1 Medicaid Health Plans of America April 20, 2006 Washington, D.C. John Lovelace, Vice President UPMC Health Plan
Transcript
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1 Medicaid Health Plans of America April 20, 2006 Washington,
D.C. John Lovelace, Vice President UPMC Health Plan
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2 ENROLLMENT COMPARISONS All SNP versus Utilizing Members
Medical and Pharmacy Medical or Pharmacy Medical Only Pharmacy Only
(By Race and By Age)
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3 Race Comparison Medical or Pharmacy Expenses
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4 Race Comparison Medical And Pharmacy Expenses
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5 Race Comparison Medical Expenses Only
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6 Race Comparison Pharmacy Expenses Only
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7 Age Comparison Data Tables UNIQUE MEMBERS TOTAL SNP
POPULATION % OF TOTAL SNP POPULATION MEDICAL OR PHARMACY EXPENSES %
OF T O T A L MEDICAL AND PHARMAC Y EXPENSE S % OF TOTA L Under 65
Years of Age7,26758.4%6,31586.9%4,82766.4% Over 65 Years of
Age5,17241.6%4,59788.9%3,55568.7% Total Unique
Members12,439100.0%10,91287.7%8,38267.4% UNDER 65 UNIQUE MEMBERS
PHARMACY EXPENSES ONLY% OF TOTAL MEDICAL EXPENSES ONLY% OF TOTAL
Under 65 Years of Age2,07728.6%1,31518.1% Over 65 Years of
Age1,39627.0%79615.4% Total Unique Members3,47331.8%2,11160.8%
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8 Age Comparison Medical or Pharmacy Expenses
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9 Age Comparison Medical and Pharmacy Expenses
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10 Risk Score Comparison By Race, Age Group SNP versus Total
Medicare Population
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11 Average Risk Score by Race and by Age Group
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12 Average Risk Score SNP compared to All Other Medicare
Members
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13 MEDICAL EXPENSE ANALYSIS Claim Stratification (No IBNR)
Unique Member (IBNR) Gender Race Financial Service Category
Inpatient, Outpatient, PCP, etc
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14 Claim Stratification Under 65 Years of Age (Total Medical
and Pharmacy Expenses No IBNR)
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15 Claim Stratification Over 65 Years of Age (Total Medical and
Pharmacy Expenses No IBNR)
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16 Medical Expense Utilization Unique Members Age, Gender
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17 Medical Expense Utilization Unique Members Age, Gender -
PMPM
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18 Medical Expense Utilization by Race
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19 Medical Expense Utilization by Race, Age Unique Members
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20 Medical Expense Utilization by Race, Age PMPM
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21 Medical Expense Utilization by Financial Service Category
PMPM
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22 Medical Expense Utilization by Financial Service Category,
by Age Group Unique Members
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23 Medical Expense Utilization by Financial Service Category,
by Age Group PMPM
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24 SNP Population Comparison All Other Medicare Members
SSI/Medicaid
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25 SNP Payment Comparison Medicare/SSI
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26 SNP Comparison to Medicare/SSI Prescriptions per Member
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27 SNP Comparison Medicare/SSI RX: Generic v Brand Scripts
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28 SNP Comparison Medicare/SSI RX: Generic v Brand -
Payment
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29 Pharmacy Utilization SNP versus Medicare/SSI The top ten
drugs (by payment) for the Special Needs Program (SNP) membership
account for 30% of total pharmacy payments and 11% of total
prescriptions. Included in the top ten are four medications used
for schizophrenia / bipolar disorder (Zyprexa, Seroquel, Risperdal
and Abilify). Also included are Zocor and Lipitor (cholesterol
medications), Plaviax (blood clot prevention), Topamaz (migraines /
seizures), Advair Diskus (asthma medication) and Oxycodone (pain).
