPY
Low Risk
6,442 members
$1,454 PMPY
PMPY amounts are plan paid.
27
Claims-Based Population Risk
KEY FACT
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.
Compliance
Stratification
Risk Category
Low Risk
Compliant
Noncompliant
Low Risk Sub-Total
Moderate Risk
Compliant
Noncompliant
TOTAL
75.3%
3.4%
$1,397 
$2,644 
$1,057
$2,252
18.8% 
1.7%
21.5%
2.2%
6,442
75.1% 
78.7%
$1,454 
$1,112
20.5% 
23.8%
914
10.7%
9.5%
$6,176 
$4,922
12.6%
13.2%
163
1.9%
2.0%
$5,585
2.5%
3.2%
$5,037
15.1%
16.4%
$10,889
18.4%
20.3%
$13,373
1,077
12.6%
11.5%
643
7.5%
6.6%
Noncompliant
180
2.1%
2.3%
$13,576
823
9.6%
8.9%
$12,984 
235
2.7%
0.9%
$77,037 
8,577
100%
100%
$5,306
High Cost Claimant
Plan Paid
Distribution
Norm
71.8% 
3.3%
Compliant
High Risk Sub-Total
Plan Paid
Paid PMPY
Distribution
Norm
6,156
286
$6,851 
$6,279 
$12,816 
Moderate Risk Sub-Total
High Risk
Member
Member
Year 2 Paid
Number of
Distribution
PMPY
Members Distribution
Norm
5.5% 
9.0%
$11,550
24.0% 
29.3%
$116,135
40.5% 
30.6%
$3,648
100%
Avg Age
33.7
46.6
47.3
49.5
100%
Distribution arrows indicate 2% or greater variance from the norm.
PMPY arrows indicate 5% or greater variance from the norm.
Norm from Lockton InfoLock® Book of Business
28
Claims-Based Population Risk
PLAN PAID PMPY BY RISK CATEGORY
MEMBERSHIP DISTRIBUTION
HCC, 2.7%
$12,984
$11,550
High, 9.6%
Moderate,
12.6%
HCC, 0.9%
High, 8.9%
Moderate,
11.5%
$6,279
$5,037
$1,454
Low,
75.1%
Low,
78.7%
Year 2
Norm
$1,112
Low Risk
Moderate
Year 2
High Risk
Norm
Norm from Lockton InfoLock® Book of Business
29
Utilization Metrics by Claims-Based Population
Risk
Low Risk
Compliant
Noncompliant
Current Year Metrics
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%
47.9%
16.5%
14.0%
358
615
% of Members with No Rx Claims
Utilization Metrics
ER Visits/1,000
81
Office Visits/1,000
2,006
7,092
8,183
Prescriptions/1,000
4,337
14,550
30,710
Preventive Care
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%
Care Avoiders
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.
30
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 noncompliant for disease management.
Chronic Conditions by Prevalence and Cost
PREVALENCE AND YEAR 2 PLAN PAID PMPY COMPARED TO BENCHMARK
QUADRANT I
Plan Paid PMPY Relative to Benchmark
2
Conditions in this quadrant
have a higher cost and
prevalence as compared to
the normative population.
Depression
Back Pain
1.5
Neck Pain
Osteoarthritis
1
0.5
0
1
1.5
2.5
2
3
0.5
QUADRANT III
Conditions in this quadrant
have a lower cost and
prevalence as compared to the
normative population.
0
Prevalence Relative to Benchmark
Back Pain
Hyperlipidemia
Diabetes
Hypertension
Depression
Asthma
COPD
Neck Pain
CAD
Osteoarthritis
Size of bubble is based on number of members with each chronic condition. Details in the Appendix
Norm from Lockton InfoLock® Book of Business
32
Cost of Noncompliance
PLAN PAID PMPY BY CHRONIC CONDITIONS AND COMPLIANCE
Asthma
Back Pain
Neck Pain
$7,964
$5,563
$9,021
$6,400
$9,093
$16,034
$11,772
$12,083
CAD
$8,379
$6,149
$8,789
$8,832
Diabetes
Hyperlipidemia
Hypertension
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.
