Laredo Trans i t Management Inc . 1301 Farragut Street , Laredo, TX 78040-4902 (956) 795-2288 (956) 795-2258
Re: Request for Sealed Bids. Health, Dental, Vision, Short-Term, and Life Insurances Laredo Transit Management, Inc. hereby requests sealed bids for the provision of Health, Dental, Vision, Short-Term, and Life Insurance, for the period of January 1, 2012 to December 31,2012 with option of 4 years in one year increments. All sealed bids are to be marked Laredo Transit Management Inc. Insurance Services and delivered to Gustavo Guevara, Laredo’s City Secretary at Houston St, 3rd floor, Laredo, Texas 78041. Bids must be received no later than 2:00 p.m., Friday, November 18, 2011, at which time they will be opened and read publicly. Laredo Transit Management Inc. reserves the right to accept or reject any and/or all bids that are in the best interest of the company. A pre-bid conference to answer questions or clarify information in this RFP will be conducted on Wednesday, November 14, 2011 at 10 a.m. in the Transit Center, 1301 Farragut St. Laredo, Texas, 78041, 3rd floor Conference room. Interested parties should request official bid specifications and bid forms from. Mari Royster, AGM. Administration and Finance 1301 Farragut St. Laredo, Texas 78041 (956) 795-2288 ext. 256 [email protected]
Re: SPECIAL SPECIFICATIONS LAREDO TRANSIT MANAGEMENT, INC.-MEDICAL INSURANCES
1. SCOPE This request for proposal (RFP) is created for the purpose of obtaining medical, dental, vision and life insurances in accordance with all specifications, terms and conditions within this RFP document.
2. TERM OF COVERAGE The Term of Coverage shall be for a period of a year, Jan.1, 2012-Dec.31, 2012, with options to extend coverage for a period of 4 years, in one year increments. Any increases in premium will be notified to the company no later than November 15th of the initial plan year and every option year.
3. COST
The cost quoted for each insurance provided shall be based on the attached benefit summary. The costs quoted shall exclude all federal, state, and local taxes. Costs quoted shall include rates for Employee only coverage, Employee +Child(ren), Employee +Spouse, and Family.
3.1 The cost quoted in the contractor’s RFP shall be FIRM/ FIXED for the initial one year Term of the Contract.
4. AWARD OF CONTRACT
LAREDO TRANSIT MANAGEMENT, INC. reserves The right to reject any and all proposals.
5. INSURANCES SPECIFICATIONS PLAN BENEFITS: All amounts payable shown are for covered Medical Services after meeting the Annual Deductible and are subject to Reasonable and Customary limitations and medical necessity reviews. Annual Plan Maximum $1,000,000 per person for 2011 $1,250,000 per person for 2012 per the Affordable Care
Act $2,000,000 per person for 2013 per the Affordable Care Act No Annual Plan Maximum effective 1/1/12014 per the Affordable Care Act Annual Deductible $200 per Individual; $400 per Family Annual Out-of-Pocket Annual Out-of-Pocket $1,000 per Individual; $2,000 per Family in non-deductible Covered Charges Network PPO Physician Office Visit $20 Employee co-payment
Network Wellness Benefit-Adult $20 Network office visit co-payment to cover (Member and Spouse Only) Annual Physical Exam (including a pap test and Mammogram for women at 100%under the Women’s Health Benefit). Additionally, after Plan Deductible is Met, routine screening tests and procedures to be covered at 80%, subject to medical necessity. A Network physician must be used. Network Wellness Benefit-Child A $20 Network office visit co-payment covering (Child and Adult Child) Well Child Exams and Immunizations at 100%, subject to medical necessity. A Network physician must be used. Out-of-Network Benefits Non-emergency care outside the network at Not more than a 10% reduction in payable benefits by the Plan. Hospital Expenses After Plan Deductible, 100% of Semi-Private Room Rate. No Maximum Day Limit. Ambulance Expense Benefit After Plan Deductible, 100% Outpatient Accidental Injury After Plan Deductible 100% on the first day of treatment only. Surgery and Obstetrical After Plan Deductible 100% Outpatient Diagnostic X-Ray and After Plan Dedcutible80%; 100% after Out-of-Pocket Lab Expense Limit is met. Major Medical Benefit Eligible medical charges which are not covered under Basic Benefits to be covered after Plan Deductible at 80%; 100% after Out-of-Pocket Expensed Limit is met. Outpatient Cancer Treatment After Plan Deductible, 100% of Covered Charges for Benefit outpatient nuclear therapy, radiation therapy, chemotherapy, and x-ray and lab procedures for the
treatment of cancer. If treatment is provided in a doctor’s office, a $20 Network office visit co- payment to be due at the time of visit. Organ Transplant Benefit After Plan Deductible, 100%. All organ transplant Procedures must have prior approval. A Pre- determination of Benefits along with medical documentation must be submitted through the Network for review. Psychiatric, Drug Abuse and After Plan Deductible, 80% of Covered Charges. Alcoholism Treatment- Maximum 21 Days per person per calendar year; Inpatient Maximum 42 Days per person Lifetime. Out-of Pocket Expenses Limit shall not apply. Psychiatric, Drug Abuse and After Plan Deductible, 80% of Covered Charges. Alcoholism Treatment- Maximum 30 Visits per person per calendar Outpatient year. Out-of-Pocket Expense Limit shall not apply. Hearing Aid Benefit After Plan Deductible, Maximum $2,000 for two (2) aids every 36 months. Chiropractic Expense After Plan Deductible, 80% Maximum $1,000 per person per calendar year. Out-of-Pocket Expense Limit shall not apply. PRESCRIPTION DRUGS If a generic equivalent of a brand name drug is available the employee must take the generic or be responsible for the cost difference. Also, by the third fill, long-term Maintenance medications must be filled through the Caremark Mail Order Program/ Maintenance Choice
or be subject to a 50% co-pay if filled through the Retail Card Program.
75% ; Under Retail Card program, insured pays 25%
co‐pay
80%; Under Mail Order program, insured pays 20%
co‐pay
Employee’s maximum expenses to be capped at
$200 per prescription
Out‐of‐Pocket Expenses Limit shall not apply
SHORT-TERM DISABILITY Also referred to as Loss of Time (Employee Only) $350 per week for first 10 weeks, $350 per week for last 16 weeks. Maximum 26 weeks. Includes continued coverage while on Short-Term Disability. DENTAL BENEFITS VISION BENEFITS LIFE INSURANCE Annual Dental Deductible $0 Eye Exam $25 Member $40,000 Annual Max Per Person $1,500 Frames $30 Accidental $40,000 Preventive Services 100% Single $30 Spouse $ 4,000 Diagnostic 100% Bi-Focals $40 Child/Adult $ 2,000 Child Restorative 100% Tri-Focals$50 TPD/Waiver $16,000 Crown/Bridge Work 80% Lenticular $60 Employee Only Dentures (Full or Partial) 100% Contacts $60 Orthodontic (Child/ $1,500 Adult Child) Lifetime Max Annual Dental Maximum does not apply to covered children under the age of 19 Eye Exam benefit for glasses for covered children under the age of 19 from non-Eye med Providers will be subject to reasonable and customary limitations or subject to the Plan’s PPO office visit co pay. 6. Proposes may quote all requested coverage’s in a single rate, or broken down by individual coverage’s.
BLUE INSIGHT MONTHLY REPORT
LAREDO TRANSIT MANAGEMENT, INC.: ALL
01/01/2011 to 10/31/2011
Non-HMO Fully Insured
TABLE OF CONTENTSTABLE OF CONTENTS
EXECUTIVE SUMMARY 1
FINANCIAL OVERVIEW 2Summary of Financial Measures 2.1
Components of Medical Billed and Allowed Amounts 2.2
Key Financial Measures by Service Category 2.3
Medical Claim Expense Distribution by Claimant 2.4
Medical Out of Pocket Distribution by Claimant 2.5
Medical Out of Pocket Analysis 2.6
Medical Lag Report 2.7
MEDICAL FINANCIAL SERVICE 3Overall Medical Paid Expenses by ICD-9 Diagnostic Category 3.1
Inpatient Facility Paid Expenses by ICD-9 Diagnostic Category 3.2
Outpatient Facility Paid Expenses by ICD-9 Diagnostic Category 3.3
Professional Paid Expenses by ICD-9 Diagnostic Category 3.4
MEDICAL AND PHARMACY LOSS RATIO OVERVIEW 4
PHARMACY FINANCIAL SUMMARY 5Summary of Pharmacy Financial Measures 5.1
ENROLLMENT 6Enrollment Overview 6.1
Enrollment by Age and Gender 6.2
Enrollment by Coverage Tier 6.3
Enrollment/Disenrollment 6.4
Enrollment by Type of Coverage 6.5
EXPENSE AND UTILIZATION OVERVIEW 7Key Indicators 7.1
MEDICAL SERVICE 8Inpatient Admission Analysis 8.1
Inpatient Provider Summary 8.3
Outpatient Facility Visit Type Analysis 8.4
Outpatient Facility Visit Type Detail for Emergency Room, Ambulatory Surgery and Radiology 8.6
Outpatient Provider Summary 8.8
Professional Service Type Analysis 8.9
PHARMACY 9Key Indicators Summary 9.1
LAREDO TRANSIT MANAGEMENT, INC.: ALL
TABLE OF CONTENTSTABLE OF CONTENTS
Generic Versus Formulary Experience 9.3
Top Therapeutic Drug Classes 9.4
Top Prescription Drugs 9.5
Specialty Drug Analysis 9.6
GLOSSARY 10
LAREDO TRANSIT MANAGEMENT, INC.: ALL
CPT copyright 2010 American Medical Association. All rights reserved.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
EXECUTIVE SUMMARYEXECUTIVE SUMMARY
CHAPTER DESCRIPTION
The Monthly Report presents key financial and utilization components for the current reporting month as well as
renewal year to date. The chapters are intended to highlight key analysis criteria to demonstrate how LAREDO
TRANSIT MANAGEMENT, INC.: ALL is doing fiscally, with focus on what is driving their costs. In addition this
report highlights what healthcare services are being utilized and how this impacts the overall cost. The report
starts with components that provide financial data showing paid claims on a month and year to date (YTD) basis.
After the enrollment chapter, components that provide utilization data are shown on an incurred year over year
basis. The data in this report can be used to predict how LAREDO TRANSIT MANAGEMENT, INC.: ALL can
budget for health costs and what they are facing in the future. In this chapter there is a brief description about the
subsequent chapters and key metrics to summarize their findings.
1.1
FINANCIAL
The financial overview chapter provides gross financial information for LAREDO TRANSIT MANAGEMENT, INC.:
ALL based on paid claims for the current reporting month and for the renewal year to date. The claims have not
been aggregated or summarized, so all transactions are reflected based on the paid date and balances back to your
Billing and Accounts Receivable System (BARS) bill.
Report Description: This report provides an overview of LAREDO TRANSIT MANAGEMENT, INC.: ALL's total health
care expenses for the current reporting month and for the year to date.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
TOTAL EXPENSES OCT'11 YEAR TO DATE
MEDICAL PAID $129,310 $1,449,294
CAPITATION PAID
PHARMACY PAID $12,024 $143,453
DENTAL PAID
TOTAL PAID $141,334 $1,592,747
RECOVERIES $0 $0
PAID + RECOVERIES $141,334 $1,592,747
FEES & CREDITS $0 $0
GROUP LIABILITY $141,334 $1,592,747
Key Findings: Medical paid made up 91.5% of the total paid amount for the current month. Medical paid made up
91.0% of the total paid amount for the year to date.
EXECUTIVE SUMMARYEXECUTIVE SUMMARY
1.2
MEDICAL CLAIM EXPENSE DISTRIBUTION BY CLAIMANT
Report Description: The distribution of medical paid expense by claimant and the average medical paid per claimant
amount are shown for the year to date.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
YEAR TO DATE
PAID CLAIMANTS CLAIMANTS % PAID PAID %
PAID/
CLAIMANT
LESS THAN $200 78 26.8% $5,726 0.4% $73
$200 - $1,000 97 33.3% $47,752 3.3% $492
$1,001 - $5,000 84 28.9% $163,290 11.3% $1,944
$5,001 - $10,000 12 4.1% $82,500 5.7% $6,875
$10,001 - $30,000 9 3.1% $146,383 10.1% $16,265
SUMMARY LESS THAN $30,001 280 96.2% $445,651 30.7% $1,592
PAID CLAIMANTS CLAIMANTS % PAID PAID %
PAID/
CLAIMANT
$30,001 - $50,000 4 1.4% $171,443 11.8% $42,861
$50,001 - $75,000 1 0.3% $61,327 4.2% $61,327
$75,001 - $100,000 2 0.7% $156,550 10.8% $78,275
$100,001 - $150,000 3 1.0% $326,121 22.5% $108,707
$150,001 - $200,000
$200,001 - $250,000
$250,001 - $500,000 1 0.3% $288,201 19.9% $288,201
GREATER THAN $500,001
SUMMARY $30,001 OR GREATER 11 3.8% $1,003,643 69.3% $91,240
COMBINED SUMMARY 291 100.0% $1,449,294 100.0% $4,980
Key Findings: The proportion of claimants who received less than $200 in services for the year to date was 26.8%.
These claimants spent 0.4% of the total paid expenses and the average paid expense per claimant was $73.
3.8% of claimants had expenses over $30,001 for the year to date. These claimants spent 69.3% of the total paid
expenses and the average paid expense per claimant was $91,240.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
LAREDO TRANSIT MANAGEMENT, INC.: ALL
EXECUTIVE SUMMARYEXECUTIVE SUMMARY
1.3
NETWORK SAVINGS ANALYSIS
Report Description: This report displays the covered amount, discount amount, discount percent and paid amount
based on paid claims. Displayed by Medicare and non-Medicare primary indicator, and by in and out of network for
the year to date. The "Discount %" is calculated as Discount/Covered.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
MEDICARE PRIMARY
INDICATOR NETWORK INDICATOR SERVICE CATEGORY COVERED DISCOUNT DISCOUNT % PAID % OF PAID
NO IN-NETWORK INPATIENT FACILITY $2,125,808 $1,468,714 69.1% $635,222 43.8%
OUTPATIENT FACILITY $1,062,852 $623,413 58.7% $380,699 26.3%
PROFESSIONAL $1,231,678 $746,669 60.6% $411,252 28.4%
SUMMARY $4,420,338 $2,838,797 64.2% $1,427,173 98.5%
OUT-OF-NETWORK INPATIENT FACILITY
OUTPATIENT FACILITY $391,273 $368,874 94.3% $12,028 0.8%
PROFESSIONAL $56,309 $45,946 81.6% $3,713 0.3%
SUMMARY $447,583 $414,821 92.7% $15,741 1.1%
SUMMARY $4,867,921 $3,253,618 66.8% $1,442,914 99.6%
YES IN-NETWORK INPATIENT FACILITY
OUTPATIENT FACILITY $9,688 $0 0.0% $291 0.0%
PROFESSIONAL $8,920 $3,838 43.0% $1,098 0.1%
SUMMARY $18,609 $3,838 20.6% $1,389 0.1%
OUT-OF-NETWORK INPATIENT FACILITY
OUTPATIENT FACILITY $827,265 $0 0.0% $4,918 0.3%
PROFESSIONAL $1,159 $795 68.6% $73 0.0%
SUMMARY $828,424 $795 0.1% $4,991 0.3%
SUMMARY $847,033 $4,633 0.5% $6,379 0.4%
SUMMARY $5,714,954 $3,258,251 57.0% $1,449,294 100.0%
Key Findings: LAREDO TRANSIT MANAGEMENT, INC.: ALL's overall network savings discount (excluding Medicare)
was 64.2% for the year to date. The in-network paid percent was 98.6% for the year to date.
ENROLLMENT
The enrollment chapter presents descriptive information on LAREDO TRANSIT MANAGEMENT, INC.: ALL's
subscribers and dependents enrolled in BCBSTX. Information on coverage tier, membership size, age and gender
are presented for subscribers and dependents for the current reporting month and the renewal year to date.
