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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.