$6,072
COPD
Depression
COMPLIANCE
$8,062
$5,662
$8,710
$5,337
$7,211
$8,562
Osteoarthritis
$10,499
Compliant
Noncompliant
This exhibit excludes high cost claimants. PMPY costs include comorbidities. Only members with at least one chronic condition are included.
33
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
34
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
35
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.
36
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
37
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.
38
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
39
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
40
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%
41
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)
42
Focus Area – Back Pain, Neck Pain, and
Intervertebral Disc Disorders
In Focus: How are Members
Treating Back Pain?
Top 10 Primary Procedure Groups for Back Pain, Neck Pain, and Disc Disorders in Year 2
Primary Procedure Group
Visits
Physical Therapy
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.
5,277
MRI Scan
Avg Paid/
Visit
Plan Paid
$767,298
$145
135
$210,388
$1,558
11
$178,565
$16,233
6
$163,023
$27,171
3,471
$152,603
$44
55
$80,997
$1,473
697
$78,382
$112
43
$66,983
$1,558
Rehab
456
$59,551
$131
Other Procedures
479
$56,860
$119
2
$55,799
$27,899
Neurosurgery
Orthopedic Surgery; exclude endoscopic
Chiropractic
Other Anesthesia
Office Visit - Established Patient
Neurology
Ambulance
X-ray
216
$47,932
$222
All Others
426
$159,841
$375
11,274
$2,078,223
$184
TOTAL
Year 2
Utilization
Category
Norm
Procedures/ Allowed/ Procedures/ Allowed/
1,000
Procedure
1,000
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
Norm from Lockton InfoLock® Book of Business
43
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
44
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
45
Malignant Neoplasms/Cancer Screenings
TOP 10 MALIGNANT NEOPLASM DIAGNOSES BY YEAR 2 PLAN PAID
Breast Cancer
Misc Cancers
Pancreatic Cancer
Prostate Cancer
Upper GI Cancer
Colorectal
6%
$440,910
Female Genital Organ
5%
$297,061
$266,848
Non-Early Identifiable
56%
Prostate
11%
Other
44%
Breast
19%
$258,026
Skin
3%
$159,893
Secondary Malignancy
$138,139
Lung Cancer
$130,359
Colorectal Cancer
$122,348
Urinary Tract Cancers
$118,367
Female Genital Organ
Cancer
$117,174
All Others
EARLY-IDENTIFIABLE CANCERS AS PERCENT OF CANCER-RELATED PLAN PAID
CANCER SCREENINGS
46%
45%
50%
50%
36%
34%
$231,759
Women >49 y/o with Women>20 y/o with pap Patients >49 y/o with any
mammogram in last 12
smear in the last two
colorectal cancer
months
years
screening in the analysis
period
Actual
Norm from Lockton InfoLock® Book of Business
Norm
46
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
47
APPENDIX
Prescription Drugs – Top 20 Drugs by Plan Paid
Amount
Year 2
Drug Name
Brand/
Generic Therapeutic Class
HUMIRA
Brand
COPAXONE
NEXIUM
Paid PMPM
PMPM
Norm
Scripts
Paid per
Pill/Unit