Report Description: This report shows the average subscribers, dependents and overall members for LAREDO
TRANSIT MANAGEMENT, INC.: ALL.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
OCT'11 YEAR TO DATE
AVERAGE SUBSCRIBERS 158 157
AVERAGE DEPENDENTS 208 205
AVERAGE MEMBERS 366 362
AVERAGE CONTRACT SIZE 2.32 2.31
AVERAGE AGE (YEARS) 34.9 34.9
Key Findings: LAREDO TRANSIT MANAGEMENT, INC.: ALL's overall membership was 366 in the current reporting
month and 362 for the year to date. The average age of members was 34.9 for the current reporting month and
34.9 for the year to date.
EXECUTIVE SUMMARYEXECUTIVE SUMMARY
1.4LAREDO TRANSIT MANAGEMENT, INC.: ALL
MEDICAL AND PHARMACY PAID CLAIMS BY AGE AND GENDER
Report Description: This report identifies the total medical and pharmacy member counts and their paid claims, by
age and gender demographics, and by subscribers and dependents for the year to date. The report compares and
analyzes claims vs. member counts within one age band compared to another to identify the members and age
group that are driving the costs.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
MALE FEMALE TOTAL
AVG
MEDICAL
MEMBERS
AVG
PHARMACY
MEMBERS PAID
AVG
MEDICAL
MEMBERS
AVG
PHARMACY
MEMBERS PAID
AVG
MEDICAL
MEMBERS
AVG
PHARMACY
MEMBERS PAID
SUBSCRIBERS UNDER 20
20-29 2 2 $1,889 1 1 $319 3 3 $2,208
30-39 16 16 $21,613 6 6 $5,071 22 22 $26,684
40-49 51 51 $47,230 13 13 $80,937 63 63 $128,167
50-64 50 50 $361,611 10 10 $113,509 60 60 $475,120
65+ 9 9 $347,819 9 9 $347,819
TOTAL 127 127 $780,163 30 30 $199,836 157 157 $979,999
DEPENDENTS UNDER 20 61 61 $28,396 56 56 $103,368 117 116 $131,764
20-29 18 18 $9,326 9 9 $15,438 27 27 $24,765
30-39 1 1 8 8 $14,367 9 9 $14,367
40-49 5 5 $1,358 23 23 $329,341 28 28 $330,699
50-64 23 23 $108,373 23 23 $108,373
65+ 2 2 $2,780 2 2 $2,780
TOTAL 84 84 $39,080 121 121 $573,668 205 205 $612,748
TOTAL MEMBERS 211 211 $819,243 150 150 $773,504 362 361 $1,592,747
Key Findings: The total subscriber count for males was highest in the 40 - 49 age range. Male subscribers in the 50
- 64 age group had the highest net paid claims. The total subscriber count for females was highest in the 40 - 49
age range. Female subscribers in the 50 - 64 age group had the highest net paid claims.
The total dependent count for males was highest in the Under 20 age range. Male dependents in the Under 20 age
group had the highest net paid claims. The total dependent count for females was highest in the Under 20 age
range. Female dependents in the 40 - 49 age group had the highest net paid claims.
EXECUTIVE SUMMARYEXECUTIVE SUMMARY
1.5LAREDO TRANSIT MANAGEMENT, INC.: ALL
EXPENSE AND UTILIZATION OVERVIEW
The expense and utilization overview chapter is intended to provide key metrics for LAREDO TRANSIT
MANAGEMENT, INC.: ALL's claims experience. Year-over-year changes and comparisons to the benchmark are
provided as well. Data in this chapter is reported based on incurred, 12-month rolling periods with 2 months
run-out.
Report Description: This report shows key metrics, paid PMPMs, and paid PEPMs by service category.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
UTILIZATION SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE
INPATIENT ADMISSIONS/1000 125.3 98.9 26.7% 61.0 105.4%
OUTPATIENT VISITS/1000 2,342.1 2,211.2 5.9% 992.3 136.0%
PROFESSIONAL SERVICES/1000 21,930.8 19,213.9 14.1% 18,944.6 15.8%
PHARMACY PRESCRIPTIONS/MEMBER 9.3 9.1 2.2% 10.8 -14.1%
DENTAL SERVICES/MEMBER 3.4
LAREDO TRANSIT MANAGEMENT, INC.: ALL
PAID PMPM SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE
TOTAL MEDICAL $374.58 $313.30 19.6% $218.07 71.8%
CAPITATION $0.00
PHARMACY $45.36 $50.82 -10.7% $51.30 -11.6%
DENTAL $20.28
PAID PEPM
TOTAL MEDICAL $861.75 $738.49 16.7% $390.14 120.9%
CAPITATION $0.00
PHARMACY $104.29 $119.79 -12.9% $91.69 13.7%
DENTAL $39.80
Key Findings: Utilization for Inpatient had the largest increase in Admissions/1000 between the current and prior
reporting periods.
Between the current and prior reporting periods, LAREDO TRANSIT MANAGEMENT, INC.: ALL's medical PMPM
expenses increased 19.6%. The pharmacy paid PMPM decreased 10.7%. LAREDO TRANSIT MANAGEMENT,
INC.: ALL's medical PEPM expenses increased 16.7%. The pharmacy paid PEPM decreased 12.9%.
FINANCIAL OVERVIEWFINANCIAL OVERVIEW
CHAPTER DESCRIPTION
This chapter provides gross financial information for LAREDO TRANSIT MANAGEMENT, INC.: ALL based on paid
claims for the current reporting month and for the renewal year to date. The claims have not been aggregated or
summarized, so all transactions are reflected based on the paid date for each individual transaction. This means
that original claims are reflected based on the original processing date and adjustments are based on the date of
the adjustment, even if the original claim was processed at a different time.
Reports in this chapter will include medical amounts only unless specifically indicated as pharmacy or dental
amounts.
The first report provides a breakdown of key gross expenditures, from billed amount to paid amount, for the current
reporting month and for the year to date. This report may highlight key measures and their potential impact on
gross paid expenses.
The second report displays the percentage of the billed amounts accounted for by discounts and the allowed
amount. Also presented is the percentage of the allowed amount accounted for by out of pocket, COB, COB
Medicare, other reductions, other payments and the paid amount. It is important to monitor how these expense
categories impact the overall costs over time. For example, changes to the plan design may be reflected by a
change in the proportion of out of pocket to the allowed amount, and ultimately what is the liability of the plan,
changes in the percentage of discounts may reflect provider contract changes or shifts in provider-mix, and
changes in COB amounts may reflect a change in benefits or a changed focus to capture funds from these sources.
The third report presents gross allowed and paid amounts by service category, along with percentages these
amounts by service category are to the total allowed amount and total paid amount. This breakdown provides a
high level view of what service categories areas are driving expenses and potentially highlights areas for further
attention.
The fourth report focuses on how expenditures are distributed by claimant. The distribution of claimants by paid
amount shows the percentage of claimants at different levels of total payments for the current reporting month and
for the year to date. Analysis of this report can highlight the impact of high cost claimants on the overall costs.
The distribution of claimants by out of pocket shows the percentage of claimants at different levels of out of pocket
expenses. This report helps determine the impact of any changes in plan design on out of pocket.
Completing the chapter are reports that provide information on network savings (for PPO and POS products), and
insight into the monthly claim lag and that can help identify Incurred But Not Reported (IBNR).
Data Note
Current reporting month represents claims paid in Oct'11.
Year to date represents claims paid from Jan'11 through Oct'11.
Raw claims for active, retiree under 65, retiree 65 and over, and COBRA members are reported (if available).
2LAREDO TRANSIT MANAGEMENT, INC.: ALL
FINANCIAL OVERVIEWFINANCIAL OVERVIEW
SUMMARY OF FINANCIAL MEASURES
Report Description: This report provides an overview of LAREDO TRANSIT MANAGEMENT, INC.: ALL's health care
expenses from billed to paid for the current reporting month and for the year to date. Some key financial measures
are displayed below. These metrics include plan performance measures, such as the degree of discounts the plan
was able to achieve, as well as COB and COB Medicare recoveries that the plan was able to receive based on other
insurance contributing to the overall expenses. Information is also provided on the amount of overall health care
expenses that the member was directly responsible for, through deductibles, coinsurance or co-payments. Other
reductions includes penalties, workers compensation savings, and subrogation savings. Other payments includes
Blue Card access fees and surcharges. Also displayed are other adjustments. Finally, the report provides
information on the level and percent changes in paid expenses, which represents LAREDO TRANSIT
MANAGEMENT, INC.: ALL's liability, with a further breakout for Fees and Credits. Definitions of these financial
measures can be found in the glossary.
2.1
BREAKDOWN OF BILLED AMOUNT
OCT'11 YEAR TO DATE0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
NOT COVERED
DISCOUNT
OUT OF POCKET
COB
COB MEDICARE
OTHER REDUCTIONS
OTHER
ADJUSTMENTS
PAID-PROVIDER
LAREDO TRANSIT MANAGEMENT, INC.: ALL
MEDICAL EXPENSES OCT'11 YEAR TO DATE
BILLED $512,860 $6,634,781
NOT COVERED $16,280 $919,827
COVERED $496,580 $5,714,954
DISCOUNT $351,648 $3,258,251
ALLOWED $144,932 $2,456,703
OUT OF POCKET $14,351 $161,984
COB $1,207 $17,597
COB MEDICARE $90 $829,371
OTHER REDUCTIONS $0 $0
OTHER ADJUSTMENTS $0 $0
PAID-PROVIDER $129,284 $1,447,751
OTHER PAYMENTS $26 $1,543
PAID $129,310 $1,449,294
LAREDO TRANSIT MANAGEMENT, INC.: ALL
TOTAL EXPENSES OCT'11 YEAR TO DATE
MEDICAL PAID $129,310 $1,449,294
CAPITATION PAID
PHARMACY PAID $12,024 $143,453
DENTAL PAID
TOTAL PAID $141,334 $1,592,747
RECOVERIES $0 $0
PAID + RECOVERIES $141,334 $1,592,747
FEES & CREDITS $0 $0
GROUP LIABILITY $141,334 $1,592,747
LAREDO TRANSIT MANAGEMENT, INC.: ALL
Paid-Provider excludes Other Payments, which are not part of the Billed Amount.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
FEES & CREDITS OCT'11 YEAR TO DATE
SUMMARY $0 $0
FINANCIAL OVERVIEWFINANCIAL OVERVIEW
2.2
COMPONENTS OF MEDICAL BILLED AND ALLOWED AMOUNTS
Report Description: The breakdown of LAREDO TRANSIT MANAGEMENT, INC.: ALL's medical billed and allowed
amounts are analyzed below. The discount amount, not covered amount and allowed amount are presented as a
percentage of the billed amount for the current reporting month and for the year to date. The out of pocket
amount, COB recoveries, other reductions, other adjustments, and paid-provider amount are presented as a
percentage of the allowed amount.
Billed Amount: The allowed amount was 28.3% of the billed amount for the current reporting month and 37.0% of
the billed amount for the year to date. Discounts were 68.6% of the billed amount for the current reporting month
and 49.1% of the billed amount for the year to date. The remaining not covered amount was 3.2% of the billed
amount for the current reporting month and 13.9% of the billed amount for the year to date.
Allowed Amount: Of the allowed amount in the current reporting month, the paid-provider amount was 89.2%, out
of pocket was 9.9%, COB was 0.8%, COB Medicare was 0.1%, and other reductions were 0.0%. Other
adjustments were 0.0%. For year to date, of the allowed amount, the paid-provider amount was 58.9%, out of
pocket was 6.6%, COB was 0.7%, COB Medicare was 33.8%, and other reductions were 0.0%. Other
adjustments were 0.0%.
BILLED AMOUNT ALLOWED AMOUNT
LAREDO TRANSIT MANAGEMENT, INC.: ALL
OCT'11 YEAR TO DATE
% NOT COVERED 3.2% 13.9%
% DISCOUNT* 68.6% 49.1%
% ALLOWED 28.3% 37.0%
LAREDO TRANSIT MANAGEMENT, INC.: ALL
OCT'11 YEAR TO DATE
% OUT OF POCKET 9.9% 6.6%
% COB 0.8% 0.7%
% COB MEDICARE 0.1% 33.8%
% OTHER REDUCTIONS 0.0% 0.0%
% OTHER ADJUSTMENTS 0.0% 0.0%
% PAID-PROVIDER 89.2% 58.9%
PERCENTAGE OF BILLED AMOUNT
28.3%37.0%
68.6% 49.1%
3.2%13.9%
OCT'11 YEAR TO DATE0%
20%
40%
60%
80%
100%
% NOT COVERED
% DISCOUNT
% ALLOWED
PERCENTAGE OF ALLOWED AMOUNT
89.2%
58.9%
0.0% 0.0%0.0% 0.0%
0.1%
33.8%
0.8%0.7%9.9% 6.6%
OCT'11 YEAR TO DATE0%
20%
40%
60%
80%
100% % OUT OF POCKET
% COB
% COB MEDICARE
% OTHER
REDUCTIONS
% OTHER
ADJUSTMENTS
% PAID-PROVIDER
LAREDO TRANSIT MANAGEMENT, INC.: ALL
*This reflects the overall discount as a percent of the billed amount. Please refer to page 1.3 'Network Savings Analysis' for
your network discount percent based off the Covered amount.
FINANCIAL OVERVIEWFINANCIAL OVERVIEW
2.3
KEY FINANCIAL MEASURES BY SERVICE CATEGORY
Report Description: The percent allowed and paid for each service category (inpatient facility, outpatient facility,
professional, pharmacy and dental) is analyzed to determine which service categories have contributed the most in
these key financial measures in the current reporting month and for the year to date.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
OCT'11 YEAR TO DATE
INPATIENT FACILITY ALLOWED $58,013 $657,094
ALLOWED % 36.0% 24.8%
PAID $53,890 $635,222
PAID % 38.1% 39.9%
OUTPATIENT FACILITY ALLOWED $43,377 $1,298,791
ALLOWED % 26.9% 49.0%
PAID $39,080 $397,937
PAID % 27.7% 25.0%
PROFESSIONAL ALLOWED $43,542 $500,818
ALLOWED % 27.0% 18.9%
PAID $36,340 $416,135
PAID % 25.7% 26.1%
CAPITATION PAID
PAID %
PHARMACY ALLOWED $16,127 $191,297
ALLOWED % 10.0% 7.2%
PAID $12,024 $143,453
PAID % 8.5% 9.0%
DENTAL ALLOWED
ALLOWED %
PAID
PAID %
SUMMARY ALLOWED $161,059 $2,648,000
ALLOWED % 100.0% 100.0%
PAID $141,334 $1,592,747
PAID % 100.0% 100.0%
ALLOWED % BY SERVICE CATEGORY
PAID % BY SERVICE CATEGORY
INPATIENT
FACILITY
OUTPATIENT
FACILITY
PROFESSIONAL PHARMACY DENTAL
0%
15%
30%
45%
OCT'11 YEAR TO DATE
OCT'11 YEAR TO DATE
INPATIENT
FACILITY
OUTPATIENT
FACILITY
PROFESSIONAL PHARMACY DENTAL
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Summary: Overall allowed expense for the current reporting month made up 6.1% of the year to date allowed
expenses. Overall paid expense for the current reporting month made up 8.9% of the year to date paid expenses.
Allowed % by Service Category: In terms of the proportion of overall allowed expenses by service category,
Outpatient Facility allowed expenses accounted for the greatest proportion of the overall allowed expenses for the
year to date. The next highest service category was Inpatient Facility, which accounted for 24.8% for the year to
date allowed expenses.
Paid % by Service Category: In terms of the proportion of overall paid expenses by service category, Inpatient
Facility paid expenses accounted for the greatest proportion of the overall paid expenses for the year to date. The
next highest service category was Professional, which accounted for 26.1% for the year to date paid expenses.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
LESS THAN $200
$200 - $1,000
$1,001 - $5,000
$5,001 - $10,000
ALL OTHER
$1,001 - $5,000
$30,001 - $50,000
$100,001 - $150,000
$250,001 - $500,000
ALL OTHER
26.8%
33.3%
28.9%
4.1%
6.9%11.3%
11.8%
22.5%
19.9%
34.5%
CLAIMANTS PAID
FINANCIAL OVERVIEWFINANCIAL OVERVIEW
2.4
MEDICAL CLAIM EXPENSE DISTRIBUTION BY CLAIMANT
Report Description: The distribution of medical paid expense by claimant and the average medical paid per claimant
amount is shown for the year to date. The graphs display the percentage of claimants and paid expenses for the
year to date.1
LAREDO TRANSIT MANAGEMENT, INC.: ALL
YEAR TO DATE
PAID CLAIMANTS CLAIMANTS % PAID PAID %
PAID/
CLAIMANT
LESS THAN $200 78 26.8% $5,726 0.4% $73
$200 - $1,000 97 33.3% $47,752 3.3% $492
$1,001 - $5,000 84 28.9% $163,290 11.3% $1,944
$5,001 - $10,000 12 4.1% $82,500 5.7% $6,875
$10,001 - $30,000 9 3.1% $146,383 10.1% $16,265
SUMMARY 280 96.2% $445,651 30.7% $1,592
The proportion of claimants who received less than $200 in services for the year to date was 26.8%. These
claimants spent 0.4% of the total paid expenses and the average paid expense per claimant was $73.
