Download UNIVERSITY OF ALASKA FY 15 MEMBER HEALTH RISK STATUS NOVEMBER 11, 2015

UNIVERSITY OF ALASKA
FY 15 MEMBER HEALTH RISK STATUS
NOVEMBER 11, 2015
L
O
C
K
T
O
N
C
O
M
P
A
N
I
E
S
Report Specifications
Reporting Period

Year 2 is based on claims paid from July 1, 2014 to June 30, 2015 (FY 15)

Year 1 is based on claims paid from July 1, 2013 to June 30, 2014 (FY 14)
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 6/30/2014.

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
1
Demographics – Total Members
Year 1
Year 2
AGE GENDER FACTOR
Norm
Average Number of Members
8,714
8,495
-
Total Number of Members
9,684
9,431
-
104,566
101,936
-
47,163
45,722
-
1.12
1.12
1.00
Employee Age Gender Factor
1.36
1.36
1.17
Spouse Age Gender Factor
1.41
1.41
1.35
Dependent Age Gender Factor
0.55
0.56
0.61
2.23
2.25
2.17
Member Months
Employee Months
Age Gender Factor
Member-to-Employee Ratio
Average Age
37.0
36.9
33.7
% Female of Total Population
52%
52%
49%
% of Female Population in Childbearing Years
42%
42%
43%
LENGTH OF ENROLLMENT (FOR CURRENT ACTIVE MEMBERS)
< 12
months
9%
36 months
70%
12-23
months
11%
24-35
months
10%
Age gender factor is 1.12, which means that costs
are expected to be 11.9% 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.
MEMBERS BY GENDER
47.7%
47.7%
51.3%
52.3%
52.3%
48.7%
Year 1
Year 2
Norm
Female
Norm from Lockton InfoLock® Book of Business
Male
2
Overview by Relationship
Employees
Average Age
Employee
Norm
Spouses
Spouse
Norm
Dependents
Dependent
Norm
Overall
Population
Overall
Population
Norm
47
44
49
46
14
13
37
34
% Female
55%
40%
51%
71%
49%
49%
52%
49%
Average RRS
1.45
1.23
1.44
1.62
0.56
0.53
1.16
1.00
Average RCGI
1.52
1.16
1.63
1.37
0.66
0.61
1.27
1.00
RELATIVE RISK SCORE (RRS)
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 1.16 indicates that your population is
predicted to spend/use 16.5% more in healthcare resources
compared to the book of business normative population.
RELATIVE CARE GAP INDEX (RCGI)
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 1.27 indicates that your population is
27.2% less compliant than the book of business normative
population.
Norm from Lockton InfoLock® Book of Business
3
Overview by Relationship
YEAR 2 – July 1, 2014 to June 30, 2015
 Employees drove 48% of the plan costs and were 44% of the population
 Spouses drove 35% of the plan costs and were 24% of the population
 Dependents drove 17% of the plan costs and were 32% of the population
MEMBER PERCENTAGE BY RELATIONSHIP
PLAN PAID PMPM BY RELATIONSHIP
$690
31%
32%
35%
Year 1
$512
$245
24%
24%
19%
$750
Year 2
$546
$256
45%
46%
44%
$399
Norm
Year 1
Year 2
Employee
Spouse
Norm
$556
$203
Employee
Dependent
Norm from Lockton InfoLock® Book of Business
Spouse
Dependent
4
InfoLock® Overview
 Overall Population’s RRS is 1.16 (norm 1.00)
 Overall Population’s RCGI is 1.27 (norm 1.00)
 High risk & Moderate risk noncompliant members cost 16.0% more than compliant members
GOAL
PRIORITY
High Cost
259 members
$79,654 PMPY
Noncompliant
358 members
$11,330 PMPY
Population
8,132 members
$6,083 PMPY
Compliant
1,587 members
$9,743 PMPY
High Risk
182 members
$14,971 PMPY
Moderate Risk
176 members
$7,572 PMPY
High Risk
666 members
$14,005 PMPY
Moderate Risk
921 members
$6,637 PMPY
Low Risk
5,928 members
$1,473 PMPY
INTERVENTION
Manage high costs
Help members
navigate system
Case Management
Close gaps in care
Steerage
Direct Intervention
Disease Management
and
Health Promotion
Manage risk factors
Reinforce and
monitor compliance
rates
Disease Management
Health Promotion
Manage risk factors
Health Promotion
Norm from Lockton InfoLock® Book of Business
5
Disease Management
Condition
Asthma
Back Pain
Prevalence
3.5%
23.7%
Noncompliance
Paid PMPY*
Notes
3.1%
39.4%
35.3%
$7,278
$4,839
Adjusted Alaska Norm $7,017
13.0%
14.1%
15.8%
$6,560
$5,319
Adjusted Alaska Norm $7,713
CAD
1.0%
1.4%
60.8%
56.2%
$9,282
$9,711
Adjusted Alaska Norm $14,081
COPD
0.3%
0.6%
82.6%
73.7%
$7,188
$9,463
Adjusted Alaska Norm $13,721
Depression
7.9%
4.4%
13.8%
16.7%
$7,227
$5,768
Adjusted Alaska Norm $8,364
Diabetes
4.1%
4.6%
82.0%
72.7%
$9,392
$7,755
Adjusted Alaska Norm $11,245
Hyperlipidemia
8.2%
8.7%
23.0%
25.2%
$6,538
$5,337
Adjusted Alaska Norm $7,739
Hypertension
9.1%
10.2%
31.9%
32.0%
$7,169
$5,597
Adjusted Alaska Norm $8,116
12.7%
5.7%
13.7%
15.0%
$7,178
$5,545
Adjusted Alaska Norm $8,040
5.5%
3.7%
29.3%
30.2%
$9,580
$9,146
Adjusted Alaska Norm $13,262
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
6
Claims-Based Population Risk
PLAN PAID PMPY BY RISK CATEGORY
MEMBERSHIP DISTRIBUTION
$14,214
$11,636
HCC, 3.2%
High,
10.4%
Moderate,
13.5%
HCC, 1.2%
High, 9.9%
Moderate,
12.0%
$6,790
$4,821
$1,473
Low,
72.9%
Low,
76.9%
Year 2
Norm
$1,096
Low Risk
Moderate
Year 2
High Risk
Norm