$3.12
$2.09
Brand
ANALGESICS - ANTI-INFLAMMATORY
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS -
$1.81
$1.15
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
$0.78
$0.42
422
$0.90
$0.76
$0.47
20
$687.11
$0.74
$1.61
38
$519.73
ONE TOUCH ULTRA TEST STRIPS Brand
143 $1,071.28
44 $4,395.44
REBIF
Brand
DIAGNOSTIC PRODUCTS
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS -
ENBREL
Brand
ANALGESICS - ANTI-INFLAMMATORY
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
49
Prescription Drugs – Top 20 Drugs by Script
Count
Year 2
Drug Name
Brand/
Generic
Therapeutic Class
LISINOPRIL
Generic
ANTIHYPERTENSIVES
Paid PMPM
Paid PMPM
Norm
$0.09
$0.05
Scripts
1,918
Paid per
Pill/Unit
$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
$0.11
$0.06
777
$0.31
MONTELUKAST SODIUM
Generic
ANTIDEPRESSANTS
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
ANTIHYPERTENSIVES
$0.04
$0.02
LISINOPRIL-HYDROCHLOROTHIAZ Generic
622
$0.12
$4.24
20,513
$0.46
All Others
$63.42
58,108
$1.70
TOTAL
$67.65
78,621
$1.45
Top 20 Drugs
50
Low Risk Members – Chronic Conditions
NUMBER OF CHRONIC CONDITIONS PER MEMBER
2
10%
TOP TEN CHRONIC CONDITIONS BY PREVALENCE
Back Pain
3+
4%
Neck Pain
1
18%
0
conditions
68%
16.2%
8.1%
Hypertension
5.6%
Depression
4.7%
Hyperlipidemia
4.3%
Asthma
2.5%
Diabetes
1.8%
Headache
1.8%
Osteoarthritis
1.6%
Congenital Anomalies
1.0%
51
Moderate and High Risk Compliant Members –
Demographics
MEMBERS BY GENDER
MEMBERS BY RELATIONSHIP
Dependent
14%
Male
37%
Spouse
29%
Female
63%
LENGTH OF ENROLLMENT
< 12
months
4%
MEMBERS BY AGE GROUP
12-23
months
10%
26%
21%
24-35
months
10%
16%
12%
7%
36 months
76%
Employee
57%
9%
8%
2%
0-1
2-19
20-29
30-39
40-49
50-59
60-64
65+
52
Low Risk Members – Demographics
MEMBERS BY GENDER
Male
51%
MEMBERS BY RELATIONSHIP
Dependent
38%
Female
49%
Employee
40%
Spouse
22%
LENGTH OF ENROLLMENT
MEMBERS BY AGE GROUP
Less than 12
months
9% 12 - 23
months
10%
27%
15%
36 months
68%
16%
16%
17%
24 - 35
months
13%
5%
2%
2%
0-1
2-19
20-29
30-39
40-49
50-59
60-64
65+
53
Moderate and High Risk Compliant Members –
Chronic Conditions
NUMBER OF CHRONIC CONDITIONS PER MEMBER
0
conditions
26%
3+
23%
2
25%
TOP TEN CHRONIC CONDITIONS BY PREVALENCE
Back Pain
42.1%
Neck Pain
1
26%
25.2%
Depression
14.3%
Hypertension
13.9%
Hyperlipidemia
13.3%
Osteoarthritis
10.5%
Headache
6.2%
Cancer
6.2%
Asthma
3.9%
Bipolar Disorder
3.2%
54
Moderate and High Risk Noncompliant Members –
Demographics
MEMBERS BY GENDER
MEMBERS BY RELATIONSHIP
Dependent
4%
Male
36%
Spouse
39%
Employee
57%
Female
64%
LENGTH OF ENROLLMENT
< 12
months
0%
MEMBERS BY AGE GROUP
12-23
months
6%
35%
24-35
months
7%
21%
19%
15%
36 months
87%
0%
0-1
2%
2%
2-19
20-29
5%
30-39
40-49
50-59
60-64
65+
55
Moderate and High Risk Noncompliant Members –
Chronic Conditions
NUMBER OF CHRONIC CONDITIONS PER MEMBER
0
conditions
3%
1
19%
TOP TEN CHRONIC CONDITIONS BY PREVALENCE
Back Pain
47.5%
Diabetes
44.3%
Hypertension
34.1%
Neck Pain
3+
57%