3.8% of claimants had expenses over $30,001 for the year to date. These claimants spent 69.3% of the total paid
expenses and the average paid expense per claimant was $91,240.
1This is a claimant analysis, where only members who had a claim are included. The tables exclude all medical enrolled
members that did not submit a claim.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
PAID CLAIMANTS CLAIMANTS % PAID PAID %
PAID/
CLAIMANT
$30,001 - $50,000 4 1.4% $171,443 11.8% $42,861
$50,001 - $75,000 1 0.3% $61,327 4.2% $61,327
$75,001 - $100,000 2 0.7% $156,550 10.8% $78,275
$100,001 - $150,000 3 1.0% $326,121 22.5% $108,707
$150,001 - $200,000
$200,001 - $250,000
$250,001 - $500,000 1 0.3% $288,201 19.9% $288,201
GREATER THAN $500,001
SUMMARY 11 3.8% $1,003,643 69.3% $91,240
FINANCIAL OVERVIEWFINANCIAL OVERVIEW
2.5
MEDICAL OUT OF POCKET DISTRIBUTION BY CLAIMANT
Report Description: The impact of cost sharing provisions is analyzed to determine the overall liability incurred by
the member. This report provides a distribution of claimants by their total medical out of pocket expenses for the
year to date. If changes have been made to plan design, this report helps analyze what the impacts of those
changes have been to the member. The graphs display the percentage of claimants and out of pocket expenses for
the year to date.1
LAREDO TRANSIT MANAGEMENT, INC.: ALL
YEAR TO DATE
OUT OF POCKET CLAIMANTS CLAIMANTS % OUT OF POCKET OUT OF POCKET %
LESS THAN $100 146 50.2% $5,579 3.4%
$100 - $200 41 14.1% $5,769 3.6%
$201 - $300 15 5.2% $3,599 2.2%
$301 - $400 12 4.1% $4,255 2.6%
$401 - $500 5 1.7% $2,151 1.3%
$501 - $750 13 4.5% $8,457 5.2%
$751 - $1,000 11 3.8% $10,001 6.2%
$1,001 - $1,500 14 4.8% $16,837 10.4%
$1,501 - $2,000 7 2.4% $11,755 7.3%
$2,001 - $2,500 6 2.1% $12,487 7.7%
$2,501 - $3,000 2 0.7% $5,582 3.4%
$3,001 - $4,000 16 5.5% $54,544 33.7%
$4,001 - $5,000 1 0.3% $4,489 2.8%
GREATER THAN $5,001 2 0.7% $16,481 10.2%
SUMMARY 291 100.0% $161,984 100.0%
50.2%
14.1%
5.2%
4.1%
1.7%
4.5%
3.8%
4.8%
2.4%
2.1%
0.7%
5.5%
0.3%
0.7%
3.4%3.6%
2.2%
2.6%
1.3%
5.2%
6.2%
10.4%
7.3%
7.7%3.4%
33.7%
2.8%
10.2%
LESS THAN $100
$100 - $200
$201 - $300
$301 - $400
$401 - $500
$501 - $750
$751 - $1,000
$1,001 - $1,500
$1,501 - $2,000
$2,001 - $2,500
$2,501 - $3,000
$3,001 - $4,000
$4,001 - $5,000
GREATER THAN $5,001
CLAIMANTS OUT OF POCKET
The average out of pocket expense per claimant was $557 for the year to date. Claimants with under $200 in out
of pocket expenses were 64.3% for the year to date. Claimants with out of pocket expenses in the range of less
than $100 showed the highest number of claimants for the year to date.
1This is a claimant analysis, where only members who had a claim are included. The tables exclude all medical enrolled
members that did not submit a claim.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
MEDICAL OUT OF POCKET ANALYSIS
Report Description: This report shows the deductible, copayment, coinsurance, and total out of pocket amounts as a
percent of the allowed amount by coverage tier for the year to date. The chart shows the total out of pocket amount
broken out by the percent the member paid for deductible, copayment, and coinsurance for claims for the year to
date.
FINANCIAL OVERVIEWFINANCIAL OVERVIEW
2.6
LAREDO TRANSIT MANAGEMENT, INC.: ALL
YEAR TO DATE
COVERAGE TIER ALLOWED DEDUCTIBLE
DEDUCT
% OF
ALLOWED COPAYMENT
COPAY
% OF
ALLOWED COINSURANCE
COINS
% OF
ALLOWED
OUT OF
OPX % OF
ALLOWED PAID
EMPLOYEE ONLY $709,651 $12,669 1.8% $9,760 1.4% $28,896 4.1% $51,325 7.2% $658,511
EMPLOYEE + ONE $1,119,668 $10,221 0.9% $7,699 0.7% $18,216 1.6% $36,136 3.2% $254,333
EMPLOYEE +
DEPENDENT(S) $85,174 $3,342 3.9% $5,169 6.1% $6,206 7.3% $14,718 17.3% $69,639
FAMILY $542,210 $18,765 3.5% $16,331 3.0% $24,710 4.6% $59,806 11.0% $466,810
SUMMARY $2,456,703 $44,998 1.8% $38,959 1.6% $78,027 3.2% $161,984 6.6% $1,449,294
LAREDO TRANSIT MANAGEMENT, INC.: ALL
OUT OF POCKET BREAKDOWN BY COVERAGE TIER
DEDUCTIBLE COPAYMENT COINSURANCE
27.8%
31.4%
22.7%
28.3%
24.7%
24.1%
27.3%
35.1%
21.3%
19.0%
48.2%
41.3%
42.2%
50.4%
56.3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
SUMMARY
FAMILY
EMPLOYEE + DEPENDENT(S)
EMPLOYEE + ONE
EMPLOYEE ONLY
The overall total out of pocket amount as a percent of allowed for the year to date was 6.6.%. The coverage tier
with the highest deductible as a percent of allowed was Employee + Dependent(s). Copayment as a percent of
allowed was highest for Employee + Dependent(s). Coinsurance as a percent of allowed was highest for Employee +
Dependent(s).
Of the total out of pocket amount, 27.8% was attributed to the deductible amount. The copayment amount
attributed 24.1%. The remaining 48.2% was attributed to the coinsurance amount.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
FINANCIAL OVERVIEWFINANCIAL OVERVIEW
2.7
LAREDO TRANSIT MANAGEMENT, INC.: ALL
INCURRED
MONTH
PAID MONTH
NOV'10 DEC'10 JAN'11 FEB'11 MAR'11 APR'11 MAY'11 JUN'11 JUL'11 AUG'11 SEP'11 OCT'11 SUMMARY
ALL PRIOR �$2,375 $1,563 $210 $0 $0 $-72 $0 $-215 $0 $89 $277 $78 $4,305
NOV'09 �$0 $0 $0 $0 $-399 $0 $0 $-399
DEC'09 $119 $0 $0 $15 $0 $135
JAN'10 �$65 $234 $0 $0 $0 $0 $38 $0 $337
FEB'10 $23 $108 $0 $214 $0 $0 $0 $345
MAR'10 �$0 $62 $0 $-864 $0 $-802
APR'10 $94 $0 $0 $0 $0 $0 $94
MAY'10 �$159 $127 $103 $0 $0 $0 $389
JUN'10 $411 $308 $23,100 $2,534 $124 $377 $0 $38 $0 $492 $0 $27,383
JUL'10 �$342 $776 $2,118 $5,519 $141 $54 $0 $170 $9,119
AUG'10 $416 $103 $6,355 $5,511 $26 $0 $107 $42 $196 $0 $12,757
SEP'10 �$4,158 $1,719 $545 $237 $358 $46 $75 $0 $7 $0 $0 $28 $7,172
OCT'10 $26,560 $2,262 $758 $148 $453 $8 $197 $105 $0 $0 $0 $30,490
NOV'10 �$44,588 $24,568 $1,670 $826 $542 $-6 $0 $186 $0 $0 $116 $72,489
DEC'10 $30,342 $98,785 $9,494 $821 $464 $0 $435 $75 $100 $0 $140,516
JAN'11 � $14,041 $110,228 $43,608 $140,057 $108 $169 $240 $0 $128 $0 $308,580
FEB'11 $23,199 $48,581 $3,473 $3,653 $1,019 $4 $738 $594 $0 $81,261
MAR'11 � $44,014 $102,440 $8,062 $4,103 $396 $2,834 $433 $-303 $161,979
APR'11 $40,891 $56,812 $6,396 $837 $2,510 $-193 $17 $107,270
MAY'11 � $23,365 $127,830 $5,167 $3,190 $235 $279 $160,067
JUN'11 $22,020 $50,379 $4,582 $474 $5,045 $82,500
JUL'11 � $46,063 $53,164 $4,947 $1,667 $105,840
AUG'11 $47,328 $70,994 $3,174 $121,496
SEP'11 � $38,058 $69,638 $107,695
OCT'11 $49,571 $49,571
SUMMARY $79,309 $61,983 $147,709 $157,756 $138,771 $287,944 $92,272 $160,962 $103,060 $114,553 $116,958 $129,310 $1,590,586
MEDICAL LAG REPORT
Report Description: This report displays, by paid month, the net medical dollars paid and the corresponding month
incurred for a 12 month rolling paid period (or the available data for your account). This report provides insight into
the monthly claim lag and can help identify IBNR.
MEDICAL FINANCIAL SERVICEMEDICAL FINANCIAL SERVICE
CHAPTER DESCRIPTION
This chapter presents information on key expenses for LAREDO TRANSIT MANAGEMENT, INC.: ALL for the
current reporting month and for the year to date.
The first report presents the Top 15 overall medical paid expenses across inpatient facility, outpatient facility, and
professional setting by ICD-9 diagnostic categories.
The second report focuses on LAREDO TRANSIT MANAGEMENT, INC.: ALL inpatient facility admission experience
and examines the leading ICD-9 Diagnostic Categories to help pinpoint what conditions are driving LAREDO
TRANSIT MANAGEMENT, INC.: ALL inpatient expenses.
The third report analyzes expenses specifically related to services provided in the outpatient facility setting for
LAREDO TRANSIT MANAGEMENT, INC.: ALL. The report examines the leading ICD-9 Diagnostic Categories to
help pinpoint what conditions are driving LAREDO TRANSIT MANAGEMENT, INC.: ALL outpatient expenses. The
expenses presented in this report are for facility expenses only and include service types such as ambulatory
surgery, emergency room, radiology, dialysis and observation room.
The fourth report encompasses all the services for LAREDO TRANSIT MANAGEMENT, INC.: ALL provided by
physicians and other clinicans, ancillary services and supplies. The report examines the leading ICD-9 Diagnostic
Categories to help pinpoint what conditions are driving LAREDO TRANSIT MANAGEMENT, INC.: ALL professional
expenses. Physician and other clinician services include surgical procedures, evaluation and management (E&M)
services, anesthesia services, physical/occupational/speech therapy services and other medical services. Ancillary
services include radiology and laboratory/pathology services. Medical services and supplies are also included in the
professional service category. This service type represents services that have been submitted with a HCPCS
(Healthcare Common Procedure Coding System) code.
Data Note
Current reporting month represents claims paid in Oct'11.
Year to date represents claims paid from Jan'11 through Oct'11.
Claims for active, retiree under 65, retiree 65 and over, and COBRA members are reported (if available).
LAREDO TRANSIT MANAGEMENT, INC.: ALL 3
MEDICAL FINANCIAL SERVICEMEDICAL FINANCIAL SERVICE
OVERALL MEDICAL PAID EXPENSES BY ICD-9 DIAGNOSTIC CATEGORY
Report Description: The table below lists the top 15 overall paid expenses across inpatient facility, outpatient
facility, and professional settings by ICD-9 diagnostic categories for the year to date and the respective experience
for the current reporting month.
LAREDO TRANSIT MANAGEMENT, INC.: ALL 3.1
LAREDO TRANSIT MANAGEMENT, INC.: ALL
OCT'11 YEAR TO DATE
ICD-9 DIAGNOSTIC CATEGORY PAID PAID % PAID PAID %
MUSCULOSKELETAL AND CONNECTIVE TISSUE $24,837 19.2% $366,486 25.3%
NEOPLASMS $5,172 4.0% $291,596 20.1%
HEALTH SERVICES $28,057 21.7% $159,265 11.0%
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES $6,383 4.9% $103,015 7.1%
INJURY & POISONING $653 0.5% $96,899 6.7%
SYMPTOMS, SIGNS & ILL-DEFINED CONDITIONS $4,470 3.5% $88,368 6.1%
CIRCULATORY $7,125 5.5% $74,112 5.1%
GENITOURINARY $2,274 1.8% $50,877 3.5%
DIGESTIVE $11,259 8.7% $32,399 2.2%
INFECTIOUS AND PARASITIC $24,141 18.7% $29,939 2.1%
WITHOUT REPORTED DIAGNOSIS $873 0.7% $25,118 1.7%
EYES $793 0.6% $23,414 1.6%
SKIN AND SUBCUTANEOUS TISSUE $344 0.3% $21,746 1.5%
RESPIRATORY $362 0.3% $18,241 1.3%
NERVOUS SYSTEM $2,266 1.8% $12,279 0.8%
ALL OTHER $10,302 8.0% $55,541 3.8%
SUMMARY $129,310 100.0% $1,449,294 100.0%
The top three ICD-9 Diagnostic Categories in the current reporting month based on paid were Health Services,
Musculoskeletal And Connective Tissue, and Infectious And Parasitic.
MEDICAL FINANCIAL SERVICEMEDICAL FINANCIAL SERVICE
INPATIENT FACILITY PAID EXPENSES BY ICD-9 DIAGNOSTIC CATEGORY
Report Description: The table below lists the top 15 inpatient facility paid expenses by ICD-9 diagnostic categories
for the year to date and the respective experience for the current reporting month.
LAREDO TRANSIT MANAGEMENT, INC.: ALL 3.2
LAREDO TRANSIT MANAGEMENT, INC.: ALL
OCT'11 YEAR TO DATE
ICD-9 DIAGNOSTIC CATEGORY PAID PAID % PAID PAID %
MUSCULOSKELETAL AND CONNECTIVE TISSUE $19,500 36.2% $274,015 43.1%
NEOPLASMS $172,357 27.1%
HEALTH SERVICES $10,778 20.0% $68,227 10.7%
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES $24,052 3.8%
INFECTIOUS AND PARASITIC $23,613 43.8% $23,613 3.7%
INJURY & POISONING $18,577 2.9%
GENITOURINARY $14,719 2.3%
CIRCULATORY $10,840 1.7%
SYMPTOMS, SIGNS & ILL-DEFINED CONDITIONS $8,371 1.3%
SKIN AND SUBCUTANEOUS TISSUE $6,259 1.0%
RESPIRATORY $5,789 0.9%
COMPLICATIONS OF PREGNANCY, CHILDBIRTH, AND THE PUERPERIUM $4,102 0.6%
DIGESTIVE $2,892 0.5%
LIVEBORN INFANTS $1,410 0.2%
BLOOD AND BLOOD-FORMING ORGANS $0 0.0%
SUMMARY $53,890 100.0% $635,222 100.0%
The top three ICD-9 Diagnostic Categories in the current reporting month based on paid were Infectious And
Parasitic, Musculoskeletal And Connective Tissue, and Health Services.