Year 2 is July 1, 2014 to June 30, 2015
Norm from Lockton InfoLock® Book of Business
7
Utilization Metrics by Claims-Based Population
Risk
Low Risk
Compliant
Noncompliant
Current Year Metrics
Number of Members
5,928
1,587
358
% of Members with No Claims
19.7%
0.1%
0.0%
% of Members with No Medical Claims
22.1%
0.3%
0.0%
% of Members with No Rx Claims
55.9%
20.4%
14.2%
66
302
705
Office Visits/1,000
1,757
6,279
6,604
Prescriptions/1,000
2,922
9,970
19,622
Preventive Care
24.9%
37.6%
28.9%
Well-Child Exam
43.3%
33.6%
41.7%
Mammogram
38.5%
62.7%
30.1%
Pap Smear
37.9%
51.0%
27.7%
Colorectal Screening
25.6%
47.0%
32.9%
Utilization Metrics
ER Visits/1,000
Adult Preventive Exam
POTENTIAL CARE AVOIDANCE
19.7% of low risk members had $0 in paid claims in Year 2, and only 24.9%
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.
8
Chronic Conditions by Prevalence and Cost
PREVALENCE AND YEAR 2 PLAN PAID PMPY COMPARED TO BENCHMARK
QUADRANT I
2
Plan Paid PMPY Relative to Benchmark
Conditions in this quadrant
have a higher cost and
prevalence as compared to
the normative population.
1.5
1
0
0.5
1
1.5
2
2.5
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.
Norm from Lockton InfoLock® Book of Business
9
Chronic Conditions per Member
NUMBER OF CHRONIC CONDITIONS PER MEMBER
% OF PLAN PAID BY NUMBER OF CHRONIC CONDITIONS
64%
55%
20%
0 conditions
18%
1 condition
13%
2 conditions
Actual
12%
10%
3 or more conditions
Norm
Norm
1 or more condition
45.1% (norm 36.4%) of the population has one or
more key chronic conditions and represents 83.5%
(norm 78.1%) of plan costs.
POTENTIAL CARE AVOIDANCE
$1,863 $1,431
Actual
Actual
$7,327
$4,850
1 condition
22%
CHRONIC CONDITIONS
$16,870
0 conditions
17%
No Chronic Conditions
$21,693
$8,329
78%
8%
PLAN PAID PMPY BY NUMBER OF CHRONIC CONDITIONS
$6,197
83%
2 conditions
3 or more
conditions
5.7% 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
10
Top 5 Chronic Conditions
TOP 5 CHRONIC CONDITIONS BY CLAIMS-BASED RISK CATEGORIES
Back Pain
935
Neck Pain
695
461
409
Hypertension
314
227
Hyperlipidemia
298
235
83 54
Depression
302
239
5049
0
163
135
88 74
132 70
500
Low Risk
1,000
Moderate Risk
1,500
High Risk
2,000
2,500
High Cost Claimant
11
Cost of Noncompliance
PLAN PAID PMPY BY CHRONIC CONDITIONS AND COMPLIANCE
COMPLIANCE
$6,568
Asthma
$8,396
$6,013
Back Pain
$10,329
$6,690
Neck Pain
The overall cost for a noncompliant
member is $8,099 versus $5,651 for a
compliant member. Compliance is
determined by a member’s Relative Care
Gap Index (RCGI). Members with high
RCGI scores are considered
noncompliant.
$10,720
$6,667
COPD
$7,289
$8,805
CAD
$9,723
$6,792
Depression
$10,332
$11,411
Diabetes
$8,948
$6,129
Hyperlipidemia
$7,949
$6,869
Hypertension
$7,837
$9,378
Osteoarthritis
$10,148
Compliant
Noncompliant
This exhibit excludes high cost claimants. PMPY costs include comorbidities. Only members with at least one chronic condition are included.
12
Cost Adjustment
 1In the ACCRA Cost of Living Index, health care costs in
Alaska’s cities (Fairbanks, Anchorage and Juneau ranged
from 37.8% to 49.1% more costly than the average U.S.
city in 2014
 The InfoLock Norm has not been adjusted for the higher
costs in Alaska
 Analysis Summary will compare UA costs to adjusted norm of norm
plus 45.0%
1http://laborstats.alaska.gov/col/col.pdf
13
Asthma Summary & Observations
 Asthma
 Prevalence is above the norm with UA costs of $7,278 per member per year (pmpy)
compared to the adjusted norm of $7,017 pmpy
 61% of the members with asthma are compliant in medication and doctor visits
 Decrease from 64% from July 2013 to June 2014 (FY 14)
 Patients with more than one asthma-related emergency room visit is slightly below
the norm
 22.3% of members with Asthma are without inhaled corticosteroids or leukotriene
inhibitors compared to the norm of 29.3% without inhalers
 An increase from 21.5% in FY 14
 Recommendation:
 Premera send communications and out-reach to members with emergency room visits for
Asthma
 Utilize Patient Care & Premera’s ESI page (MyPharmacyPlus) to find the lowest cost
asthma medications
14
COPD Summary & Observations
 COPD (Chronic Obstructive Pulmonary Disease)
 Prevalence is below the norm with UA costs of $7,188 pmpy compared to the
adjusted norm of $13,721 pmpy
 83% of the members with COPD are non-compliant due to lack of doctor visits and
increased ER visits
 Improvement from 87% of members with COPD being non-complaint
 52% have three or more co-morbidities up from 43% in FY 14
 17.4% of members with COPD had more than one hospitalization (norm of 17.2%)
 The number of members with COPD who had an ER visit was 26.1% with the norm
@ 14.4%
 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. One of Healthyroads
coaching tracks is for tobacco cessation and it is a wellness credit.