For the SSI membership within Medical Assistance, these same ten
drugs account for 26% of pharmacy payments and 8% of total
prescriptions. For the rest of Medicare (excluding SNP), only the
cholesterol medications (Zocor and Lipitor), Plavix and Advair
Diskus are in the top ten drugs by payment. However, these same ten
drugs still account for 25% of payments and 8% of prescriptions for
the rest of Medicare. Other drugs utilized frequently by the SNP
population and other Medicare members include One Touch Ultra
Strips and Actos (diabetes medications), Fosamax (osteoporosis) and
Remicade (rheumatoid arthritis / Chrohn's Disease)
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30 Pharmacy Utilization SNP Population Utilizing Members
Prescriptions per 1000 PMPM Top 10 Drugs/Therapy Classes Rx
Utilization for Members > 6 Drugs Rx Utilization Trends
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31 Pharmacy Utilization SNP Population UNDER 65OVER 65ALL SNP
MEMBER MONTHS20,43614,60035,036 UTILIZING MEMBERS5,9524,37610,328
PMPM$337.70$216.41$287.16 PRESCRIPTIONS PER
100049,883.154,512.951,812.4
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32 Pharmacy Utilization SNP Population
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33 Pharmacy Utilization SNP Population
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34 Pharmacy Utilization SNP Population
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35 Pharmacy Utilization SNP Population By Race
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36 Pharmacy Utilization SNP Population By Race
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37 Pharmacy Utilization SNP Population By Race
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38 Pharmacy Utilization SNP Population By Gender
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39 Pharmacy Utilization SNP Population By Gender
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40 SNP Population Top 10 Drugs DRUGS FIRST QUARTER 2006 Rank
Drug Name PMPM% of Rx PMPMScripts / 1,000Cost / Unit 1 ZYPREXA $
15.655.5%445.3 $ 421.83 2 SEROQUEL 12.154.2%626.1 232.89 3 ZOCOR
11.203.9%1,032.7 130.10 4 RISPERDAL 10.713.7%548.0 234.44 5 LIPITOR
10.073.5%1,352.2 89.39 6 ABILIFY 6.862.4%228.5 360.13 7 PLAVIX
5.752.0%568.6 121.31 8 TOPAMAX 5.281.8%274.0 231.31 9 ADVAIR DISKUS
5.111.8%369.9 165.63 10 OXYCODONE HCL 4.251.5%484.3 105.38
42 TOP 5 THERAPY CLASSES BY MEMBER COUNT FOR MEMBERS UTILIZING
> 6 DRUGS RANKTHERAPY CLASS 1ANTIDEPRESSANTS (Depression, Nerve
Pain) 2HMG-COA REDUCTASE INHIBITORS (High Cholesterol) 3OPIATE
AGONISTS (Pain) 4BETA-ADRENERGIC BLOCKING AGENTS (Asthma, Lung
Disease) 5PROTON-PUMP INHIBITORS (Reflux, Ulcers) # of Therapy
Classes Used by MemberUnique Members% MbrsCumulative Only
11,32830.4% Any Combination of 21,63337.3%67.7% Any Combination of
399822.8%90.5% Any Combination of 43638.3%98.8% All 5531.2%100.0%
Total4,375100.0%
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43 TOP 5 THERAPY CLASSES BY MEMBER COUNT FOR MEMBERS UTILIZING
> 6 DRUGS
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44 Rx Utilization Trend/Drug Stratification
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45 Rx Utilization Trend/Drug Stratification
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46 Rx Utilization Drug Stratification - Month
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47 Rx Utilization Drug Stratification Age Group
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48 Rx Utilization Drug Stratification Age Group
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49 Rx Utilization Drug Stratification Age Group
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50 SNP Members Behavioral Health Analysis
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51 Behavioral Health Analysis
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52 Behavioral Health Analysis UNDER 65 Top 10 Diagnosis (PMPM)
- Mental Disorder Related Only UNDER 65 Unique MembersPMPM ADMITS
PER 1000 CLAIMS PER 1000 SCHIZOPHRENIC DISORDERS278$25.9152.2626.5
AFFECTIVE PSYCHOSES306$25.4257.3552.6 DEPRESSIVE DISORDER NOT
ELSEWHERE C97$6.0218.5149.7 SPECIAL SYMPTOMS OR SYNDROMES
NEC13$2.141.826.4 NEUROTIC DISORDERS72$1.963.0101.0 OTHER
NONORGANIC PSYCHOSES37$1.873.541.7 ALCOHOLIC PSYCHOSES5$1.748.2
HYPERKINETIC SYNDROME OF CHILDHOOD1$1.422.40.6 DISTURBANCE OF
CONDUCT NOT ELSEWHER19$0.892.023.5 NONDEPENDENT ABUSE OF
DRUGS15$0.730.912.3
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53 Behavioral Health Analysis OVER 65 Top 10 Diagnosis (PMPM) -
Mental Disorder Related Only OVER 65 Unique MembersPMPM ADMITS PER