MEDICAL FINANCIAL SERVICEMEDICAL FINANCIAL SERVICE
LAREDO TRANSIT MANAGEMENT, INC.: ALL
LAREDO TRANSIT MANAGEMENT, INC.: ALL
OCT'11 YEAR TO DATE
ICD-9 DIAGNOSTIC CATEGORY PAID PAID % PAID PAID %
HEALTH SERVICES $15,539 39.8% $87,035 21.9%
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES $4,589 11.7% $55,216 13.9%
SYMPTOMS, SIGNS & ILL-DEFINED CONDITIONS $2,449 6.3% $47,855 12.0%
INJURY & POISONING $0 0.0% $39,783 10.0%
MUSCULOSKELETAL AND CONNECTIVE TISSUE $0 0.0% $32,378 8.1%
CIRCULATORY $2,448 6.3% $24,681 6.2%
NEOPLASMS $1,440 3.7% $23,407 5.9%
GENITOURINARY $1,531 3.9% $22,076 5.5%
DIGESTIVE $10,238 26.2% $20,648 5.2%
WITHOUT REPORTED DIAGNOSIS $439 1.1% $13,877 3.5%
SKIN AND SUBCUTANEOUS TISSUE $47 0.1% $6,466 1.6%
RESPIRATORY $5,443 1.4%
EYES $5,083 1.3%
NERVOUS SYSTEM $4,462 1.1%
EARS AND MASTOID PROCESS $3,586 0.9%
ALL OTHER $360 0.9% $5,940 1.5%
SUMMARY $39,080 100.0% $397,937 100.0%
OUTPATIENT FACILITY PAID EXPENSES BY ICD-9 DIAGNOSTIC CATEGORY
Report Description: The table below lists the top 15 outpatient facility paid expenses by ICD-9 diagnostic categories
for the year to date and the respective experience for the current reporting month.
The top three ICD-9 Diagnostic Categories in the current reporting month based on paid were Health Services,
Digestive, and Endocrine, Nutritional And Metabolic Diseases.
3.3
MEDICAL FINANCIAL SERVICEMEDICAL FINANCIAL SERVICE
PROFESSIONAL PAID EXPENSES BY ICD-9 DIAGNOSTIC CATEGORY
Report Description: The table below lists the top 15 professional paid expenses by ICD-9 diagnostic categories for
the year to date and the respective experience for the current reporting month.
3.4LAREDO TRANSIT MANAGEMENT, INC.: ALL
LAREDO TRANSIT MANAGEMENT, INC.: ALL
OCT'11 YEAR TO DATE
ICD-9 DIAGNOSTIC CATEGORY PAID PAID % PAID PAID %
NEOPLASMS $3,732 10.3% $95,833 23.0%
MUSCULOSKELETAL AND CONNECTIVE TISSUE $5,337 14.7% $60,093 14.4%
CIRCULATORY $4,677 12.9% $38,591 9.3%
INJURY & POISONING $653 1.8% $38,538 9.3%
SYMPTOMS, SIGNS & ILL-DEFINED CONDITIONS $2,021 5.6% $32,143 7.7%
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES $1,794 4.9% $23,747 5.7%
EYES $793 2.2% $18,331 4.4%
GENITOURINARY $743 2.0% $14,082 3.4%
OTHER CIRCUMSTANCES $8,611 23.7% $11,479 2.8%
WITHOUT REPORTED DIAGNOSIS $434 1.2% $11,241 2.7%
SKIN AND SUBCUTANEOUS TISSUE $297 0.8% $9,022 2.2%
DIGESTIVE $1,020 2.8% $8,858 2.1%
HEALTH SERVICES: REPRODUCTION AND DEVELOPMENT $33 0.1% $7,849 1.9%
NERVOUS SYSTEM $2,266 6.2% $7,817 1.9%
RESPIRATORY $362 1.0% $7,009 1.7%
ALL OTHER $3,566 9.8% $31,504 7.6%
SUMMARY $36,340 100.0% $416,135 100.0%
The top three ICD-9 Diagnostic Categories in the current reporting month based on paid were Other Circumstances,
Musculoskeletal And Connective Tissue, and Circulatory.
MEDICAL AND PHARMACY LOSS RATIO OVERVIEWMEDICAL AND PHARMACY LOSS RATIO OVERVIEW
4.1
CHAPTER DESCRIPTION
This chapter provides information for LAREDO TRANSIT MANAGEMENT, INC.: ALL based on paid claims,
membership and premium for the most recent twelve reporting months. Premium is reported on an incurred month
basis. Paid claims and premium include both medical and pharmacy dollars.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
MONTH
MEDICAL
SUBSCRIBERS
MEDICAL
MEMBERS
PHARMACY
SUBSCRIBERS
PHARMACY
MEMBERS
NOV'10 156 357 156 357
DEC'10 156 357 156 357
JAN'11 155 355 155 355
FEB'11 155 355 155 355
MAR'11 156 356 156 356
APR'11 155 355 155 355
MAY'11 157 366 157 366
JUN'11 157 365 157 365
JUL'11 158 365 158 365
AUG'11 158 364 158 364
SEP'11 158 366 158 366
OCT'11 158 366 158 366
SUMMARY 1,879 4,327 1,879 4,327
MONTH PREMIUM
MEDICAL
PAID CLAIMS
PHARMACY
PAID CLAIMS CAPITATION TOTAL PAID
MEDICAL AND
PHARMACY
LOSS RATIO
NOV'10 $132,342 $79,309 $30,538 $0 $109,847 83.0%
DEC'10 $132,342 $61,983 $23,115 $0 $85,097 64.3%
JAN'11 $135,262 $147,709 $14,981 $0 $162,690 120.3%
FEB'11 $135,262 $157,756 $13,066 $0 $170,822 126.3%
MAR'11 $135,857 $138,771 $9,994 $0 $148,765 109.5%
APR'11 $135,262 $287,944 $16,174 $0 $304,118 224.8%
MAY'11 $138,164 $92,272 $10,635 $0 $102,907 74.5%
JUN'11 $137,803 $160,962 $11,329 $0 $172,291 125.0%
JUL'11 $138,037 $103,060 $27,474 $0 $130,534 94.6%
AUG'11 $137,654 $114,553 $12,098 $0 $126,650 92.0%
SEP'11 $137,945 $116,958 $15,678 $0 $132,635 96.2%
OCT'11 $137,945 $129,310 $12,024 $0 $141,334 102.5%
SUMMARY $1,633,876 $1,590,586 $197,105 $0 $1,787,691 109.4%
NOV'10 DEC'10 JAN'11 FEB'11 MAR'11 APR'11 MAY'11 JUN'11 JUL'11 AUG'11 SEP'11 OCT'110%
25%
50%
75%
100%
125%
150%
175%
200%
225%
250%
LOSS RATIO BY MONTH
SUMMARY OF MEDICAL AND PHARMACY LOSS RATIO
Report Description: This report provides an overview of LAREDO TRANSIT MANAGEMENT, INC.: ALL's membership,
premium, and combined medical and pharmacy loss ratio and paid claims for the most recent twelve months.
Definitions of these financial measures can be found in the glossary.
SUMMARY OF FINDINGS
The medical and pharmacy loss ratio for the current month was 6.9% lower than the average of the most recent
twelve months, which was 109.4%.
Data Note
Reporting is based on paid, 12-month rolling periods.
Current reporting period represents claims paid from Nov'10 through Oct'11.
Paid claims for active, retiree under 65, retiree 65 and over, and COBRA members are reported (if available).
PHARMACY FINANCIAL SUMMARYPHARMACY FINANCIAL SUMMARY
CHAPTER DESCRIPTION
Pharmacy includes all outpatient, non-professional prescription drug services provided to LAREDO TRANSIT
MANAGEMENT, INC.: ALL's members. This report provides a breakdown of key pharmacy expenditures, from
billed amount to paid amount, for the current reporting month and for the year to date on a paid basis. This report
will balance back to billing and accounts receivable system (BARS).
Data Note
Current reporting month represents claims paid in Oct'11.
Year to date represents claims paid from Jan'11 through Oct'11.
Claims for active, retiree under 65, retiree 65 and over, and COBRA members are reported (if available).
5LAREDO TRANSIT MANAGEMENT, INC.: ALL
PHARMACY FINANCIAL SUMMARYPHARMACY FINANCIAL SUMMARY
LAREDO TRANSIT MANAGEMENT, INC.: ALL
PHARMACY EXPENSES OCT'11 YEAR TO DATE
BILLED $30,858 $346,889
NOT COVERED $0 $0
COVERED $30,858 $346,889
DISCOUNT $14,731 $155,592
ALLOWED $16,127 $191,297
OUT OF POCKET $4,134 $47,875
COB $0 $0
COB MEDICARE $0 $0
OTHER REDUCTIONS $0 $0
OTHER ADJUSTMENTS $-30 $-30
PAID-PROVIDER $12,024 $143,453
OTHER PAYMENTS $0 $0
PAID $12,024 $143,453
5.1LAREDO TRANSIT MANAGEMENT, INC.: ALL
SUMMARY OF PHARMACY FINANCIAL MEASURES
Report Description: This report provides an overview of LAREDO TRANSIT MANAGEMENT, INC.: ALL's pharmacy
expenses from billed to paid for the current reporting month and for the year to date. These key financial
measures are on a paid basis and balance back to your billing and accounts receivable system (BARS). These
metrics include plan performance measures, such as the degree of discounts the plan was able to achieve, as well
as COB and COB Medicare recoveries that the plan was able to receive based on other insurance contributing to
the overall expenses. Information is also provided on the amount of overall health care expenses that the member
was directly responsible for, through deductibles, coinsurance or co-payments. Other reductions include penalties,
workers compensation savings, and subrogation savings. Other payments includes Blue Card access fees and
surcharges. Also displayed are other adjustments. Definitions of these financial measures can be found in the
glossary.
Paid-Provider excludes Other Payments, which are not part of the Billed Amount.
NOT COVERED
DISCOUNT
OUT OF POCKET
COB
COB MEDICARE
OTHER REDUCTIONS
OTHER ADJUSTMENTS
PAID-PROVIDER
OCT'11 YEAR TO DATE 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
BREAKDOWN OF BILLED AMOUNT
ENROLLMENTENROLLMENT
CHAPTER DESCRIPTION
The enrollment chapter presents descriptive information on LAREDO TRANSIT MANAGEMENT, INC.: ALL's
subscribers and dependents enrolled in BCBSTX. The ability to track changes in the characteristics of LAREDO
TRANSIT MANAGEMENT, INC.: ALL's enrolled population is critical information for effective plan management.
Information on membership size, age and gender are presented for subscribers and dependents for the current
reporting month and for the year to date. Enrollment by age band is shown for both subscribers and dependents for
the current reporting month and for the year to date. Additionally, the proportion of LAREDO TRANSIT
MANAGEMENT, INC.: ALL's enrollment by coverage tier is presented. The final report provides an analysis of
enrollment/disenrollment to provide detailed information necessary to understand monthly count variances.
Data Note
Current reporting month represents members enrolled in Oct'11.
Year to date represents average membership enrolled from Jan'11 through Oct'11.
Enrollment for active, retiree under 65, retiree 65 and over, and COBRA members are reported (if available).
6LAREDO TRANSIT MANAGEMENT, INC.: ALL
ENROLLMENTENROLLMENT
ENROLLMENT OVERVIEW
Report Description: For medical membership only, the average number of subscribers, dependents, members and
average contract size for LAREDO TRANSIT MANAGEMENT, INC.: ALL are shown below in addition to the average
age, overall proportion of males, females, and females 20-44 years.
6.1
LAREDO TRANSIT MANAGEMENT, INC.: ALL
OCT'11 YEAR TO DATE
AVERAGE SUBSCRIBERS 158 157
AVERAGE DEPENDENTS 208 205
AVERAGE MEMBERS 366 362
AVERAGE CONTRACT SIZE 2.32 2.31
AVERAGE AGE (YEARS) 34.9 34.9
PROPORTION OF MALES 58.5% 58.4%
PROPORTION OF FEMALES 41.5% 41.6%
PROPORTION OF FEMALES (20-44 YEARS) 12.6% 12.3%
ENROLLMENT BY GENDER AND RELATIONSHIP
OCT'11 YEAR TO DATE OCT'11 YEAR TO DATE OCT'11 YEAR TO DATE0
50
100
150
200
250
300
350
400
SUBSCRIBERS DEPENDENTS MEMBERS
Size: LAREDO TRANSIT MANAGEMENT, INC.: ALL's overall membership was 366 in the current reporting month
and 362 for the year to date.
Gender: The average proportion of males was 58.5% in the current reporting month and 58.4% for the year to date.
Relationship:
Subscribers - For the current reporting month, 81.0% of subscribers were male and 19.0% were female. Forthe year to date, 80.9% of subscribers were male and 19.1% were female.
Dependents - For the current reporting month, 41.3% of dependents were male and 58.7% were female. Forthe year to date, 41.0% of dependents were male and 59.0% were female.
MALE FEMALE
LAREDO TRANSIT MANAGEMENT, INC.: ALL
ENROLLMENTENROLLMENT
ENROLLMENT BY AGE AND GENDER
Report Description: For medical membership only, LAREDO TRANSIT MANAGEMENT, INC.: ALL's average age of
subscribers (employees), dependents (spouse and/or children) and total members are displayed in the table below,
as well as the average age by gender for the current reporting month and for the year to date. The graph shows
various age bands for the year to date, broken down by subscribers, dependents and total members.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
AVERAGE AGE (IN YEARS) BY GENDER
OCT'11 YEAR TO DATE
MALE FEMALE SUMMARY MALE FEMALE SUMMARY
SUBSCRIBERS 49.7 46.6 49.1 49.7 46.2 49.0
DEPENDENTS 16.3 29.7 24.1 16.1 29.7 24.2
MEMBERS 36.3 33.0 34.9 36.3 33.0 34.9
6.2
ENROLLMENT BY AGE BAND FOR THE YEAR TO DATE
<1-19 20-29 30-39 40-49 50-59 60-64 65+0
15
30
45
60
75
90
105
120
135
Subscriber Age: The average age for subscribers was 49.1 for the current reporting month and 49.0 for the year to
date. In the current reporting month, males were older than females and most subscribers fell into the 40-49 age
band.
Dependent Age: The average age for dependents was 24.1 for the current reporting month and 24.2 for the year to
date. In the current reporting month, males were younger than females and most dependents fell into the <1-19
age band.
SUBSCRIBERS DEPENDENTS MEMBERS
AGE BAND (YEARS)
LAREDO TRANSIT MANAGEMENT, INC.: ALL
ENROLLMENTENROLLMENT
ENROLLMENT BY COVERAGE TIER
Report Description: The average number of medical members and proportion of medical members in each coverage
tier are displayed in the table and chart below as well as the average contract size for the current reporting month
and for the year to date.
6.3
LAREDO TRANSIT MANAGEMENT, INC.: ALL
MEDICAL MEMBERS OCT'11 YEAR TO DATE
COVERAGE TIER
AVERAGE
MEMBERS % MEMBERS
AVERAGE
CONTRACT
SIZE
AVERAGE
MEMBERS % MEMBERS
AVERAGE
CONTRACT
SIZE
EMPLOYEE ONLY 84 23.0% 1.00 83 22.8% 1.00
EMPLOYEE+ONE 36 9.8% 2.00 40 11.0% 2.00
EMPLOYEE+DEPENDENT(S) 47 12.8% 3.36 45 12.3% 3.38
FAMILY 199 54.4% 4.74 195 53.9% 4.73
SUMMARY 366 100.0% 2.32 362 100.0% 2.31
ENROLLMENT BY COVERAGE TIER
22.8%
23.0%
11.0%
9.8%
12.3%
12.8%
53.9%
54.4%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
YEAR TO DATE
OCT'11
Employee Only: Made up 23.0% of the overall membership in the current reporting month and 22.8% for the yearto date.
Employee + One: Made up 9.8% of the overall membership in the current reporting month and 11.0% for the yearto date.
Employee + Dependent(s): Made up 12.8% of the overall membership in the current reporting month and 12.3% forthe year to date.
Family: Made up 54.4% of the overall membership in the current reporting month and 53.9% for the year to date.