15
CAD Summary & Observations
 CAD (Coronary Artery Disease)
 Prevalence is below the norm with UA costs of $9,282 pmpy compared to the
adjusted norm of $14,081 pmpy
 High Risk members make up 41% of the group was 34%
 High Cost Claimants make up 34% of the group was 30%
 52% have 3 or more co-morbidities
 6.3% are depressed which is above the norm of 5.3%
 15.4% are not taking their medications (Beta-blockers, ACE/ARB or Statins)
 Patients with obesity are above the norm (3.8% vs. norm at 2.3%
 There was an decrease in compliance from 43% to 39% of members being
compliant and now 61% of members non-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
16
Depression Summary & Observations
 Depression
 Prevalence is significantly above the norm and UA costs are $7,227 pmpy compared
to the adjusted norm of $8,364 pmpy
 Employees make up 53% of the depressed population
 Back and Neck pain are the top two co-morbidities
 There is a high compliance rate of 86%
 Below the norm for hospitalization and depression-related ER visits
 Patients without an office visit in the last 12 months is slightly above the norm (4.5% vs.
4.4%)
 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.
17
Diabetes Summary & Observations
 Diabetes
 Prevalence is below the norm with UA costs of $9,392 pmpy compared to the
adjusted norm of $11,245 pmpy
 82% of the population is non-compliant was at 79% in FY 14
 There is significant non-compliance in this population with 58% in the moderate and high
risk category and 10% are High Cost Claimants
 There were 5.0% of the diabetic members with a diabetes-related ER visit
 92.8% did not have a semi-annual HbA1c test
 Obesity is an issue within the University as the percent of the diabetic population
that is obese is slightly below the norm (2.8% to 3.5%)
 Continue to promote Disease Management, On-Campus wellness visits and vision
exams
 Promote biometric screenings to keep pre-diabetic from becoming diabetic
 Encourage participation in the Wellness Program
 Implement Weight Loss program (i.e. Retrofit)
18
Hyperlipidemia Summary & Observations
 Hyperlipidemia (High Cholesterol)
 Lower prevalence to the norm with UA costs of $6,538 pmpy compared to the
adjusted norm of $7,739
 65% of the population are employees
 23% of the population is high risk but has a high compliance rate of 77%
 8% of the population are high cost claimants
 16.4% did not have lab tests in the last 12 months (norm of 16.8%)
 Recommend pharmacy oversight (i.e. Excelsior Rx) to ensure new Cholesterol
drug(s) are administered per clinical best practices
19
Hypertension Summary & Observations
 Hypertension (High Blood Pressure)
 Prevalence is lower the norm and UA costs of $7,169 pmpy compared to the
adjusted norm of $8,116 pmpy
 67% of members with hypertension are employees
 48% of the population is high or moderate risk but with a moderate compliance rate
of 68%
 30% of members have 3+ comorbidities
 Hypertension related ER visits are above the norm
 6.2% of the population did not have an office visit in the last 12 months compared
to the norm at 4.7%
 Recommend health coaching for stress management and weight management
through HealthyRoads and Retrofit.
20
Back & Neck Pain Summary & Observations
 Back & Neck Pain
 56% of the members with back pain were employees
 21% of the members with back pain are categorized as high risk
 Approximately 53% of back pain members had associated neck pain
 Significantly higher utilization of chiropractic and physical therapy care compared to
the norm
 Chiropractic visits/1,000 are 640 compared to the norm of 370
 Physical Therapy visits/1,000 are 787 compared to the norm of 331
 MRI Scans and CT Scans are below the norm on visits/1,000
 Paid per procedure for CT Scans are below the adjusted norm cost
 Paid per procedure for MRI Scans are significantly above the adjusted norm cost
 Utilize Patient Care price transparency tools
21
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
Orthopedic Surgery; exclude endoscopic
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.