100 0 CLAIMS PER 100 0 OTHER ORGANIC PSYCHOTIC
CONDITIONS7$2.114.712.3 SCHIZOPHRENIC DISORDERS 30$1.886.658.4
AFFECTIVE PSYCHOSES 28$1.791.337.8 UNSPECIFIED MENTAL RETARDATION
1$1.620.02.5 OTHER NONORGANIC PSYCHOSES 8$0.961.514.8 NEUROTIC
DISORDERS 12$0.866.916.4 DEPRESSIVE DISORDER NOT ELSEWHERE
C6$0.340.013.2 DRUG PSYCHOSES 2$0.144.91.6 TRANSIENT ORGANIC
PSYCHOTIC CONDITI4$0.100.09.9 SENILE&PRESENILE ORGANIC
PSYCHOTIC 6$0.040.05.8
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54 Behavioral Health Analysis Comorbidities UNDER 65 Top 10
Diagnosis (PMPM) - Excludes Mental Disorders UNDER 65 Unique
MembersPMPM ADMITS PER 1000 CLAIMS PER 1000 CURVATURE OF
SPINE3$6.522.61.8 SYMPTOMS INVLV RESP SYSTEM&OTH
CHST82$4.206.5151.5 GENERAL SYMPTOMS100$3.692.8155.6 OSTEOARTHROSIS
AND ALLIED DISORDERS19$1.893.231.1 OTHER SYMPTOMS INVOLVING ABDOMEN
AN39$1.210.761.1 OTHER DISORDERS OF CERVICAL REGION19$1.170.030.5
OTHER FORMS OF CHRONIC ISCHEMIC HEA10$0.940.718.8 OTHER CELLULITIS
AND ABSCESS11$0.941.324.1 MULTIPLE SCLEROSIS4$0.922.410.6
INTERVERTEBRAL DISC DISORDERS26$0.840.735.2
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55 Behavioral Health Analysis Comorbidities OVER 65 Top 10
Diagnosis (PMPM) - Excludes Mental Disorders OVER 65 Unique Me mb
ersPMPM ADMITS PE R 100 0 CLAIMS PE R 100 0 SYMPTOMS INVOLVING
DIGESTIVE SYSTEM7$6.563.616.4 OTHER DISORDERS OF URETHRA AND
URIN7$2.988.113.2 HEART FAILURE 4$1.341.812.3 GENERAL SYMPTOMS
21$1.320.040.3 OTHER CEREBRAL DEGENERATIONS 3$1.113.43.3 CARE
INVOLVING USE OF REHABILITATIO4$0.701.04.1 OTHER BACTERIAL
PNEUMONIA 1$0.520.90.8 OTHER DISORDERS OF SOFT TISSUES5$0.500.98.2
OTHER AND UNSPECIFIED DISORDERS OF8$0.481.012.3 SYMPTOMS INVLV
NERVOUS&MUSCULOSKELE 1$0.460.00.8
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56 Behavioral Health Analysis Under 65 Age Group UNDER 65
Unique MembersPMPM ADMITS PER 1000 CLAIMS PER 1000 Member
Months20,436 Total Unique Members7,149 Top 10 Diagnosis Classes
Mental Disorders717$69.99155.31,637.1 Symptoms, Signs and
Ill-Defined Conditions164$13.597.2345.9 Musculoskeletal System and
Connective Tissue230$11.3110.0510.3 Circulatory
System124$3.715.3160.3 Nervous System and Sense
Organs133$3.082.4159.1 Respiratory System71$2.912.0122.7 Injury and
Poisoning81$2.763.5115.1 Digestive System120$2.492.8158.5 V
Codes141$1.501.4154.4 Endocrine, Nutritional, Metabolic,
Immunity145$1.410.0186.7
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57 Behavioral Health Analysis Over 65 Age Group OVER 65 Unique
MembersPMPM ADMITS PER 1000 CLAIMS PER 1000 Member Months14,600
Total Unique Members5,118 Top 10 Diagnosis Classes Mental
Disorders89$9.8925.8180.0 Symptoms, Signs and Ill-Defined
Conditions29$1.531.964.9 Musculoskeletal System and Connective
Tissue42$9.794.5151.2 Circulatory System37$2.082.974.8 Nervous
System and Sense Organs20$1.293.423.8 Respiratory
System14$0.660.034.5 Injury and Poisoning14$0.340.923.8 Digestive
System25$1.231.860.0 V Codes17$0.791.027.9 Endocrine, Nutritional,
Metabolic, Immunity27$0.780.942.7
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58 Behavioral Health Analysis Top 10 Diagnostic Related Groups
(DRGs) Under 65 Age Group UNDER 65 Rank Diagnostic Related Group
Description UNIQUE MEMBE RSPMPMADMITS PER 1000 1
Psychoses84$46.06113.0 2 Combined Anterior/Posterior Spinal
Fusion1$6.52 2.58 3 Depressive Neuroses14$4.89 19.61 4 Disorders of
Personality and Impulse Control3$2.04 2.88 5 Alcohol/Drug Abuse or
Dependence with CC6$1.74 7.00 6 Childhood Mental Disorders1$1.42
2.45 7 Chest Pain3$1.25 6.54 8 Local Excis & Remov of Int Fix
Dev Except Hip & Femur w/o CC1$1.05 2.58 9 Esophagitis,
Gastroenteritis and Miscellaneous Digestive Disorders, Age Greater
than 17 with CC2$0.87 0.73 10 Peripheral Vascular Disorders with
CC1$0.75 3.31
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59 Behavioral Health Analysis Top 10 Diagnostic Related Groups
(DRGs) Over 65 Age Group OVER 65 Rank Diagnostic Related Group
DescriptionUNIQUE MEMBERSPMPMADMITS PER 1000 1 Extensive OR
Procedure Unrelated to Principal Diagnosis1$5.903.6 2 Organic
Disturbances and Mental Retardation3$3.12 4.70 3 Kidney and Urinary
Tract Infections, Age Greater than 17 with CC2$2.71 8.13 4
Psychoses6$2.34 9.35 5 Degenerative Nervous System Disorders1$1.10
3.43 6 Heart Failure and Shock1$0.74 1.82 7 Rehabilitation1$0.53
1.03 8 Acute Adjustment Reactions and Disturbances of Psychosocial
Dysfunction1$0.52 6.86 9 Respiratory Infections and Inflammations,
Age Greater than 17 with CC1$0.52 0.91 10 Signs and Symptoms
without CC1$0.36 0.91