2
21%
26.2%
Hyperlipidemia
22.2%
Osteoarthritis
19.8%
Depression
15.2%
Asthma
14.6%
Headache
CAD
10.8%
9.3%
56
High Cost Claimants – Demographics
MEMBERS BY GENDER
MEMBERS BY RELATIONSHIP
Dependent
14%
Male
47%
Female
53%
Spouse
30%
LENGTH OF ENROLLMENT
< 12
months
3%
Employee
56%
MEMBERS BY AGE GROUP
12-23
months
8%
28%
24-35
months
10%
19%
17%
14%
9%
36 months
79%
3%
0-1
6%
5%
2-19
20-29
30-39
40-49
50-59
60-64
65+
57
High Cost Claimants – Chronic Conditions
NUMBER OF CHRONIC CONDITIONS PER MEMBER
0
conditions
4%
1
21%
TOP TEN CHRONIC CONDITIONS BY PREVALENCE
Back Pain
47.2%
Osteoarthritis
29.4%
Neck Pain
28.9%
Hypertension
3+
56%
2
19%
24.3%
Depression
22.6%
Cancer
19.6%
Hyperlipidemia
19.6%
Diabetes
Headache
CAD
15.3%
11.5%
9.8%
58
Moderate and High Risk Noncompliant Members –
Top Noncompliance Issues
Most Prevalent Gaps in Quality Care among Priority Segment of Population
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%).
Stoplights are yellow within 0.5% of the norm. The analysis period is the most recent 36 months of paid claims loaded in InfoLock®
59
Chronic Conditions per Member
NUMBER OF CHRONIC CONDITIONS PER MEMBER
56%
% OF PLAN PAID BY NUMBER OF CHRONIC CONDITIONS
63%
20%
0 conditions
19%
1 condition
13%
2 conditions
Actual
11%
10%
3 or more conditions
Norm
Actual
Actual
Norm
$7,247 $6,518
2 conditions
1 or more condition
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
$1,878 $1,333
1 condition
22%
CHRONIC CONDITIONS
$14,833
0 conditions
20%
No Chronic Conditions
$19,077
$4,269
78%
9%
PLAN PAID PMPY BY NUMBER OF CHRONIC CONDITIONS
$5,668
80%
3 or more
conditions
5.6% of members identified as having one or
more key chronic conditions had $0 in paid
claims in Year 2.
Norm
Norm from Lockton InfoLock® Book of Business
60
Top 5 Chronic Conditions
TOP 5 CHRONIC CONDITIONS BY CLAIMS-BASED RISK CATEGORIES
Back Pain
1,044
Neck Pain
655
519
Hypertension
358
Depression
300
Hyperlipidemia
280
0
392
217
223
207
163
111
90 68
117 57
5253
76 46
500
Low Risk
1,000
Moderate Risk
1,500
High Risk
2,000
2,500
High Cost Claimant
61
Asthma
Employees
47%
Members by Relationship
0-17
24%
Members by Age Group
18-39
25%
0%
50
276
Prevalence
0
Hypertension
31
Depression
30
Headache
$8,742
$8,807
$5,800
54
100
1%
1%
102
ASTHMA MEMBERS ALLOWED PMPY
24
Norm
$4,597
150
2%
Back Pain
Neck Pain
HCC
1%
$6,720
200
2%
High Risk
19%
Noncompliant
34%
300
250
3%
3+
20%
Moderate Risk
21%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
3%
2
15%
$6,804
ASTHMA PREVALENCE
3.2%
65+
5%
Compliant
66%
Members by Compliance
3.2%
1 comorbidity
25%
Low Risk
59%
Members by Risk Category
4%
40-64
47%
Asthma Only
40%
Number of Comorbidities
Dependents
32%
Spouses
21%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
62
Asthma Quality and Risk Measures
Asthma-Related 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%).
Asthma-Related Quality Care Gap Measures
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%).