Physical Therapy
15
$909,849
$60,657
5,008
$800,044
$160
Neurosurgery
18
$532,306
$29,573
143
$231,707
$1,620
3,463
$154,365
$45
869
$152,575
$176
52
$117,760
$2,265
MRI Scan
Chiropractic
Avg Paid/
Visit
Plan Paid
Office Visit - Established Patient
Other Anesthesia
Neurology
Rehab
Emergency Room
52
$117,314
$2,256
408
$58,280
$143
63
$57,472
$912
X-ray
214
$51,168
$239
Other Procedures
426
$49,507
$116
All Others
428
$203,111
$475
11,159
$3,435,458
$308
TOTAL
Utilization
Year 2
Norm
Procedures/
1,000
Allowed/
Procedure
Procedures/
1,000
Allowed/
Procedure
Chiropractic
640
$72
370
$38
Physical Therapy
787
$158
331
$54
CT Scan
1.6
$723
4.4
$669
MRI Scan
17
$1,944
29
$856
Category
Norm from Lockton InfoLock® Book of Business
22
Osteoarthritis Summary & Observations
 Osteoarthritis
 Prevalence is above the norm and UA costs of $9,580 pmpy compared to the
adjusted norm of $13,262 pmpy
 58% of the members with osteoarthritis were employees
 29% of the members with osteoarthritis are categorized as high risk
 20% of the members with osteoarthritis are high cost claimants
 71% of the members are compliant
23
Cancer & Screenings Summary & Observations
 Malignant Neoplasms & Cancer Screenings
 Cancer screenings (e.g. colonoscopy) are at or better than the norm except for pap
smear
 66% 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
24
Malignant Neoplasms/Cancer Screenings
TOP 10 MALIGNANT NEOPLASM DIAGNOSES BY YEAR 2 PLAN PAID
Breast Cancer
$857,508
Colorectal Cancer
Misc Cancers
$817,379
$298,229
Upper GI Cancer
$157,812
Prostate Cancer
$157,416
ENT Cancers
Non-Early
Identifiable
34%
$128,770
Female Genital Organ
Cancer
$126,845
Colorectal
27%
Breast
29%
Other
66%
Skin
1%
$153,406
Multiple Myeloma
Prostate
5%
Female Genital Organ
4%
CANCER SCREENINGS
46%
46%
42%
44%
35%
Lymphoma and
Lymphosarcoma
$81,808
Secondary Malignancy
$65,552
All Others
EARLY-IDENTIFIABLE CANCERS AS PERCENT OF CANCER-RELATED PLAN PAID
34%
$170,462
Women >49 y/o with
mammogram in last 12
months
Women>20 y/o with pap Patients >49 y/o with any
smear in the last two
colorectal cancer
years
screening in the analysis
period
Actual
Norm from Lockton InfoLock® Book of Business
Norm
25
Recommendations
 Better integrate Patient Care & Best Doctors with Premera & HealthyRoads
 Encourage & Promote Patient Care to assist members in choosing the lowest
cost service provider/facility
 Communicate to employees no cost preventive care and screenings
 Emergency Room - Specific communication on using alternative care setting
for non-emergent care
 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
 Promotion of Wellness program to know your numbers and encourage use of
programs and tools to improve lifestyle and behaviors
 Stress & Weight Management
 Promotion of medical travel benefit for back and neck procedures
 Investigate Retrofit weight loss program
26
APPENDIX
Medical Pharmacy
Year 1
Medical Plan Paid PMPM
Rx Plan Paid PMPM
Total Plan Paid PMPM
Year 2
% Change
MEDICAL PHARMACY DRUGS
Norm
$23.86
$20.20
-15%
$13.22
$8.80
$10.84
23%
$9.78
$32.66
$31.05
-5%
$23.01
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
Trastuzumab
$416,108
Norm
$7,174
$3,676
Injection, Bendamustine Hcl, 1
$157,506
$14,319
$4,959
Injection, natalizumab, 1 mg
$155,799
$7,419
$4,150
INJECTION, IMIGLUCERASE, 10
UN
$144,161
$5,545
$16,036
Omalizumab Injection
$132,816
$2,043
$1,379
Rituximab Cancer Treatment
$128,450
$18,350
$5,178
Infliximab Injection
$124,969
$3,571
$4,308
INJECTION, DOCETAXEL, 1 MG
$74,250
$4,368
$1,551
INJECTION, TOCILIZUMAB, 1 MG
$68,209
$1,949
$1,628
Low osmolar contrast material,
$66,788
$175
$98
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.
28
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
2,102
21.7%
-$546,091
-1.0%
2,041
21.6%
-$162,159
-0.3%
23.2%
-0.2%
$1 - $1,999
4,236
43.7%
$2,987,285
5.6%
4,107
43.5%
$2,928,156
5.3%
52.7%
8.6%
$2,000 - $4,999
1,393
14.4%
$4,673,603
8.7%
1,352
14.3%
$4,448,720
8.0%
11.4%
10.3%
$5,000 - $24,999
1,520
15.7%
$16,186,098
30.3%
1,453
15.4%
$15,584,253
28.0%
10.1%
30.2%
$25,000 - $49,999
255
2.6%
$8,916,494
16.7%
271
2.9%
$9,601,401
17.3%
1.5%
14.6%
$50,000 - $74,999
71
0.7%
$4,423,272
8.3%
96
1.0%
$5,899,805
10.6%
0.5%
8.4%
$75,000 - $99,999
22
0.2%
$2,021,425
3.8%
32
0.3%
$2,926,913
5.3%
0.2%
5.2%
$100,000 - $149,999
43
0.4%
$5,226,814
9.8%
39
0.4%
$5,051,961
9.1%
0.2%
6.7%
$150,000 +
42
0.4%
$9,523,790
17.8%
40
0.4%
$9,355,667
16.8%
0.2%
16.1%
178
1.8%
$21,195,301
39.7%
207
2.2%
$23,234,346
41.8%
1.1%
36.5%
9,684
100.0%
$53,412,690
100.0%
9,431
100.0%
$55,634,717
100.0%
100.0%
100.0%
High Cost Claimants > $50,000
ALL MEMBERS
KEY OBSERVATIONS
21.6% of members have $0 or less in paid claims, compared to the
norm of 23.2%. These members may be care avoiders or young and
healthy dependents.
20.5% of members have more than $5,000 in paid claims per year
(norm 12.6%) and account for 87.0% of costs (norm 81.3%).
Exhibit includes all members who were enrolled or had a claim paid during the time period.
Norm from Lockton InfoLock® Book of Business
29
High Cost Claimants (HCC)
HIGH COST CLAIMANTS (HCC)
High Cost Claimants
High cost claimants are members who
incurred $50,000 or more in claims
expense in either Year 1 or Year 2.