EMPLOYEE ONLY EMPLOYEE+ONE EMPLOYEE+DEPENDENT(S) FAMILY
PERCENTAGE OF MEMBERS
LAREDO TRANSIT MANAGEMENT, INC.: ALL
ENROLLMENTENROLLMENT
6.4
ENROLLMENT/DISENROLLMENT
Report Description: This report displays monthly medical subscriber and member enrollment and disenrollment counts
for the current policy year. This report breaks by Medicare and non-Medicare eligibility and enables you to identify
significant monthly count variances soon after they occur. This report is filtered to display Plan Eligibility only.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
TOTAL MEDICAL SUBSCRIBERS
MONTH
MEDICARE NON-ELIGIBLE MEDICARE ELIGIBLE
TOTAL
SUBSCRIBERS
NEW
ENROLLMENT DISENROLLMENT
SUBSCRIBER
VARIANCE
NEW
ENROLLMENT DISENROLLMENT
SUBSCRIBER
VARIANCE
JAN'11 0 0 0 0 1 -1 155
FEB'11 0 0 0 0 0 0 155
MAR'11 1 0 1 0 0 0 156
APR'11 0 1 -1 0 0 0 155
MAY'11 2 0 2 0 0 0 157
JUN'11 0 0 0 0 0 0 157
JUL'11 1 0 1 0 0 0 158
AUG'11 0 0 0 0 0 0 158
SEP'11 0 0 0 0 0 0 158
OCT'11 1 0 1 0 1 -1 158
NOV'11
DEC'11
SUMMARY 5 1 4 0 2 -2 157
LAREDO TRANSIT MANAGEMENT, INC.: ALL
TOTAL MEDICAL MEMBERS
MONTH
MEDICARE NON-ELIGIBLE MEDICARE ELIGIBLE
TOTAL
MEMBERS
NEW
ENROLLMENT DISENROLLMENT
MEMBER
VARIANCE
NEW
ENROLLMENT DISENROLLMENT
MEMBER
VARIANCE
JAN'11 7 9 -2 1 1 0 355
FEB'11 0 0 0 0 0 0 355
MAR'11 1 0 1 0 0 0 356
APR'11 0 1 -1 0 0 0 355
MAY'11 11 0 11 0 0 0 366
JUN'11 0 1 -1 0 0 0 365
JUL'11 1 0 1 0 1 -1 365
AUG'11 0 1 -1 0 0 0 364
SEP'11 2 0 2 0 0 0 366
OCT'11 1 0 1 0 1 -1 366
NOV'11
DEC'11
SUMMARY 23 12 11 1 3 -2 361
LAREDO TRANSIT MANAGEMENT, INC.: ALL
ENROLLMENT BY TYPE OF COVERAGE
Report Description: This report provides a high-level view of LAREDO TRANSIT MANAGEMENT, INC.: ALL's
membership, broken down by employee status. These numbers show if a certain employee status was a key driver
to any changes in overall membership for the current reporting month and for the year to date.
ENROLLMENTENROLLMENT
6.5
LAREDO TRANSIT MANAGEMENT, INC.: ALL
AVERAGE ENROLLED MEMBERSHIP BY EMPLOYEE STATUS FOR OCT'11
EMPLOYEE STATUS MEDICAL PHARMACY DENTAL
ACTIVE 365 365
RETIREE UNDER 65
RETIREE 65 AND OVER
COBRA 1 1
SUMMARY 366 366
LAREDO TRANSIT MANAGEMENT, INC.: ALL
AVERAGE ENROLLED MEMBERSHIP BY EMPLOYEE STATUS FOR YEAR TO DATE
EMPLOYEE STATUS MEDICAL PHARMACY DENTAL
ACTIVE 361 361
RETIREE UNDER 65
RETIREE 65 AND OVER
COBRA 1 1
SUMMARY 362 361
LAREDO TRANSIT MANAGEMENT, INC.: ALL
EXPENSE AND UTILIZATION OVERVIEWEXPENSE AND UTILIZATION OVERVIEW
CHAPTER DESCRIPTION
The expense and utilization overview chapter is intended to provide key metrics for LAREDO TRANSIT
MANAGEMENT, INC.: ALL's claims and eligibility experience. Year-over-year changes and comparisons to the
benchmark are provided as well. Typically, when analyzing the health plan's overall performance in the last year,
two sets of questions are asked:
1. What is the percent change in membership and paid expenses?
2. How does LAREDO TRANSIT MANAGEMENT, INC.: ALL's experience compare to the benchmark?
The report provides a high-level breakdown of year-over-year expense and utilization changes and comparisons to
the benchmark. The Key Indicators table provides information related to the demographic make-up of LAREDO
TRANSIT MANAGEMENT, INC.: ALL and how paid expenses are distributed across all service categories.
Demographic information is calculated using medical enrollment only. All per 1000, per employee, and per
member measures are calculated using medical, dental, or pharmacy enrollment as appropriate. A graph is also
provided that shows the proportion of paid by service category.
Data Note
Reporting is based on incurred, 12-month rolling periods with 2 months run-out.
Current reporting period represents claims incurred Sep'10 through Aug'11 and paid through Oct'11.
Prior reporting period represents claims incurred Sep'09 through Aug'10 and paid through Oct'10.
Claims for active, retiree under 65, retiree 65 and over, and COBRA members are reported (if available).
Benchmarks are based on BCBSTX's non-HMO fully insured and self insured book of business. The book of
business includes all groups with between 51 and 500 subscribers.
7
SUMMARY OF FINDINGS
Overall membership decreased 4.0%. Contract size shrank and the average age remained stable.
Overall medical paid PMPM increased 19.6%. Paid PMPM for pharmacy decreased 10.7%. For medical paid
PMPM by service category, inpatient facility increased 47.7%, outpatient facility decreased 14.0% and
professional increased 30.1%.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
EXPENSE AND UTILIZATION OVERVIEWEXPENSE AND UTILIZATION OVERVIEW
KEY INDICATORS
LAREDO TRANSIT MANAGEMENT, INC.: ALL
SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK1 % VARIANCE
DEMOGRAPHICS (MEDICAL ONLY)
AVERAGE SUBSCRIBERS 156 159 -1.6%
AVERAGE DEPENDENTS 203 215 -5.7%
AVERAGE MEMBERS 359 374 -4.0%
AVERAGE CONTRACT SIZE 2.30 2.36 -2.4% 1.79 28.6%
AVERAGE AGE (YEARS) 34.8 34.4 1.2%
PROPORTION OF MALES 58.1% 56.4% 3.2% 51.8% 12.2%
PROPORTION OF FEMALES 41.9% 43.6% -4.1% 48.2% -13.1%
PROPORTION OF FEMALES (20-44 YEARS) 12.3% 13.1% -5.6% 21.2% -41.8%
OVERALL EXPENSES (PAID PMPM)
INPATIENT FACILITY $153.92 $104.24 47.7% $69.70 120.8%
OUTPATIENT FACILITY $100.05 $116.33 -14.0% $64.90 54.2%
PROFESSIONAL $120.62 $92.73 30.1% $83.48 44.5%
MANAGEMENT SERVICES $0.00
TOTAL MEDICAL $374.58 $313.30 19.6% $218.07 71.8%
PHARMACY $45.36 $50.82 -10.7% $51.30 -11.6%
DENTAL $20.28
OVERALL EXPENSES (PAID PEPM)
INPATIENT FACILITY $354.10 $245.70 44.1% $124.69 184.0%
OUTPATIENT FACILITY $230.17 $274.21 -16.1% $116.10 98.2%
PROFESSIONAL $277.49 $218.58 27.0% $149.35 85.8%
MANAGEMENT SERVICES $0.00
TOTAL MEDICAL $861.75 $738.49 16.7% $390.14 120.9%
PHARMACY $104.29 $119.79 -12.9% $91.69 13.7%
DENTAL $39.80
7.1
OVERALL EXPENDITURES (PAID) FOR CURRENT REPORTING PERIOD
36.7%
23.8%
28.7%
10.8%INPATIENT FACILITY
OUTPATIENT FACILITY
PROFESSIONAL
MANAGEMENT SERVICES
PHARMACY
DENTAL
LAREDO TRANSIT MANAGEMENT, INC.: ALL
1The benchmark is age/gender adjusted.
EXPENSE AND UTILIZATION OVERVIEWEXPENSE AND UTILIZATION OVERVIEW
7.2
LAREDO TRANSIT MANAGEMENT, INC.: ALL
SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE
INPATIENT FACILITY UTILIZATION AND EXPENSE
TOTAL INPATIENT FACILITY PAID $663,221 $467,817 41.8%
INPATIENT FACILITY PAID PMPM $153.92 $104.24 47.7% $69.70 120.8%
ADMISSIONS/1000 125.3 98.9 26.7% 61.0 105.4%
IN-NETWORK ADMISSIONS % 100.0% 100.0% 0.0% 98.4% 1.6%
DAYS/1000 593.2 623.0 -4.8% 288.1 105.9%
AVERAGE LENGTH OF STAY (ALOS) 4.7 6.3 -24.8% 4.7 0.3%
PAID/ADMISSION $14,738 $12,644 16.6% $13,707 7.5%
IN-NETWORK PAID % 100.0% 100.0% 0.0% 98.9% 1.2%
PAID/DAY $3,114 $2,008 55.1% $2,903 7.2%
OUTPATIENT FACILITY UTILIZATION AND EXPENSE
TOTAL OUTPATIENT FACILITY PAID $431,101 $522,097 -17.4%
OUTPATIENT FACILITY PAID PMPM $100.05 $116.33 -14.0% $64.90 54.2%
VISITS/1000 2,342.1 2,211.2 5.9% 992.3 136.0%
IN-NETWORK VISITS % 80.9% 79.6% 1.6% 96.2% -16.0%
PAID/VISIT $513 $631 -18.8% $785 -34.7%
IN-NETWORK PAID % 95.6% 90.9% 5.2% 97.5% -2.0%
EMERGENCY ROOM VISITS/1000 133.7 176.5 -24.3% 191.4 -30.2%
EMERGENCY ROOM PAID/VISIT $1,012 $1,183 -14.5% $912 11.0%
PROFESSIONAL UTILIZATION AND EXPENSE
TOTAL PROFESSIONAL PAID $519,731 $416,170 24.9%
PROFESSIONAL PAID PMPM $120.62 $92.73 30.1% $83.48 44.5%
VISITS/MEMBER 8.5 7.8 10.1%
SERVICES/MEMBER 21.9 19.2 14.1% 18.9 15.8%
IN-NETWORK SERVICES % 98.5% 98.2% 0.3% 97.5% 1.0%
PAID/VISIT $170 $144 18.1%
PAID/SERVICE $66 $58 14.0% $53 24.8%
IN-NETWORK PAID % 99.1% 99.3% -0.2% 98.8% 0.3%
OFFICE VISITS/MEMBER 5.3 4.7 11.0%
OFFICE SERVICES/MEMBER 12.8 11.8 8.2% 15.4 -16.6%
OFFICE PAID/VISIT $152 $143 6.5%
OFFICE PAID/SERVICE $62 $57 9.1% $43 45.8%
PHARMACY UTILIZATION AND EXPENSE
TOTAL PHARMACY PAID $195,329 $228,072 -14.4%
PHARMACY PAID PMPM $45.36 $50.82 -10.7% $51.30 -11.6%
PRESCRIPTIONS/MEMBER 9.3 9.1 2.2% 10.8 -14.1%
GENERIC DISPENSING RATE 65.9% 55.4% 18.9% 69.3% -4.9%
PAID/PRESCRIPTION $59 $67 -12.7% $57 2.9%
DENTAL UTILIZATION AND EXPENSE
TOTAL DENTAL PAID
DENTAL PAID PMPM $20.28
SERVICES/MEMBER 3.4
IN-NETWORK SERVICES % 50.7%
PAID/SERVICE $71
IN-NETWORK PAID % 45.3%
SUMMARY
TOTAL MEDICAL PAID PMPM $374.58 $313.30 19.6% $218.07 71.8%
AVERAGE SUBSCRIBERS 156 159 -1.6%
AVERAGE DEPENDENTS 203 215 -5.7%
AVERAGE MEMBERS 359 374 -4.0%
LAREDO TRANSIT MANAGEMENT, INC.: ALL
KEY INDICATORS, CONTINUED
MEDICAL SERVICEMEDICAL SERVICE
CHAPTER DESCRIPTION
This chapter presents information on key expense and utilization metrics for LAREDO TRANSIT MANAGEMENT,
INC.: ALL, how they changed over time and how they compare with the benchmark.
This first group of reports focuses on LAREDO TRANSIT MANAGEMENT, INC.: ALL inpatient facility admission
experience. The first inpatient report details key statistics for maternity and non-maternity admissions (medical,
surgical, mental health/substance abuse and non-acute) with percent change and benchmark comparisons. The
second inpatient report lists the top ten inpatient providers ranked by number of admissions and by paid PMPM.
The second group of reports analyzes expense and utilization specifically related to visits provided in the outpatient
facility setting for LAREDO TRANSIT MANAGEMENT, INC.: ALL. The first report presents outpatient expense and
utilization by visit type with percent change and benchmark comparisons. The second report examines the top ten
most frequent reasons for an outpatient emergency room visit, surgical procedure, and radiology service. The third
report lists the top ten outpatient providers ranked by number of admissions and by paid.
The last report encompasses all the services for LAREDO TRANSIT MANAGEMENT, INC.: ALL provided by
physicians and other clinicians, ancillary services and supplies. This report analyzes the expense and utilization of
professional services by service type with percent change and benchmark comparisons.
Data Note
Reporting is based on incurred, 12-month rolling periods with 2 months run-out.
Current reporting period represents claims incurred Sep'10 through Aug'11 and paid through Oct'11.
Prior reporting period represents claims incurred Sep'09 through Aug'10 and paid through Oct'10.
Claims for active, retiree under 65, retiree 65 and over, and COBRA members are reported (if available).
Benchmarks are based on BCBSTX's non-HMO fully insured and self insured book of business. The book of
business includes all groups with between 51 and 500 subscribers.
8LAREDO TRANSIT MANAGEMENT, INC.: ALL
MEDICAL SERVICEMEDICAL SERVICE
SERVICE TYPE
LAREDO TRANSIT MANAGEMENT, INC.: ALL
SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE
MEDICAL ADMISSIONS/1000 69.6 64.2 8.5% 23.2 200.2%
DAYS/1000 381.5 355.6 7.3% 108.7 250.9%
AVERAGE LENGTH OF STAY 5.5 5.5 -1.1% 4.7 16.9%
PAID PMPM $65.51 $39.58 65.5% $22.93 185.7%
PAID/ADMISSION $11,291 $7,401 52.6% $11,865 -4.8%
PAID/DAY $2,060 $1,335 54.3% $2,531 -18.6%
SURGICAL ADMISSIONS/1000 44.6 21.4 108.3% 17.6 152.6%
DAYS/1000 194.9 173.8 12.2% 80.4 142.4%
AVERAGE LENGTH OF STAY 4.4 8.1 -46.2% 4.6 -4.0%
PAID PMPM $85.96 $56.18 53.0% $37.31 130.4%
PAID/ADMISSION $23,150 $31,515 -26.5% $25,382 -8.8%
PAID/DAY $5,291 $3,879 36.4% $5,568 -5.0%
MATERNITY ADMISSIONS/1000 11.1 10.7 4.2% 15.0 -25.9%
DAYS/1000 16.7 18.7 -10.7% 44.4 -62.4%
AVERAGE LENGTH OF STAY 1.5 1.8 -14.3% 3.0 -49.2%
PAID PMPM $2.45 $1.62 50.9% $6.19 -60.4%
PAID/ADMISSION $2,638 $1,821 44.9% $4,938 -46.6%
PAID/DAY $1,759 $1,041 69.0% $1,672 5.2%
MENTAL HEALTH/
SUBSTANCE ABUSE
ADMISSIONS/1000 4.1
DAYS/1000 34.8
AVERAGE LENGTH OF STAY 8.5
PAID PMPM $1.64
PAID/ADMISSION $4,834
PAID/DAY $567
NON-ACUTE ADMISSIONS/1000 2.7 1.1
DAYS/1000 74.9 19.7
AVERAGE LENGTH OF STAY 28.0 18.5
PAID PMPM $6.86 $1.63
PAID/ADMISSION $30,800 $18,232
PAID/DAY $1,100 $988
SUMMARY ADMISSIONS/1000 125.3 98.9 26.7% 61.0 105.4%
DAYS/1000 593.2 623.0 -4.8% 288.1 105.9%
AVERAGE LENGTH OF STAY 4.7 6.3 -24.8% 4.7 0.3%
PAID PMPM $153.92 $104.24 47.7% $69.70 120.8%
PAID/ADMISSION $14,738 $12,644 16.6% $13,707 7.5%
PAID/DAY $3,114 $2,008 55.1% $2,903 7.2%
8.1LAREDO TRANSIT MANAGEMENT, INC.: ALL
INPATIENT ADMISSION ANALYSIS
Report Description: Expense and utilization measures are displayed in the table below for the following admission
categories: maternity, medical, mental health/substance abuse, non-acute, and surgical. Current reporting period,
prior reporting period, and benchmark measures are analyzed in the table. Non-acute refers to admissions for
rehabilitation, skilled nursing facilities, and hospice care. The paid amount is based on the inpatient facility
component only. Inpatient professional statistics are not reported.