Stoplights are yellow within 0.5% of the norm. The analysis period is the most recent 36 months of paid claims loaded in InfoLock®
Norm from Lockton InfoLock® Book of Business
63
Chronic Obstructive Pulmonary Disease (COPD)
Employees
48%
Members by Relationship
Members by Age Group
Number of Comorbidities
Members by Risk Category
Members by Compliance
0-17
4%
Spouses
48%
40-64
52%
COPD Only
0%
65+
44%
1 comorbidity
33%
Low Risk
19%
2
22%
3+
44%
Moderate Risk
22%
High Risk
41%
Compliant
19%
COPD PREVALENCE
HCC
19%
Noncompliant
81%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
1%
Dependents
4%
COPD MEMBERS ALLOWED PMPY
30
0.7%
1%
25
$16,079
Back Pain
10
$12,914
$11,158
1%
15
0.3%
0%
0%
0%
0%
Hypertension
8
10
5
27
Prevalence
0
Norm
Depression
6
Osteoarthritis
6
$9,096
0%
9
$12,547
1%
Diabetes
$10,214
20
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
64
COPD Quality and Risk Measures
COPD-Related 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%).
COPD-Related Quality Care Gap Measures
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%).
Stoplights are yellow within 0.5% of the norm. The analysis period is the most recent 36 months of paid claims loaded in InfoLock®
Norm from Lockton InfoLock® Book of Business
65
Coronary Artery Disease (CAD)
Members by Relationship
CAD Only
11%
1.7%
Moderate Risk
20%
High Risk
37%
1%
80
70
1.0%
60
1%
50
1%
40
1%
20
Back Pain
36
Hyperlipidemia
Prevalence
0
Hypertension
33
Diabetes
Norm
Osteoarthritis
$12,254
$11,087
34
26
10
90
CAD MEMBERS ALLOWED PMPY
$14,768
30
0%
HCC
26%
Noncompliant
63%
100
90
0%
3+
52%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
2%
0%
2
18%
Compliant
37%
CAD PREVALENCE
1%
1 comorbidity
19%
Low Risk
18%
Members by Compliance
2%
65+
38%
21
$9,101
Members by Risk Category
40-64
61%
18-39
1%
Dependents
0%
$9,749
Number of Comorbidities
Spouses
40%
$12,146
Members by Age Group
Employees
60%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
66
CAD Quality and Risk Measures
CAD-Related 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%).
CAD-Related Quality Care Gap Measures
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%).
Stoplights are yellow within 0.5% of the norm. The analysis period is the most recent 36 months of paid claims loaded in InfoLock®
Norm from Lockton InfoLock® Book of Business
67
Depression
Employees
55%
Members by Relationship
0-17
7%
18-39
35%
40-64
55%
Depression Only
31%
Number of Comorbidities
1 comorbidity
26%
500
4.2%
4%
100
628
Prevalence
0
Norm
$8,611
$7,027
173
Hypertension
76
200
2%
0%
Neck Pain
$8,680
400
300
3%
288
Hyperlipidemia
65
Headache
63
$5,562
5%
Back Pain
DEPRESSION MEMBERS ALLOWED PMPY
$6,500
6%
1%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
600
HCC
8%
Noncompliant
15%
700
7%
High Risk
21%
Compliant
85%
DEPRESSION PREVALENCE
7.3%
3+
24%
Moderate Risk
23%
Members by Compliance
8%
65+
4%
2
20%
Low Risk
48%
Members by Risk Category
Dependents
20%
$6,739
Members by Age Group
Spouses
25%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
68
Depression Quality and Risk Measures
Depression-Related 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%).
Depression-Related Quality Care Gap Measures
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%).