Number of Members
Year 2
% Change
Norm
180
210
16.7%
-
% Medical Paid
41.7%
44.2%
5.9%
40.7%
% Rx Paid
27.6%
27.8%
0.6%
27.3%
$19,093,243
$20,974,547
9.9%
-
$2,102,058
$2,259,799
7.5%
-
$21,195,301
$23,234,346
9.6%
-
$106,074
$99,879
-5.8%
$99,602
Medical Paid
Rx Paid
Total Paid
Average Medical Paid
Average Rx Paid
$11,678
$10,761
-7.9%
$18,037
$117,752
$110,640
-6.0%
$117,639
Average RRS
9.1
11.5
25.7%
14.7
Average RCGI
2.9
3.0
4.1%
3.9
Average Total Paid
NUMBER OF CHRONIC CONDITIONS PER HCC
HIGH COST CLAIMANTS (HCC)
0 conditions
4.7%
1 condition
18.9%
3 or more
conditions
56.2%
Year 1
There are 339 unique members who were high cost
claimants in Year 1 or Year 2. HCCs account for 44.2% of
total plan paid medical costs (norm 40.7%). 95.3% of HCCs
have at least one chronic condition, with 76.3% having
comorbid conditions. Prevent future high cost claimants by
managing chronic illness (please see Glossary for more
information on chronic conditions).
2 conditions
20.1%
Norm from Lockton InfoLock® Book of Business
30
InfoLock® Overview
Illness Burden



45.1% (norm 36.4%) of the population has one or more key chronic conditions and represents
83.5% (norm 78.1%) of plan costs. [page 48]
The top five chronic conditions based on prevalence are back pain, neck pain, hypertension,
hyperlipidemia, and depression. [page 49]
The goal for an effective disease management and comprehensive health promotion program is
to prevent the natural progression towards comorbid chronic conditions (please see Glossary for
definition of comorbidities).
 Having multiple chronic conditions increases cost significantly.
NUMBER OF CHRONIC CONDITIONS PER MEMBER
PLAN PAID PMPY BY NUMBER OF CHRONIC CONDITIONS
$21,693
64%
55%
$16,870
20%
0 conditions
18%
1 condition
Actual
13%
10%
2 conditions
12%
$6,197
8%
3 or more conditions
$8,329
$7,327
$4,850
$1,863 $1,431
0 conditions
1 condition
Actual
Norm
Norm from Lockton InfoLock® Book of Business
2 conditions
3 or more
conditions
Norm
31
Asthma
Employees
45%
Members by Relationship
0-17
26%
Members by Age Group
18-39
20%
Asthma Only
40%
Number of Comorbidities
ASTHMA PREVALENCE
HCC
7%
Back Pain
100
ASTHMA MEMBERS ALLOWED PMPY
$8,261
$9,035
$6,111
Neck Pain
49
100
1%
Hypertension
Depression
41
36
50
287
Prevalence
0
Hyperlipidemia
33
Norm
$4,839
150
2%
$7,278
200
2%
0%
300
250
3%
High Risk
18%
Noncompliant
39%
350
3.1%
3+
23%
Moderate Risk
24%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
3%
1%
2
13%
$6,588
4%
1 comorbidity
24%
65+
9%
Compliant
61%
Members by Compliance
3.5%
Dependents
34%
40-64
46%
Low Risk
51%
Members by Risk Category
4%
Spouses
21%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
32
Asthma Quality and Risk Measures
Asthma-Related Risk Measures
9.8% of the 287 members with asthma had an asthma-related ER visit in the analysis period (norm 11.5%).
1.4% of the 287 members with asthma had an asthma-related hospitalization in the analysis period (norm 2.5%).
3.1% of the 287 members with asthma had more than one asthma-related ER visit in the analysis period (norm 3.2%).
0.0% of the 287 members with asthma had more than one asthma-related hospitalization in the analysis period (norm 0.2%).
Asthma-Related Quality Care Gap Measures
0.0% of the 37 members with an asthma-related ER visit did not have an office visit in the analysis period (norm 3.7%).
0.0% of the 5 members with an asthma-related admission did not have an office visit in the analysis period (norm 1.6%).
22.3% of the 287 members with asthma did not have inhaled corticosteroids or leukotriene inhibitors in the analysis period (norm 29.3%).
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
33
Chronic Obstructive Pulmonary Disease (COPD)
Employees
61%
Members by Relationship
Members by Age Group
0-17 18-39
0%
0%
Number of Comorbidities
COPD Only
13%
Members by Compliance
2
22%
3+
52%
Moderate Risk
17%
High Risk
17%
HCC
35%
Noncompliant
83%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
COPD MEMBERS ALLOWED PMPY
25
Back Pain
10
20
1%
Diabetes
7
Hyperlipidemia
7
Hypertension
7
15
0%
0.3%
10
0%
5
0%
23
Prevalence
0
Osteoarthritis
7
Norm
$10,247
$11,527
$9,029
$9,463
1%
$7,188
0.6%
$7,486
1%
0%
1 comorbidity
13%
Dependents
0%
65+
52%
Compliant
17%
COPD PREVALENCE
0%
40-64
48%
Low Risk
30%
Members by Risk Category
Spouses
39%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
34
COPD Quality and Risk Measures
COPD-Related Risk Measures
26.1% of the 23 members with COPD had a COPD-related ER visit in the analysis period (norm 14.4%).
13.0% of the 23 members with COPD had a COPD-related hospitalization in the analysis period (norm 8.8%).
8.7% of the 23 members with COPD had more than one COPD-related ER visit in the analysis period (norm 4.2%).
17.4% of the 23 members with COPD had more than one hospitalization in the analysis period (norm 17.2%).