MEDICAL SERVICEMEDICAL SERVICE
INPATIENT ADMISSION ANALYSIS, CONTINUED
Medical: Over the two reporting periods, LAREDO TRANSIT MANAGEMENT, INC.: ALL's expense (paid PMPM)
increased 65.5%, utilization (admissions/1,000) increased 8.5% and paid per admission increased 52.6% for
medical admissions. In addition, the average length of stay remained relatively stable. Compared to the
benchmark, LAREDO TRANSIT MANAGEMENT, INC.: ALL had higher expenses, higher utilization, lower paid per
admission and longer length of stay.
Surgical: Over the two reporting periods, LAREDO TRANSIT MANAGEMENT, INC.: ALL's expense (paid PMPM)
increased 53.0%, utilization (admissions/1,000) increased 108.3% and paid per admission decreased 26.5% for
surgical admissions. In addition, the average length of stay decreased 46.2%. Compared to the benchmark,
LAREDO TRANSIT MANAGEMENT, INC.: ALL had higher expenses, higher utilization, lower paid per admission
and slightly shorter length of stay.
Maternity: Over the two reporting periods, LAREDO TRANSIT MANAGEMENT, INC.: ALL's expense (paid PMPM)
increased 50.9%, utilization (admissions/1,000) increased slightly and paid per admission increased 44.9% for
maternity admissions. In addition, the average length of stay decreased 14.3%. Compared to the benchmark,
LAREDO TRANSIT MANAGEMENT, INC.: ALL had lower expenses, lower utilization, lower paid per admission and
shorter length of stay.
Mental Health/Substance Abuse: Insufficient data for comparison (>12 months required)
Non-Acute: Insufficient data for comparison (>12 months required)
8.2LAREDO TRANSIT MANAGEMENT, INC.: ALL
MEDICAL SERVICEMEDICAL SERVICE
LAREDO TRANSIT MANAGEMENT, INC.: ALL 8.3
INPATIENT PROVIDER SUMMARY
Report Description: The provider listings below include top ten inpatient facility providers ranked by admissions and
by paid for the current reporting period. Expense and utilization measures are featured in both listings.
The top three inpatient facility providers that comprised 86.7% of the total admissions were Doctors Hospital Of
Laredo, Laredo Medical Center, and Methodist Hospital.
The top three inpatient facility providers that comprised 85.3% of the total paid were Methodist Hospital, Laredo
Medical Center, and Doctors Hospital Of Laredo.
TOP 10 INPATIENT FACILITY PROVIDERS BY ADMISSIONS FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL
PROVIDER NAME
PROVIDER
STATE ADMISSIONS
% OF TOTAL
ADMISSIONS DAYS
AVG
LENGTH
OF STAY
PAID/
ADMISSION PAID
% OF TOTAL
PAID
DOCTORS HOSPITAL OF LAREDO TX 19 42.2% 84 4.4 $6,806 $129,311 19.5%
LAREDO MEDICAL CENTER TX 15 33.3% 58 3.9 $12,165 $182,482 27.5%
METHODIST HOSPITAL TX 5 11.1% 53 10.6 $50,733 $253,666 38.2%
UNIVERSITY HEALTH SYSTEM TX 3 6.7% 11 3.7 $22,823 $68,470 10.3%
CHRISTUS SANTA ROSA CHILDRENS HOS TX 2 4.4% 4 2.0 $11,149 $22,298 3.4%
METHODIST SPECIALTY AND TRANSPLANT
HOSPI TX 1 2.2% 3 3.0 $6,995 $6,995 1.1%
SUMMARY 45 100.0% 213 4.7 $14,738 $663,221 100.0%
TOP 10 INPATIENT FACILITY PROVIDERS BY PAID FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL
PROVIDER NAME
PROVIDER
STATE ADMISSIONS
% OF TOTAL
ADMISSIONS DAYS
AVG
LENGTH
OF STAY
PAID/
ADMISSION PAID
% OF TOTAL
PAID
METHODIST HOSPITAL TX 5 11.1% 53 10.6 $50,733 $253,666 38.2%
LAREDO MEDICAL CENTER TX 15 33.3% 58 3.9 $12,165 $182,482 27.5%
DOCTORS HOSPITAL OF LAREDO TX 19 42.2% 84 4.4 $6,806 $129,311 19.5%
UNIVERSITY HEALTH SYSTEM TX 3 6.7% 11 3.7 $22,823 $68,470 10.3%
CHRISTUS SANTA ROSA CHILDRENS HOS TX 2 4.4% 4 2.0 $11,149 $22,298 3.4%
METHODIST SPECIALTY AND TRANSPLANT
HOSPI TX 1 2.2% 3 3.0 $6,995 $6,995 1.1%
SUMMARY 45 100.0% 213 4.7 $14,738 $663,221 100.0%
MEDICAL SERVICE
OUTPATIENT FACILITY VISIT TYPE ANALYSIS
Report Description: Outpatient facility expense and utilization measures are displayed in the table below by visit
type. Current reporting period, prior reporting period, and benchmark measures are analyzed in the table. The
visit type Other Services refers to all visits that could not be classified into other visit types that are displayed
below.
MEDICAL SERVICE
LAREDO TRANSIT MANAGEMENT, INC.: ALL
LAREDO TRANSIT MANAGEMENT, INC.: ALL
PAID PMPM SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE
RADIOLOGY $39.70 $23.45 69.3% $12.76 211.0%
SURGICAL $25.78 $27.51 -6.3% $24.43 5.5%
LABORATORY $15.98 $22.43 -28.8% $3.02 428.9%
EMERGENCY ROOM $11.28 $17.40 -35.2% $14.55 -22.5%
PT/OT/ST $3.32 $5.37 -38.1% $1.86 78.9%
OTHER SERVICES $2.23 $8.56 -74.0% $1.66 34.3%
DIALYSIS $1.38 $6.41 -78.6% $1.32 4.6%
OBSERVATION ROOM $0.39 $0.93 -58.1% $1.80 -78.4%
MEDICAL SPECIALTIES SERVICES $4.28 $2.82
PSYCHIATRIC $0.69
SUMMARY $100.05 $116.33 -14.0% $64.90 54.2%
LAREDO TRANSIT MANAGEMENT, INC.: ALL
VISITS/1000 SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE
RADIOLOGY 746.3 336.9 121.5% 253.4 194.5%
SURGICAL 222.8 171.1 30.2% 131.1 70.0%
LABORATORY 523.6 604.3 -13.4% 142.2 268.2%
EMERGENCY ROOM 133.7 176.5 -24.3% 191.4 -30.2%
PT/OT/ST 192.2 374.3 -48.7% 112.0 71.5%
OTHER SERVICES 139.2 243.3 -42.8% 54.3 156.2%
DIALYSIS 364.8 211.2 72.7% 49.2 641.0%
OBSERVATION ROOM 19.5 21.4 -8.9% 26.3 -25.8%
MEDICAL SPECIALTIES SERVICES 72.2 8.1
PSYCHIATRIC 24.3
SUMMARY 2,342.1 2,211.2 5.9% 992.3 136.0%
LAREDO TRANSIT MANAGEMENT, INC.: ALL
PAID/VISIT SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE
RADIOLOGY $638 $835 -23.6% $604 5.6%
SURGICAL $1,389 $1,929 -28.0% $2,236 -37.9%
LABORATORY $366 $445 -17.8% $255 43.6%
EMERGENCY ROOM $1,012 $1,183 -14.5% $912 11.0%
PT/OT/ST $208 $172 20.7% $199 4.3%
OTHER SERVICES $192 $422 -54.6% $366 -47.6%
DIALYSIS $45 $364 -87.6% $321 -85.9%
OBSERVATION ROOM $239 $521 -54.1% $821 -70.9%
MEDICAL SPECIALTIES SERVICES $711 $4,171
PSYCHIATRIC $343
SUMMARY $513 $631 -18.8% $785 -34.7%
$0 $5 $10 $15 $20 $25 $30 $35 $40 $45
PSYCHIATRIC
MEDICAL SPECIALTIES SERVICES
OBSERVATION ROOM
DIALYSIS
OTHER SERVICES
PT/OT/ST
EMERGENCY ROOM
LABORATORY
SURGICAL
RADIOLOGY
0 150 300 450 600 750 900
PSYCHIATRIC
MEDICAL SPECIALTIES SERVICES
OBSERVATION ROOM
DIALYSIS
OTHER SERVICES
PT/OT/ST
EMERGENCY ROOM
LABORATORY
SURGICAL
RADIOLOGY
$0
$5
00
$1
,00
0
$1
,50
0
$2
,00
0
$2
,50
0
$3
,00
0
$3
,50
0
$4
,00
0
$4
,50
0
PSYCHIATRIC
MEDICAL SPECIALTIES SERVICES
OBSERVATION ROOM
DIALYSIS
OTHER SERVICES
PT/OT/ST
EMERGENCY ROOM
LABORATORY
SURGICAL
RADIOLOGY
SEP'10-AUG'11 SEP'09-AUG'10 BENCHMARK
8.4
PAID PMPM
VISITS/1000
PAID/VISIT
MEDICAL SERVICE
OUTPATIENT FACILITY VISIT TYPE ANALYSIS, CONTINUED
Expense: Overall, LAREDO TRANSIT MANAGEMENT, INC.: ALL's change in paid PMPM for outpatient facility visits
was -14.0%, which was 54.2% above the benchmark. A comparison of paid PMPM by visit type shows that
ambulatory surgery was 5.5% above the benchmark, emergency room was 22.5% below the benchmark and
radiology was 211.0% above the benchmark.
Utilization: The change in outpatient facility visits/1,000 was 5.9%, which was 136.0% higher than the
benchmark. A comparison of visits/1,000 by visit type shows that ambulatory surgery was 70.0% higher than the
benchmark, emergency room was 30.2% lower than the benchmark and radiology was 194.5% higher than the
benchmark.
Paid per Visit: The overall change in the paid per visit was -18.8% and was 34.7% lower than the benchmark. Paid
per visit for emergency room was 11.0% higher than the benchmark, 37.9% lower than the benchmark for
ambulatory surgery and 5.6% higher than the benchmark for radiology.
MEDICAL SERVICE
LAREDO TRANSIT MANAGEMENT, INC.: ALL 8.5
MEDICAL SERVICE
OUTPATIENT FACILITY VISIT TYPE DETAIL FOR EMERGENCY ROOM, AMBULATORY SURGERY ANDRADIOLOGY
Report Description: In the first table, key utilization and expense metrics are displayed for the ten most frequent
emergency room diagnoses in the current reporting period. The ambulatory surgery table shows key utilization and
expense metrics for the ten most frequent diagnostic categories in the current reporting period. The last table
displays key utilization and expense metrics for the most frequent outpatient radiology services in the current
reporting period.
MEDICAL SERVICE
LAREDO TRANSIT MANAGEMENT, INC.: ALL 8.6
EMERGENCY ROOM - TOP 10 DIAGNOSES BY VISITS FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL FOR THE CURRENT REPORTING PERIOD
3-DIGIT PRINCIPAL DIAGNOSES VISITS/1000
% OF TOTAL
VISITS/1000 PAID/VISIT PAID PMPM
% OF TOTAL
PAID PMPM
780 GENERAL SYMPTOMS 11.1 8.3% $1,230 $1.14 10.1%
789 OTHER SYMPTOMS INVOLVING ABDOMEN AND PELVIS 11.1 8.3% $599 $0.56 4.9%
844 SPRAINS AND STRAINS OF KNEE AND LEG 8.4 6.2% $1,272 $0.89 7.9%
382 SUPPURATIVE AND UNSPECIFIED OTITIS MEDIA 5.6 4.2% $855 $0.40 3.5%
592 CALCULUS OF KIDNEY AND URETER 5.6 4.2% $984 $0.46 4.1%
786 SYMPTOMS INVOLVING RESPIRATORY SYSTEM AND OTHER CHEST
SYMPTOMS 5.6 4.2% $2,399 $1.11 9.9%
924 CONTUSION OF LOWER LIMB AND OF OTHER AND UNSPECIFIED
SITES 5.6 4.2% $1,021 $0.47 4.2%
204 LYMPHOID LEUKEMIA 2.8 2.1% $1,011 $0.23 2.1%
276 DISORDERS OF FLUID, ELECTROLYTE AND ACID-BASE BALANCE 2.8 2.1% $587 $0.14 1.2%
381 NONSUPPURATIVE OTITIS MEDIA AND EUSTACHIAN TUBE DISORDERS 2.8 2.1% $251 $0.06 0.5%
ALL OTHER 72.4 54.2% $965 $5.82 51.6%
SUMMARY 133.7 100.0% $1,012 $11.28 100.0%
AMBULATORY SURGERY - TOP 10 DIAGNOSES BY VISITS FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL FOR THE CURRENT REPORTING PERIOD
ICD-9 DIAGNOSTIC CATEGORY VISITS/1000
% OF TOTAL
VISITS/1000 PAID/VISIT PAID PMPM
% OF TOTAL
PAID PMPM
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES 78.0 35.0% $1,079 $7.01 27.2%
EYES 27.8 12.5% $564 $1.31 5.1%
NEOPLASMS 22.3 10.0% $956 $1.77 6.9%
SYMPTOMS, SIGNS & ILL-DEFINED CONDITIONS 19.5 8.8% $1,055 $1.71 6.7%
DIGESTIVE 16.7 7.5% $849 $1.18 4.6%
INJURY & POISONING 13.9 6.2% $4,235 $4.91 19.1%
GENITOURINARY 11.1 5.0% $3,309 $3.07 11.9%
WITHOUT REPORTED DIAGNOSIS 11.1 5.0% $840 $0.78 3.0%
CIRCULATORY 5.6 2.5% $6,136 $2.85 11.0%
HEALTH SERVICES 5.6 2.5% $503 $0.23 0.9%
ALL OTHER 11.1 5.0% $1,014 $0.94 3.7%
SUMMARY 222.8 100.0% $1,389 $25.78 100.0%
MEDICAL SERVICEMEDICAL SERVICE
LAREDO TRANSIT MANAGEMENT, INC.: ALL 8.7
OUTPATIENT FACILITY VISIT TYPE DETAIL FOR EMERGENCY ROOM, AMBULATORY SURGERY ANDRADIOLOGY, CONTINUED
RADIOLOGY SERVICE CATEGORIES BY VISITS FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL FOR THE CURRENT REPORTING PERIOD
DETAILED SERVICE TYPE VISITS/1000
% OF TOTAL
VISITS/1000 PAID/VISIT PAID PMPM
% OF TOTAL
PAID PMPM
DIAGNOSTIC RADIOLOGY: OTHER 495.7 66.4% $408 $16.86 42.5%
THERAPEUTIC RADIOLOGY 156.0 20.9% $1,080 $14.04 35.4%
OTHER IMAGING 44.6 6.0% $398 $1.48 3.7%
CT SCAN 39.0 5.2% $1,712 $5.56 14.0%
MRI 11.1 1.5% $1,894 $1.76 4.4%
NUCLEAR MEDICINE
ALL OTHER
SUMMARY 746.3 100.0% $638 $39.70 100.0%
The top three diagnoses in terms of total ER visits were 780 General Symptoms, 789 Other Symptoms Involving
Abdomen And Pelvis, and 844 Sprains And Strains Of Knee And Leg. These diagnoses accounted for 22.9% of
the total ER visits evaluated in this analysis.
The top five paid ambulatory surgical procedures accounted for 58.8% of the total ambulatory surgical visits and
for 76.1% of the total ambulatory surgical expenses.
The top five paid radiology services accounted for 100.0% of the total radiology visits and for 100.0% of the total
radiology expenses.
MEDICAL SERVICEMEDICAL SERVICE
OUTPATIENT PROVIDER SUMMARY
Report Description: The provider listings below include top ten outpatient facility providers ranked by visits and by
paid dollars for the current reporting period.