Stoplights are yellow within 0.5% of the norm. The analysis period is the most recent 36 months of paid claims loaded in InfoLock®
Norm from Lockton InfoLock® Book of Business
69
Diabetes
Employees
60%
Members by Relationship
Members by Age Group
0-17 18-39
2% 12%
124
$11,482
$10,400
$8,585
250
3%
200
2%
150
2%
100
1%
50
341
Prevalence
0
Norm
Hypertension
98
Hyperlipidemia
71
Neck Pain
Osteoarthritis
64
45
$6,960
3%
0%
Back Pain
DIABETES MEMBERS ALLOWED PMPY
300
4%
1%
Noncompliant
80%
400
350
4.0%
HCC
11%
$8,211
4%
High Risk
28%
$9,280
5%
3+
30%
Moderate Risk
28%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
4.7%
5%
2
19%
Compliant
20%
DIABETES PREVALENCE
65+
16%
1 comorbidity
20%
Low Risk
34%
Members by Risk Category
Dependents
5%
40-64
70%
Diabetes Only
31%
Number of Comorbidities
Members by Compliance
Spouses
35%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
70
Diabetes Quality and Risk Measures
Diabetes-Related 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%).
Diabetes-Related Quality Care Gap Measures
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%).
Stoplights are yellow within 0.5% of the norm. The analysis period is the most recent 36 months of paid claims loaded in InfoLock®
Norm from Lockton InfoLock® Book of Business
71
Hyperlipidemia
Employees
65%
Members by Relationship
Members by Age Group
Number of Comorbidities
Hyperlipidemia Only
21%
1 comorbidity
29%
9.7%
High Risk
22%
600
HCC
8%
Noncompliant
22%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
500
7.1%
3+
28%
Moderate Risk
25%
700
10%
HYPERLIPIDEMIA MEMBERS ALLOWED PMPY
$8,670
Back Pain
246
$8,150
$6,281
Hypertension
196
134
200
2%
100
609
Prevalence
0
Norm
Osteoarthritis
Diabetes
104
71
$5,009
Neck Pain
$6,269
300
4%
$6,780
400
6%
0%
2
21%
Compliant
78%
Members by Compliance
8%
65+
15%
Low Risk
46%
HYPERLIPIDEMIA PREVALENCE
Dependents
1%
40-64
78%
18-39
6%
Members by Risk Category
12%
Spouses
34%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
72
Hyperlipidemia Quality and Risk Measures
Hyperlipidemia-Related Quality Care Gap 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%).
Stoplights are yellow within 0.5% of the norm. The analysis period is the most recent 36 months of paid claims loaded in InfoLock®
Norm from Lockton InfoLock® Book of Business
73
Hypertension
Employees
64%
Members by Relationship
Members by Age Group
Hypertension Only
32%
HYPERTENSION PREVALENCE
HCC
8%
Noncompliant
28%
800
HYPERTENSION MEMBERS ALLOWED PMPY
$7,968
Back Pain
252
$7,651
$6,565
400
300
4%
200
2%
100
749
0
Norm
196
Neck Pain
142
Osteoarthritis
Diabetes
119
98
$5,240
6%
Hyperlipidemia
$5,828
500
Prevalence
High Risk
21%
600
8%
0%
Moderate Risk
23%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
700
8.7%
3+
25%
$6,153
10%
2
17%
Compliant
72%
Members by Compliance
10.9%
65+
16%
1 comorbidity
26%
Low Risk
48%
Members by Risk Category
Dependents
1%
40-64
76%
18-39
8%
Number of Comorbidities
12%
Spouses
34%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
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Hypertension Quality and Risk Measures
Hypertension-Related Risk Measures
3.5% of the 749 members with hypertension had more than one hospitalization in the analysis period (norm 5.2%).
Hypertension-Related Quality Care Gap Measures
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%).