8.7% of the 23 members with COPD had a claim for sleep apnea in the analysis period (norm 15.2%).
8.7% of the 23 members with COPD had a claim for tobacco use disorder in the analysis period (norm 10.8%).
COPD-Related Quality Care Gap Measures
0.0% of the 23 members with COPD did not have an office visit in the analysis period (norm 0.6%).
0.0% of the 9 members with a COPD-related ER visit did not have an office visit in the analysis period (norm 1.7%).
0.0% of the 4 members with a COPD-related admission did not have an office visit in the analysis period (norm 0.5%).
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
35
Coronary Artery Disease (CAD)
Members by Relationship
Members by Age Group
Number of Comorbidities
Members by Risk Category
0-17
0%
18-39
0%
CAD Only
10%
Low Risk
13%
CAD PREVALENCE
1.4%
1.0%
2
20%
3+
52%
High Risk
41%
HCC
34%
Noncompliant
61%
90
80
60
Hyperlipidemia
37
CAD MEMBERS ALLOWED PMPY
$11,785
$11,376
$11,776
Hypertension
35
27
30
0%
20
25
10
79
Prevalence
Diabetes
0
Osteoarthritis
18
Norm
$9,711
Back Pain
$9,282
40
1%
$9,661
50
1%
0%
65+
35%
Dependents
0%
70
1%
0%
40-64
65%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
1%
1%
Moderate Risk
13%
Spouses
35%
Compliant
39%
Members by Compliance
2%
1 comorbidity
18%
Employees
65%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
36
CAD Quality and Risk Measures
CAD-Related Risk Measures
12.7% of the 79 members with CAD had a CAD-related ER visit in the analysis period (norm 16.9%).
21.5% of the 79 members with CAD had a CAD-related hospitalization in the analysis period (norm 18.1%).
12.7% of the 79 members with CAD had a MI-related hospitalization in the analysis period (norm 9.3%).
19.0% of the 79 members with CAD had more than one hospitalization in the analysis period (norm 14.6%).
41.8% of the 79 members with CAD had a cardiac catheterization in the analysis period (norm 37.9%).
21.5% of the 79 members with CAD had a cardiac stenting in the analysis period (norm 16.4%).
7.6% of the 79 members with CAD had a coronary artery bypass graft (CABG) in the analysis period (norm 4.9%).
6.3% of the 79 members with CAD have cerebrovascular disease (CVD) (norm 9.2%).
6.3% of the 79 members with CAD have depression (norm 5.7%).
46.8% of the 79 members with CAD have hyperlipidemia (norm 53.4%).
3.8% of the 79 members with CAD have obesity (norm 2.3%).
1.3% of the 79 members with CAD have peripheral vascular disease (PVD) (norm 4.6%).
CAD-Related Quality Care Gap Measures
2.5% of the 79 members with CAD did not have an office visit in the last 12 months (norm 3.2%).
0.0% of the 12 members with a CAD-related ER visit did not have an office visit in the analysis period (norm 0.7%).
0.0% of the 18 members with a CAD-related admission did not have an office visit in the analysis period (norm 0.5%).
11.4% of the 35 members with CAD and hypertension did not have antihypertensive drugs in the analysis period (norm 4.3%).
15.4% of the 78 members with CAD (current members only) have not taken Beta-blockers, ACE/ARB, or Statins in the last 12 months (norm 12.6%).
16.7% of the 78 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 18.8%).
29.5% of the 78 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 32.8%).
8.5% of the 59 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 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
37
Depression
Employees
53%
Members by Relationship
0-17
10%
18-39
36%
40-64
48%
Depression Only
33%
Number of Comorbidities
1 comorbidity
20%
Low Risk
47%
Members by Risk Category
500
5%
4.4%
4%
200
2%
0%
$8,896
Back Pain
300
Neck Pain
Prevalence
$7,305
198
Hyperlipidemia
68
Hypertension
68
100
640
$9,340
400
300
3%
DEPRESSION MEMBERS ALLOWED PMPY
0
Headache
59
Norm
$5,768
6%
1%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
600
HCC
8%
Noncompliant
14%
700
7%
High Risk
23%
$7,227
8%
3+
24%
Compliant
86%
DEPRESSION PREVALENCE
7.9%
65+
5%
2
22%
Moderate Risk
23%
Members by Compliance
9%
Dependents
24%
$6,890
Members by Age Group
Spouses
23%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
38
Depression Quality and Risk Measures
Depression-Related Risk Measures
4.8% of the 640 members with depression had a depression-related ER visit in the analysis period (norm 5.4%).
4.4% of the 640 members with depression had a depression-related hospitalization in the analysis period (norm 6.1%).
3.6% of the 640 members with depression had more than one hospitalization in the analysis period (norm 6.6%).
12.5% of the 640 members with depression have taken SSRI and bupropion in the analysis period (norm 13.9%).
Depression-Related Quality Care Gap Measures
4.5% of the 640 members with depression did not have an office visit in the last 12 months (norm 4.4%).
28.6% of the 28 members with a depression-related admission did not have a mental health office visit within 14 days of discharge (norm 20.3%).
12.5% of the 80 members with depression on SSRI and bupropion did not have an an office visit in the last six months (norm 10.4%).
0.0% of the 2 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 21.0%).
13.6% of the 22 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 24.9%).
15.0% of the 20 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 23.6%).
11.1% of the 9 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 5.9%).