TOP 10 OUTPATIENT FACILITY PROVIDERS BY VISITS FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL
PROVIDER NAME
PROVIDER
STATE VISITS PAID
% OF TOTAL
PAID PAID/VISIT
LAREDO MEDICAL CENTER TX 354 $233,366 54.1% $659
DOCTORS HOSPITAL OF LAREDO TX 223 $124,813 29.0% $560
USRC LAREDO SOUTH DIALYSIS LP TX 130 $5,806 1.3% $45
GLOBAL NURSING SERVICES INC TX 28 $6,496 1.5% $232
LAREDO LASER & SURGERY LTD TX 28 $13,178 3.1% $471
LAREDO HOME HEALTH TX 25 $3,277 0.8% $131
CHRISTUS SANTA ROSA HOSP CITY CTR TX 15 $5,491 1.3% $366
UNIVERSITY HEALTH SYSTEM TX 8 $12,825 3.0% $1,603
CHRISTUS SANTA ROSA CHILDRENS HOS TX 6 $1,334 0.3% $222
METHODIST HOSPITAL TX 6 $6,469 1.5% $1,078
ALL OTHER 18 $18,047 4.2% $1,003
SUMMARY 841 $431,101 100.0% $513
TOP 10 OUTPATIENT FACILITY PROVIDERS BY PAID FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL
PROVIDER NAME
PROVIDER
STATE VISITS PAID
% OF TOTAL
PAID PAID/VISIT
LAREDO MEDICAL CENTER TX 354 $233,366 54.1% $659
DOCTORS HOSPITAL OF LAREDO TX 223 $124,813 29.0% $560
LAREDO LASER & SURGERY LTD TX 28 $13,178 3.1% $471
UNIVERSITY HEALTH SYSTEM TX 8 $12,825 3.0% $1,603
GLOBAL NURSING SERVICES INC TX 28 $6,496 1.5% $232
METHODIST HOSPITAL TX 6 $6,469 1.5% $1,078
USRC LAREDO SOUTH DIALYSIS LP TX 130 $5,806 1.3% $45
CHRISTUS SANTA ROSA HOSP CITY CTR TX 15 $5,491 1.3% $366
THE CNTR FOR SPECIAL SURGERY TCA TX 2 $5,426 1.3% $2,713
CORPUS CHRISTI MEDICAL CENTER BAY
AREA
TX 2 $3,695 0.9% $1,847
ALL OTHER 45 $13,538 3.1% $301
SUMMARY 841 $431,101 100.0% $513
8.8LAREDO TRANSIT MANAGEMENT, INC.: ALL
MEDICAL SERVICEMEDICAL SERVICE
LAREDO TRANSIT MANAGEMENT, INC.: ALL
PROFESSIONAL SERVICE TYPE ANALYSIS
Report Description: Expense and utilization measures for professional services by service type are displayed in the
table below. Current reporting period, prior reporting period, and benchmark measures are analyzed in the table.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
PAID PMPM SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE
MEDICAL SERVICES & SUPPLIES (HCPCS II) $30.71 $14.65 109.6% $12.82 139.5%
EVALUATION & MANAGEMENT $25.30 $26.43 -4.3% $23.96 5.6%
SURGICAL $19.88 $12.90 54.1% $11.26 76.6%
MEDICAL $15.16 $18.94 -20.0% $13.49 12.4%
RADIOLOGY $12.55 $8.55 46.8% $7.44 68.7%
PATHOLOGY & LABORATORY $9.82 $6.66 47.3% $8.14 20.5%
ANESTHESIA $4.85 $2.99 62.1% $4.65 4.3%
PT/OT/ST $2.34 $1.60 46.9% $1.72 36.5%
OTHER $0.00
SUMMARY $120.62 $92.73 30.1% $83.48 44.5%
LAREDO TRANSIT MANAGEMENT, INC.: ALL
SERVICES/1000 SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE
MEDICAL SERVICES & SUPPLIES (HCPCS II) 1,690.4 978.6 72.7% 1,106.4 52.8%
EVALUATION & MANAGEMENT 4,366.7 4,569.5 -4.4% 4,193.3 4.1%
SURGICAL 1,203.1 799.5 50.5% 1,376.7 -12.6%
MEDICAL 2,667.9 2,582.9 3.3% 3,275.3 -18.5%
RADIOLOGY 1,821.3 1,478.6 23.2% 1,297.8 40.3%
PATHOLOGY & LABORATORY 8,705.5 7,510.7 15.9% 6,359.7 36.9%
ANESTHESIA 100.3 107.0 -6.3% 133.2 -24.8%
PT/OT/ST 1,375.7 1,187.2 15.9% 1,200.8 14.6%
OTHER 1.3
SUMMARY 21,930.8 19,213.9 14.1% 18,944.6 15.8%
LAREDO TRANSIT MANAGEMENT, INC.: ALL
PAID/SERVICE SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE
MEDICAL SERVICES & SUPPLIES (HCPCS II) $218 $180 21.3% $139 56.8%
EVALUATION & MANAGEMENT $70 $69 0.2% $69 1.4%
SURGICAL $198 $194 2.4% $98 102.1%
MEDICAL $68 $88 -22.5% $49 38.0%
RADIOLOGY $83 $69 19.1% $69 20.2%
PATHOLOGY & LABORATORY $14 $11 27.1% $15 -11.9%
ANESTHESIA $581 $336 72.9% $419 38.6%
PT/OT/ST $20 $16 26.8% $17 19.1%
OTHER $27
SUMMARY $66 $58 14.0% $53 24.8%
Expense: Over the current reporting period, LAREDO TRANSIT MANAGEMENT, INC.: ALL's top three paid service
types were Medical Services & Supplies (HCPCS II), Evaluation & Management and Surgical.
Utilization: The highest utilized service type was Pathology & Laboratory which was 36.9% higher than the
benchmark. Next was Evaluation & Management which was 4.1% higher than the benchmark, followed by Medical.
Paid per Service: The most expensive service type was Anesthesia which was 38.6% higher than the benchmark.
Next was Medical Services & Supplies (HCPCS II) which was 56.8% higher than the benchmark, followed by
Surgical.
8.9
PHARMACYPHARMACY
CHAPTER DESCRIPTION
Pharmacy includes all outpatient, non-professional prescription drug services provided to LAREDO TRANSIT
MANAGEMENT, INC.: ALL's members. These services are categorized into generic, brand formulary, brand
non-formulary, and specialty drugs. Once the patent for a brand drug expires, a generic version of the drug which
is the same chemically as the brand version can be available at cheaper prices. Generic drugs are less expensive
because generic manufacturers do not have the investment expenses of a new drug developer. When appropriate,
plan sponsors encourage the use of generics over brand drugs. Formulary brand drugs are those that appear on the
plan's approved list of brands. Non-formulary brand drugs are all other brand drugs which generally have equally
effective and less expensive generic equivalents and/or have one or more formulary options. Specialty drugs
generally have unique uses, require special dosing or administration, are typically prescribed by a specialist
provider and are significantly more expensive than alternative drugs or therapies.
This chapter presents information on key expense and utilization metrics for prescription drugs. These metrics are
provided on a paid basis with compression logic applied, consequently the report will not balance back to BARS.
When available, metrics for the current reporting month are compared to the year to date.
Prescription drugs are classified by therapeutic class. Number of prescriptions, total paid by plan, and whether
generic or formulary is presented for the top 25 therapeutic drug classes. Descriptive information on the top 25
prescription drugs is also provided based on number of prescriptions, total paid by plan, and whether generic or
formulary.
A report on Specialty drugs is included showing key expense and utilization metrics.
Data Note
Current reporting month represents claims paid in Oct'11.
Year to date represents claims paid from Jan'11 through Oct'11.
Claims for active, retiree under 65, retiree 65 and over, and COBRA members are reported (if available).
9LAREDO TRANSIT MANAGEMENT, INC.: ALL
SUMMARY OF FINDINGS
Generic drugs were dispensed at a(n) 67.3% rate in the current reporting month. Increasing the generic
dispensing rate by 2% points would result in a savings of $9,178 for LAREDO TRANSIT MANAGEMENT, INC.:
ALL for the year to date.
Multi-source brand (brands with an exact generic equivalent) utilization was 2.0% for the year to date.
The top therapeutic classes, based on total ingredient cost in the year to date were HMG CoA Reductase Inhibitors,
Antihypertensive Combinations, and Proton Pump Inhibitors. The top prescription drugs, based on total ingredient
cost, were Lamictal Xr, Temodar, and Actos in the year to date. These drugs accounted for 14.8% of the total
ingredient cost amount.
The number of members utilizing specialty medication for the year to date was 3. These 3 members received 5
specialty medications which represented 8.3% of the total pharmacy paid amount for the year to date. The top
specialty drugs, based on total ingredient cost were Temodar, Enbrel, and Xeloda in the year to date. These drugs
accounted for 100.0% of the total ingredient cost amount.
PHARMACYPHARMACY
9.1
65.3%
69.4% 68.8%67.3% 67.8%
85.0% 85.9%88.2% 87.8% 86.5%
Q1 Q2 Q3 Q4 YEAR TO DATE 0%
15%
30%
45%
60%
75%
LAREDO TRANSIT MANAGEMENT, INC.: ALL
KEY INDICATORS SUMMARY
Report Description: This report provides an overview of LAREDO TRANSIT MANAGEMENT, INC.: ALL's prescription
expenses and utilization as well as providing percent change in these expenses between the current reporting
month and year to date periods.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
SAVINGS SUMMARY
OCT'11 YEAR TO DATE
RETAIL MAIL ORDER SUMMARY RETAIL MAIL ORDER SUMMARY
TOTAL PHARMACY DISCOUNT $16,442 $16,442 $152,922 $2,810 $155,733
MAC PROGRAM SAVINGS $11,461 $11,461 $104,334 $2,796 $107,130
PHARMACY DISCOUNT % 45.7% 45.7% 44.4% 89.4% 44.8%
GENERIC DISPENSING AND FORMULARY COMPLIANCE RATES1
LAREDO TRANSIT MANAGEMENT, INC.: ALL
COST SHARING DISTRIBUTION
OCT'11 YEAR TO DATE
RETAIL MAIL ORDER RETAIL MAIL ORDER
MEMBER: OUT OF POCKET 25.2% 24.9% 84.2%
PLAN: PAID 74.8% 75.1% 15.8%
LAREDO TRANSIT MANAGEMENT, INC.: ALL
KEY INDICATORS SUMMARY OCT'11
YEAR TO
DATE
UNIQUE PHARMACY MEMBERS 366 371
PHARMACY MEMBER MONTHS 366 3,613
CLAIMANTS 105 238
PERCENT OF UTILIZING MEMBERS 28.7% 64.2%
PRESCRIPTIONS 278 2,669
PRESCRIPTIONS PMPM 0.76 0.74
PAID $14,650 $144,000
PAID PMPM $40.03 $39.86
AVERAGE INGREDIENT
COST/PRESCRIPTION $68.95 $70.47
GENERIC DISPENSING RATE 67.3% 67.8%
FORMULARY COMPLIANCE RATE 87.8% 86.5%
GENERIC SUBSTITUTION RATE 98.4% 97.2%
OUT OF POCKET PERCENT OF ALLOWED 25.2% 25.0%
RETAIL AS A PERCENT OF
PRESCRIPTIONS 100.0% 99.6%
MAIL ORDER AS A PERCENT OF
PRESCRIPTIONS 0.4%
SPECIALTY PERCENT OF TOTAL
PRESCRIPTIONS 0.4% 0.2%
1When displaying quarterly information, the first and last month of the reported quarters may have incomplete quarterly data.
GENERIC DISPENSING RATE
FORMULARY COMPLIANCE RATE
PHARMACYPHARMACY
KEY INDICATORS SUMMARY, CONTINUED
During the current reporting month there were 278 prescriptions dispensed for LAREDO TRANSIT MANAGEMENT,
INC.: ALL's members. The total amount paid for these prescriptions was $14,650.
Overall current reporting month pharmacy paid PMPM was $40.03. Pharmacy paid PMPM was $39.86 for the
year to date.
LAREDO TRANSIT MANAGEMENT, INC.: ALL's overall ingredient cost per prescription was $68.95 in the current
reporting month. The year to date ingredient cost per prescription was $70.47.
Generic drugs represented 67.3% of all claims in the current reporting month and 67.8% for the year to date.
Formulary drugs represented 87.8% for the current reporting month and 86.5% for the year to date.
For the current reporting month, members' out of pocket contribution was 25.2% to their prescription drug costs
through any applicable copay, coinsurance or deductible amounts. For the year to date the members' out of pocket
contribution was 25.0%. For the year to date at retail the members' share is 24.9%, while at mail it is 84.2%.
Specialty pharmacy claims represented 0.4% of all prescriptions during the current reporting month and 0.2% for
the year to date.
9.2LAREDO TRANSIT MANAGEMENT, INC.: ALL
PHARMACYPHARMACY
GENERIC VERSUS FORMULARY EXPERIENCE
Report Description: For the year to date, LAREDO TRANSIT MANAGEMENT, INC.: ALL's prescription drug expenses
are displayed below for retail and mail order providers and broken out by drug type and formulary indicator. The
brand type is broken down by single-source and multi-source. In addition, the total expense for each category is
shown by the member and the plan.