Stoplights are yellow within 0.5% of the norm. The analysis period is the most recent 36 months of paid claims loaded in InfoLock®
Norm from Lockton InfoLock® Book of Business
75
Musculoskeletal – Back Pain
Employees
56%
Members by Relationship
Members by Age Group
0-17
6%
Spouses
30%
18-39
28%
40-64
61%
Back Pain Only
25%
Number of Comorbidities
1 comorbidity
35%
Moderate Risk
22%
BACK PAIN PREVALENCE
2,500
1035
$6,468
5%
500
1,973
Prevalence
0
Norm
288
Hypertension
252
Hyperlipidemia
246
Osteoarthritis
213
$5,116
1,000
Depression
$5,998
1,500
$6,105
13.0%
10%
0%
$7,955
2,000
15%
HCC
6%
BACK PAIN MEMBERS ALLOWED PMPY
$7,931
Neck Pain
20%
High Risk
19%
Noncompliant
14%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
23.0%
3+
18%
Compliant
86%
Members by Compliance
25%
65+
6%
2
22%
Low Risk
53%
Members by Risk Category
Dependents
13%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
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Musculoskeletal – Back Pain Quality and Risk
Measures
Back Pain-Related 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%).
Back Pain-Related Quality Care Gap Measures
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%).
Stoplights are yellow within 0.5% of the norm. The analysis period is the most recent 36 months of paid claims loaded in InfoLock®
Norm from Lockton InfoLock® Book of Business
77
Musculoskeletal – Neck Pain
Employees
58%
Members by Relationship
18-39
27%
Neck Pain Only
1%
40-64
62%
1 comorbidity
44%
2
30%
Low Risk
49%
Members by Risk Category
1,200
10%
800
8%
5.7%
6%
0%
1035
200
1,069
Prevalence
0
Norm
Hypertension
142
Hyperlipidemia
134
Osteoarthritis
$6,729
173
400
4%
2%
600
Depression
$8,879
122
$5,321
1,000
NECK PAIN MEMBERS ALLOWED PMPY
$8,758
Back Pain
HCC
6%
Noncompliant
15%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
12%
High Risk
20%
Compliant
85%
NECK PAIN PREVALENCE
12.5%
3+
25%
Moderate Risk
25%
Members by Compliance
14%
65+
5%
$6,742
Number of Comorbidities
0-17
6%
Dependents
12%
$6,811
Members by Age Group
Spouses
30%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
78
Musculoskeletal – Osteoarthritis
Employees
58%
Members by Relationship
Members by Age Group
18-39
4%
Number of Comorbidities
Osteoarthritis Only
17%
Members by Risk Category
Low Risk
25%
1 comorbidity
22%
3.5%
Moderate Risk
22%
High Risk
35%
HCC
17%
Noncompliant
28%
Back Pain
213
OSTEOARTHRITIS MEMBERS ALLOWED PMPY
$12,107
$11,924
$10,575
350
300
3%
Neck Pain
122
Hypertension
119
2%
1%
100
1%
50
404
Prevalence
0
Norm
Hyperlipidemia
Depression
104
57
$8,684
150
$9,068
200
2%
$9,574
250
3%
0%
3+
36%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
400
4%
2
25%
450
5%
4%
65+
16%
Compliant
72%
OSTEOARTHRITIS PREVALENCE
4.7%
Dependents
1%
40-64
80%
Members by Compliance
5%
Spouses
41%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
79
Musculoskeletal – Osteoarthritis Quality and Risk
Measures
Osteoarthritis-Related 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%).
Stoplights are yellow within 0.5% of the norm. The analysis period is the most recent 36 months of paid claims loaded in InfoLock®
Norm from Lockton InfoLock® Book of Business
80
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 worklife 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.
81
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.
82
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.
83
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.
84
Glossary (continued)










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.
85
Glossary (continued)





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.
86
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.
87
Our Mission
To be the worldwide value and service leader in
insurance
insurance brokerage,
brokerage, employee
employee benefits,
benefits, and
and risk
risk management
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
© 2013 Lockton, Inc. All rights reserved.
Images © 2013 Thinkstock. All rights reserved.
© 2012 Lockton, Inc. All rights reserved.
Images © 2012 Thinkstock. All rights reserved.
88