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
39
Diabetes
Employees
62%
Members by Relationship
Diabetes Only
23%
5%
4.1%
4%
250
3%
200
3%
2%
150
2%
100
1%
0%
High Risk
32%
Prevalence
0
DIABETES MEMBERS ALLOWED PMPY
$10,489
Back Pain
Hypertension
$9,449
114
Neck Pain
74
Hyperlipidemia
Osteoarthritis
$11,281
130
71
50
333
HCC
10%
Noncompliant
82%
350
300
4%
1%
Moderate Risk
26%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
4.6%
3+
32%
57
Norm
$7,755
5%
2
19%
Compliant
18%
DIABETES PREVALENCE
65+
15%
1 comorbidity
27%
Low Risk
32%
Members by Risk Category
Members by Compliance
40-64
72%
$9,392
Number of Comorbidities
0-17 18-39
1% 12%
Dependents
5%
$8,617
Members by Age Group
Spouses
32%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
40
Diabetes Quality and Risk Measures
Diabetes-Related Risk Measures
5.0% of the 321 members with diabetes had a diabetes-related ER visit in the analysis period (norm 4.9%).
1.9% of the 321 members with diabetes had a diabetes-related hospitalization in the analysis period (norm 2.5%).
5.3% of the 321 members with diabetes had more than one hospitalization in the analysis period (norm 6.6%).
0.9% of the 321 members with diabetes had a dialysis in the analysis period (norm 1.7%).
4.1% of the 321 members with diabetes had renal failure in the analysis period (norm 4.2%).
6.2% of the 321 members with diabetes had an ulcer or open wound in the analysis period (norm 8.0%).
7.8% of the 321 members with diabetes have CAD (norm 9.1%).
21.2% of the 321 members with diabetes have hyperlipidemia (norm 35.6%).
67.3% of the 321 members with diabetes have hypertension or are taking antihypertensive drugs (norm 74.6%).
2.8% of the 321 members with diabetes have obesity (norm 3.5%).
0.3% of the 321 members with diabetes have peripheral vascular disease (PVD) (norm 1.6%).
3.1% of the 321 members with diabetes have retinopathy (norm 2.5%).
Diabetes-Related Quality Care Gap Measures
0.0% of the 16 members with a diabetes-related ER visit did not have an office visit in the analysis period (norm 1.4%).
16.7% of the 6 members with a diabetes-related admission did not have a diabetes-related office visit in the analysis period (norm 6.0%).
92.8% of the 321 members with diabetes did not have a semiannual HbA1c test (norm 91.3%).
19.0% of the 321 members with diabetes did not have a HbA1c test in the last 12 months (norm 21.5%).
46.1% of the 321 members with diabetes did not have any claims for home glucose testing supplies in the last 12 months (norm 50.6%).
38.9% of the 321 members with diabetes did not have a micro or macroalbumin screening test in the last 12 months (norm 37.9%).
78.2% of the 321 members with diabetes did not have a retinal eye exam in the last 12 months (norm 74.4%).
8.3% of the 133 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 28.5%).
7.0% of the 128 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 21.4%).
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
41
Hyperlipidemia
Employees
65%
Members by Relationship
Members by Age Group
Number of Comorbidities
0-17 18-39
0% 5%
8.2%
8%
High Risk
23%
HYPERLIPIDEMIA MEMBERS ALLOWED PMPY
$8,356
800
700
HCC
8%
Noncompliant
23%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
Back Pain
$8,400
275
$6,681
5%
400
4%
300
3%
200
2%
239
Neck Pain
149
Osteoarthritis
133
100
670
Prevalence
Hypertension
0
Diabetes
71
Norm
$5,337
500
$6,538
6%
0%
Moderate Risk
25%
600
7%
1%
3+
29%
$6,549
9%
2
23%
Compliant
77%
Members by Compliance
8.7%
65+
17%
1 comorbidity
26%
Low Risk
44%
HYPERLIPIDEMIA PREVALENCE
Dependents
1%
40-64
78%
Hyperlipidemia Only
22%
Members by Risk Category
10%
Spouses
34%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
42
Hyperlipidemia Quality and Risk Measures
Hyperlipidemia-Related Quality Care Gap Measures
4.2% of the 264 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 21.0%).
16.4% of the 745 members with antihyperlipidemic agents did not have any laboratory tests in the last 12 months (norm 16.8%).
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
43
Hypertension
Employees
67%
Members by Relationship
Members by Age Group
Number of Comorbidities
0-17 18-39
0%
6%
40-64
77%
Hypertension Only
26%
HYPERTENSION PREVALENCE
3+
30%
Moderate Risk
25%
High Risk
23%
9.1%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
700
HCC
9%
Noncompliant
32%
HYPERTENSION MEMBERS ALLOWED PMPY
$9,119
800
10.2%
10%
2
16%
Compliant
68%
Members by Compliance
Dependents
1%
65+
17%
1 comorbidity
28%
Low Risk
42%
Members by Risk Category
12%
Spouses
32%
Back Pain
285
$7,952
$6,998
600
400
Neck Pain
148
300
4%
200
2%
0%
239
134
100
743
Prevalence
Osteoarthritis
0
Diabetes
114
Norm
$5,597
6%
Hyperlipidemia
$7,169
500
$6,215
8%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
44
Hypertension Quality and Risk Measures
Hypertension-Related Risk Measures
3.6% of the 743 members with hypertension had more than one hospitalization in the analysis period (norm 5.1%).
Hypertension-Related Quality Care Gap Measures
6.2% of the 743 members with hypertension did not have an office visit in the last 12 months (norm 4.7%).
0.5% of the 743 members with hypertension did not have an office visit in the analysis period (norm 0.6%).
4.8% of the 21 members with a hypertension-related ER visit did not have an office visit in the analysis period (norm 2.1%).
0.0% of the members with a hypertension-related admission did not have an office visit in the analysis period (norm 1.2%).
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
45
Musculoskeletal – Back Pain
Employees
56%
Members by Relationship
0-17
5%
18-39
29%
Back Pain Only
24%
Number of Comorbidities
40-64
59%
1 comorbidity
33%
2,500
15%
1,500
1,000
5%
0%
500
1,928
Prevalence
0
1014
Depression
300
Hypertension
285
Hyperlipidemia
275
Osteoarthritis
249
Norm
$6,757
$5,319
2,000
$8,537
$6,560
20%
BACK PAIN MEMBERS ALLOWED PMPY
$7,953
Neck Pain
10%
HCC
7%
Noncompliant
14%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
13.0%
High Risk
21%
Compliant
86%
BACK PAIN PREVALENCE
23.7%
3+
21%
Moderate Risk
24%
Members by Compliance
25%
65+
7%
2
22%
Low Risk
48%
Members by Risk Category
Dependents
13%
$6,079
Members by Age Group
Spouses
31%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
46
Musculoskeletal – Back Pain Quality and Risk
Measures
Back Pain-Related Risk Measures
6.5% of the 1,111 members with low back pain have taken three or more narcotic prescriptions in a month (norm 10.8%).
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 5.3%).
0.0% of the 10 members with a back pain-related admission did not have office visit in the analysis period (norm 0.4%).
4.2% of the 674 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 11.6%).
0.4% of the 674 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 1.2%).
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
47
Musculoskeletal – Neck Pain
Employees
57%
Members by Relationship
18-39
28%
Neck Pain Only
1%
40-64
61%
1 comorbidity
40%
2
29%
Low Risk
45%
Members by Risk Category
1,200
800
8%
5.7%
6%
Depression
1014
200
2%
1,032
Prevalence
0
Osteoarthritis
153
Hyperlipidemia
149
Hypertension
$8,591
$9,285
$7,044
198
400
4%
0%
600
Back Pain
NECK PAIN MEMBERS ALLOWED PMPY
148
Norm
$5,545
1,000
10%
HCC
7%
Noncompliant
14%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
12%
High Risk
23%
Compliant
86%
NECK PAIN PREVALENCE
12.7%
3+
30%
Moderate Risk
25%
Members by Compliance
14%
65+
6%
$7,178
Number of Comorbidities
0-17
6%
Dependents
12%
$6,597
Members by Age Group
Spouses
31%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
48
Musculoskeletal – Osteoarthritis
Employees
58%
Members by Relationship
Members by Age Group
Number of Comorbidities
0-17 18-39
0%
4%
1 comorbidity
20%
Low Risk
25%
2
24%
3+
40%
High Risk
29%
HCC
20%
Compliant
71%
Noncompliant
29%
TOP 5 COMORBIDITIES BY NUMBER OF MEMBERS
OSTEOARTHRITIS MEMBERS ALLOWED PMPY
500
5.5%
450
5%
Back Pain
249
$11,219
$12,179
$11,151
400
Neck Pain
3%
250
200
2%
150
100
1%
134
Hyperlipidemia
133
50
450
Prevalence
Hypertension
0
Depression
57
Norm
$9,146
153
300
$9,580
350
$8,741
3.7%
4%
0%
65+
17%
Moderate Risk
26%
Members by Compliance
OSTEOARTHRITIS PREVALENCE
Dependents
1%
40-64
79%
Osteoarthritis Only
16%
Members by Risk Category
6%
Spouses
41%
Year 1
Year 2
Norm
Plan Paid
Employee Paid
Excludes high cost claimants
Norm from Lockton InfoLock® Book of Business
49
Musculoskeletal – Osteoarthritis Quality and Risk
Measures
Osteoarthritis-Related Risk Measures
4.2% of the 450 members with osteoarthritis had continuous use of opiates across the last 12 months (norm 11.3%).
10.4% of the 450 members with osteoarthritis had hylan injections in the analysis period (norm 11.9%).
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
50
Pregnancy and Neonates
PREGNANCY AND NEONATES AS % OF YEAR 2 PLAN PAID
Total, 6.7%
Neonates,
1.9%
PREGNANCIES BY RELATIONSHIP
Total, 7.2%
Neonates,
2.3%
29
17
81
64
Pregnancy,
4.8%
Year 2
Pregnancy,
4.9%
Norm
77
89
Year 1
Year 2
Employees
Spouses
Dependents
Pregnancy-Related Risk Measures
24.7% of the 243 pregnant women in the analysis period had a pregnancy-related ER visit (norm 22.8%).
5.8% of the 243 pregnant women in the analysis period had a hospitalization for a pregnancy-related diagnosis other than
delivery (norm 4.6%).
Norm from Lockton InfoLock® Book of Business
51
Pregnancy and Neonates
HCC % OF NEONATES-RELATED ALLOWED AMOUNT
HCC % OF PREGNANCY-RELATED ALLOWED AMOUNT
64.2%
54.5%
47.6%
14.1%
5.8%
2.6%
Year 1
Year 2
Norm
Year 1
Norm from Lockton InfoLock® Book of Business
Year 2
Norm
52
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.
53
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.
54
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.
55
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 12/31/2014 from Lockton’s Normative Database,
composed of 1.5 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.
56
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.
57
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.

Specialty Drugs
 Lockton has formulated specialty drug logic based on the following definition from IMS Health. Specialty drugs are medicines that treat specific, complex
diseases with five or more of the following attributes:
 Use in treatment of chronic conditions
 Initiated by a specialist
 Requiring special handling and administration, including subcutaneous injection
 Subject to unique distribution arrangements
 High price points
 Extensive patient care service, monitoring, or education

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.
58
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.
© 2015 Lockton, Inc. All rights reserved.
Images © 2015 Thinkstock. All rights reserved.