RETAIL PRESCRIPTIONS PRESCRIPTIONS
% OF TOTAL
PRESCRIPTIONS
TOTAL EXPENSE MEMBER EXPENSE PLAN EXPENSE
ALLOWED
ALLOWED/
PRESCRIPTION
OUT OF
OUT OF
POCKET/
PRESCRIPTION PAID
PAID/
PRESCRIPTION
GENERIC 1,798 67.7% $29,764 $16.55 $14,313 $7.96 $15,451 $8.59
BRAND 859 32.3% $161,828 $188.39 $33,362 $38.84 $128,496 $149.59
SUMMARY 2,657 100.0% $191,592 $72.11 $47,674 $17.94 $143,947 $54.18
BRAND TYPE BREAKDOWN:
SINGLE SOURCE BRAND 806 30.3% $157,611 $195.55 $31,330 $38.87 $126,311 $156.71
MULTI-SOURCE BRAND 53 2.0% $4,217 $79.57 $2,031 $38.33 $2,186 $41.24
MULTI-SOURCE BRAND W/DAW1 10 0.4% $602 $60.20 $306 $30.57 $296 $29.63
BRAND FORMULARY 500 18.8% $87,633 $175.27 $15,982 $31.96 $71,652 $143.30
BRAND NON-FORMULARY 359 13.5% $74,195 $206.67 $17,380 $48.41 $56,845 $158.34
MAIL ORDER PRESCRIPTIONS PRESCRIPTIONS
% OF TOTAL
PRESCRIPTIONS
TOTAL EXPENSE MEMBER EXPENSE PLAN EXPENSE
ALLOWED
ALLOWED/
PRESCRIPTION
OUT OF
OUT OF
POCKET/
PRESCRIPTION PAID
PAID/
PRESCRIPTION
GENERIC 12 100.0% $333 $27.73 $280 $23.33 $53 $4.39
BRAND
SUMMARY 12 100.0% $333 $27.73 $280 $23.33 $53 $4.39
BRAND TYPE BREAKDOWN:
SINGLE SOURCE BRAND
MULTI-SOURCE BRAND
MULTI-SOURCE BRAND W/DAW1
BRAND FORMULARY
BRAND NON-FORMULARY
TOTAL PRESCRIPTIONS PRESCRIPTIONS
% OF TOTAL
PRESCRIPTIONS
TOTAL EXPENSE MEMBER EXPENSE PLAN EXPENSE
ALLOWED
ALLOWED/
PRESCRIPTION
OUT OF
OUT OF
POCKET/
PRESCRIPTION PAID
PAID/
PRESCRIPTION
GENERIC 1,810 67.8% $30,096 $16.63 $14,593 $8.06 $15,503 $8.57
BRAND 859 32.2% $161,828 $188.39 $33,362 $38.84 $128,496 $149.59
SUMMARY 2,669 100.0% $191,924 $71.91 $47,955 $17.97 $144,000 $53.95
BRAND TYPE BREAKDOWN:
SINGLE SOURCE BRAND 806 30.2% $157,611 $195.55 $31,330 $38.87 $126,311 $156.71
MULTI-SOURCE BRAND 53 2.0% $4,217 $79.57 $2,031 $38.33 $2,186 $41.24
MULTI-SOURCE BRAND W/DAW1 10 0.4% $602 $60.20 $306 $30.57 $296 $29.63
BRAND FORMULARY 500 18.7% $87,633 $175.27 $15,982 $31.96 $71,652 $143.30
BRAND NON-FORMULARY 359 13.5% $74,195 $206.67 $17,380 $48.41 $56,845 $158.34
9.3LAREDO TRANSIT MANAGEMENT, INC.: ALL
PHARMACYPHARMACY
TOP THERAPEUTIC DRUG CLASSES
Report Description: The top 25 therapeutic drug classes for the year to date are displayed below ranked by
ingredient cost.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
TOP 25 THERAPEUTIC DRUG CLASSES BY INGREDIENT COST
PLAN THERAPEUTIC CLASS PRESCRIPTIONS
INGREDIENT
COST
% OF TOTAL
INGREDIENT
COST
AVG INGREDIENT
COST/
PRESCRIPTION % FORMULARY % GENERIC
RANK BY
VOLUME
1 HMG COA REDUCTASE INHIBITORS 213 $15,027 8.0% $70.55 77.0% 53.5% 1
2 ANTIHYPERTENSIVE COMBINATIONS 177 $12,126 6.4% $68.51 84.2% 54.8% 2
3 PROTON PUMP INHIBITORS 100 $12,053 6.4% $120.53 79.0% 46.0% 4
4 ANTIDIABETIC COMBINATIONS 75 $11,710 6.2% $156.13 100.0% 42.7% 10
5 ANTICONVULSANTS - MISC. 38 $11,608 6.2% $305.47 52.6% 50.0% 18
6 DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS 52 $10,749 5.7% $206.71 76.9% 0.0% 13
7 PHOSPHATE BINDER AGENTS 14 $9,516 5.1% $679.69 21.4% 14.3% 43
8 ALKYLATING AGENTS 3 $8,680 4.6% $2,893.21 0.0% 0.0% 107
9 INSULIN SENSITIZING AGENTS 32 $8,434 4.5% $263.58 100.0% 0.0% 24
10 INSULIN 32 $7,378 3.9% $230.55 100.0% 0.0% 23
11 STIMULANTS - MISC. 19 $4,568 2.4% $240.39 0.0% 0.0% 34
12 FIBRIC ACID DERIVATIVES 41 $4,514 2.4% $110.10 90.2% 2.4% 16
13
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
(NSAIDS) 83 $3,894 2.1% $46.91 97.6% 79.5% 8
14 ANGIOTENSIN II RECEPTOR ANTAGONISTS 48 $2,859 1.5% $59.55 97.9% 43.8% 14
15 INCRETIN MIMETIC AGENTS 7 $2,672 1.4% $381.71 0.0% 0.0% 74
16 ACNE PRODUCTS 15 $2,646 1.4% $176.42 26.7% 26.7% 39
17 ANTIMETABOLITES 5 $2,060 1.1% $412.10 80.0% 80.0% 92
18 CALCIUM CHANNEL BLOCKERS 87 $2,007 1.1% $23.07 100.0% 100.0% 5
19
SOLUBLE TUMOR NECROSIS FACTOR
RECEPTOR AGENTS 1 $1,877 1.0% $1,876.80 100.0% 0.0% 151
20 OXAZOLIDINONES 1 $1,854 1.0% $1,854.04 100.0% 0.0% 147
21 COUGH/COLD/ALLERGY COMBINATIONS 60 $1,825 1.0% $30.41 66.7% 65.0% 12
22 DIBENZAPINES 9 $1,745 0.9% $193.86 100.0% 0.0% 61
23 SEROTONIN AGONISTS 6 $1,706 0.9% $284.41 66.7% 0.0% 89
24 ANTIFUNGALS - TOPICAL 20 $1,700 0.9% $85.00 70.0% 70.0% 32
25 PLATELET AGGREGATION INHIBITORS 7 $1,642 0.9% $234.60 100.0% 0.0% 78
ALL OTHER 1,524 $43,241 23.0% $28.37 90.6% 82.9%
SUMMARY 2,669 $188,090 100.0% $70.47 86.5% 67.8%
The top three therapeutic drug classes based on ingredient cost for LAREDO TRANSIT MANAGEMENT, INC.: ALL
were HMG CoA Reductase Inhibitors, Antihypertensive Combinations, and Proton Pump Inhibitors. Together these
therapeutic classes accounted for 20.8% of the total ingredient cost and 18.4% of all prescriptions for year to
date.
The top three therapeutic drug classes based on volume for LAREDO TRANSIT MANAGEMENT, INC.: ALL were
HMG CoA Reductase Inhibitors, Antihypertensive Combinations, and ACE Inhibitors. Together these prescription
drugs accounted for 21.0% of all prescriptions for the year to date.
9.4LAREDO TRANSIT MANAGEMENT, INC.: ALL
PHARMACYPHARMACY
TOP PRESCRIPTION DRUGS
Report Description: The top 25 prescription drugs for the year to date are displayed below ranked by ingredient cost.
LAREDO TRANSIT MANAGEMENT, INC.: ALL
TOP 25 PRESCRIPTION DRUGS BY INGREDIENT COST
BRAND NAME PLAN THERAPEUTIC CLASS PRESCRIPTIONS
INGREDIENT
COST
% OF TOTAL
INGREDIENT
COST
AVG
INGREDIENT
COST/
PRESCRIPTION
FORMULARY
INDICATOR
GENERIC
INDICATOR
RANK BY
VOLUME
1 LAMICTAL XR ANTICONVULSANTS - MISC. 17 $10,763 5.7% $633.09 NO NO 38
2 TEMODAR ALKYLATING AGENTS 3 $8,680 4.6% $2,893.21 NO NO 197
3 ACTOS INSULIN SENSITIZING AGENTS 32 $8,434 4.5% $263.58 YES NO 17
4 JANUVIA
DIPEPTIDYL PEPTIDASE-4 (DPP-4)
INHIBITORS 40 $8,258 4.4% $206.45 YES NO 14
5 CRESTOR HMG COA REDUCTASE INHIBITORS 50 $7,577 4.0% $151.53 YES NO 8
6 ACTOPLUS MET ANTIDIABETIC COMBINATIONS 25 $7,320 3.9% $292.79 YES NO 23
7 LIPITOR HMG COA REDUCTASE INHIBITORS 49 $6,604 3.5% $134.78 NO NO 9
8 RENAGEL PHOSPHATE BINDER AGENTS 8 $6,588 3.5% $823.52 NO NO 91
9 NEXIUM PROTON PUMP INHIBITORS 33 $6,374 3.4% $193.16 YES NO 16
10 DIOVAN HCT ANTIHYPERTENSIVE COMBINATIONS 47 $4,900 2.6% $104.27 YES NO 11
11 ACIPHEX PROTON PUMP INHIBITORS 14 $3,874 2.1% $276.73 NO NO 47
12 NOVOLOG MIX 70-30 INSULIN 5 $3,669 2.0% $733.73 YES NO 131
13 JANUMET ANTIDIABETIC COMBINATIONS 17 $3,482 1.9% $204.84 YES NO 37
14 TRICOR FIBRIC ACID DERIVATIVES 27 $2,774 1.5% $102.75 YES NO 22
15 CELEBREX
NONSTEROIDAL ANTI-INFLAMMATORY
AGENTS (NSAIDS) 15 $2,631 1.4% $175.42 YES NO 44
16 VICTOZA 3-PAK INCRETIN MIMETIC AGENTS 6 $2,402 1.3% $400.38 NO NO 116
17 CONCERTA STIMULANTS - MISC. 9 $2,385 1.3% $264.96 NO NO 48
18 ONGLYZA
DIPEPTIDYL PEPTIDASE-4 (DPP-4)
INHIBITORS 11 $2,295 1.2% $208.60 NO NO 63
19 DIOVAN ANGIOTENSIN II RECEPTOR ANTAGONISTS 21 $2,117 1.1% $100.80 YES NO 27
20 LANTUS SOLOSTAR INSULIN 10 $1,991 1.1% $199.13 YES NO 69
21
AMLODIPINE
BESYLATE-BENAZEPRIL ANTIHYPERTENSIVE COMBINATIONS 20 $1,955 1.0% $97.75 YES YES 31
22 FOSRENOL PHOSPHATE BINDER AGENTS 3 $1,906 1.0% $635.34 NO NO 181
23 ENBREL
SOLUBLE TUMOR NECROSIS FACTOR
RECEPTOR AGENTS 1 $1,877 1.0% $1,876.80 YES NO 287
24 ZYVOX OXAZOLIDINONES 1 $1,854 1.0% $1,854.04 YES NO 357
25 SEROQUEL DIBENZAPINES 9 $1,745 0.9% $193.86 YES NO 81
ALL OTHER ALL OTHER 2,196 $75,635 40.2% $34.44
SUMMARY 2,669 $188,090 100.0% $70.47
The top three prescription drugs based on ingredient cost for LAREDO TRANSIT MANAGEMENT, INC.: ALL were
Lamictal Xr, Temodar and Actos. Together these prescription drugs accounted for 14.8% of the total ingredient
cost and 1.9% of all prescriptions for the year to date.
The top three prescription drugs based on volume for LAREDO TRANSIT MANAGEMENT, INC.: ALL were
Simvastatin, Metformin Hcl, and Enalapril Maleate. Together these prescription drugs accounted for 9.0% of all
prescriptions for the year to date.
9.5LAREDO TRANSIT MANAGEMENT, INC.: ALL
PHARMACYPHARMACY
LAREDO TRANSIT MANAGEMENT, INC.: ALL
KEY INDICATORS SUMMARY OCT'11
YEAR TO
DATE
UNIQUE PHARMACY MEMBERS 366 371
PHARMACY MEMBER MONTHS 366 3,613
SPECIALTY CLAIMANTS 1 3
PERCENT OF UTILIZING MEMBERS 0.3% 0.8%
PRESCRIPTIONS 1 5
SPECIALTY PERCENT OF TOTAL PAID 12.6% 8.3%
PERCENT OF TOTAL PRESCRIPTIONS PAID 0.4% 0.2%
PLAN EXPENSE: PAID $1,848 $11,962
PLAN EXPENSE: PAID PMPM $5.05 $3.31
AVERAGE INGREDIENT COST/PRESCRIPTION $1,877 $2,437
MEMBER EXPENSE: OUT OF POCKET $30 $230
MEMBER EXPENSE: OUT OF POCKET PMPM $0.08 $0.06
OUT OF POCKET PERCENT OF ALLOWED 1.6% 1.9%
9.6LAREDO TRANSIT MANAGEMENT, INC.: ALL
SPECIALTY DRUG ANALYSIS
Report Description: Specialty drugs generally have unique uses, require special dosing or administration, are
typically prescribed by a specialist provider and are significantly more expensive than alternative drugs or
therapies. The report below shows LAREDO TRANSIT MANAGEMENT, INC.: ALL's prescription drug utilization
and expenses for the current reporting month and year to date.
71.2%
15.4%
13.4%
LAREDO TRANSIT MANAGEMENT, INC.: ALL
TOP 10 SPECIALTY DRUGS BY INGREDIENT COST FOR THE YEAR TO DATE
BRAND NAME SPECIALTY CLASS
INGREDIENT
COST PRESCRIPTIONS
AVG INGREDIENT COST/
PRESCRIPTION
SPECIALTY
CLAIMANTS
TEMODAR ORAL CANCER $8,680 3 $2,893 1
ENBREL ARTHRITIS & SKIN $1,877 1 $1,877 1
XELODA ORAL CANCER $1,629 1 $1,629 1
ALL OTHER ALL OTHER
SUMMARY $12,185 5 $2,437 3
The number of members utilizing specialty medication for the year to date was 3. These 3 members received 5
specialty medications which represented 8.3% of the total pharmacy paid amount for the year to date. The overall
specialty pharmacy paid PMPM was $5.05 for the current reporting month and $3.31 for the year to date. The
average cost of a specialty medication was $1,877 during the current reporting month and $2,437 for the year to
date.
The top three specialty drugs based on ingredient cost for LAREDO TRANSIT MANAGEMENT, INC.: ALL were
Temodar, Enbrel, and Xeloda. Together these specialty drugs accounted for 100.0% of the total ingredient cost
and 100.0% of all specialty prescriptions in the year to date.
TOP SPECIALTY DRUGS BY INGREDIENT COST FOR THE YEAR TO
DATE
TEMODAR
ENBREL
XELODA
ALL OTHER
GLOSSARYGLOSSARY
3-Digit Principal Diagnosis: Grouping of principal diagnoses based on the first three digits of the ICD-9 diagnosis
code
Admissions/1000: The number of hospital admissions for each 1000 persons covered within a given time period.
This allows for comparison of the group experience to a normative or benchmark population. It is calculated
as: (admissions/member months) *1000 * 12
Aggregate: Constituting or amounting to a whole. For example, an aggregate account report includes data for the
entire account.
Allowed: Amount considered eligible for payment by the plan
Allowed/Claimant: Amount considered eligible for payment by the plan per claimant. It is calculated as: Allowed /
Claimants
Allowed/Day: Amount considered eligible for payment by the plan per inpatient day. It is calculated as: Allowed /
Days
Allowed/Service: Amount considered eligible for payment per admit (inpatient facility), per visit (outpatient facility
and professional) or per script (prescription Rx). It is calculated as: Allowed / Services
Average Age: The difference between the claimant's year of enrollment and year of birth. Calculated using the
measure Average Age divided by the members represented in the report.
Average Contract Size: The average number of members per subscriber. It is calculated as: Medical Members /
Medical Subscribers
Average Dependents: Calculated using the measure Member Months (filtered on the Relationship = Dependents)
divided by the number of months in the report.
Average Ingredient Cost: Represents the cost of the medication and is determined from the lowest submission of the
pharmacy network rate, Usual & Customary amount, or Maximum Allowable Cost (MAC)
Average Length of Stay: Admit last date of service minus admit first date of service (plus 1 if last day=first day). It is
calculated as: Days / Services
Average Members: Calculated using the measure Member Months divided by the number of months included in the
report.
Average Subscribers: Calculated using the measure Subscriber Months divided by the number of months included
in the report.
Benchmark: Represents the BCBSTX book of business that is loaded into Blue Insight. The age/gender adjustment
factors are built using the paid claims and enrollment information over a 3 year period from BCBSTX book of
business. Some of the benchmark utilization and expense rates have been age/gender adjusted to reflect the
potential difference in the age/gender distribution between the individual company and BCBSTX book of
business. The demographic makeup of a specific group can be very different from any other group. It is for
this reason that it is beneficial in providing benchmarks that have been adjusted by age and gender. These
adjusted benchmarks will allow for more meaningful comparisons. These age / gender adjustments are present
in metrics such as the paid PMPM benchmarks as well as all benchmarks that are displayed as a 'per 1,000'
number however not all of the benchmark categories are adjusted by age / gender
10.1LAREDO TRANSIT MANAGEMENT, INC.: ALL
GLOSSARYGLOSSARY
Billed: Amount submitted for payment by the provider
Billing and Accounts Receivable System (BARS): An HCSC financial system where all Administrative Services Only
(ASO) customer bills are generated.
Blue Card Access Fee: Interplan Teleprocessing Services fee charged on out-of-state claims for accessing the local
plan's provider network
Brand Formulary: Brand name medications that are listed on the formulary
Brand Non-Formulary: Brand name medications that are not listed on the formulary
Capitation: A method of payment, exclusively for HMO members, where a physician or hospital is paid a fixed
amount for each enrolled member for healthcare services regardless of the actual number or nature of services
provided to each individual
Claimants: Number of individual members submitting a claim
Claim Lag: The amount of time between the date a claim is incurred and the date the claim payment is made.
COB: Portion of amount considered eligible for payment that has been paid by another insurance company
(Coordination of Benefits)
COB Medicare: Portion of amount considered eligible for payment that has been paid by Medicare
COBRA Members: Consolidated Omnibus Budget Reconciliation Act - A federal law which requires most employers
sponsoring group health plans to offer employees and their families the opportunity for a temporary extension
of health coverage (called continuation coverage) when coverage under the plan would otherwise end.
Coinsurance: Portion of covered amount member is responsible to pay for the claim
Compression Logic: Used to roll up all claims data into episodes of care. By normalizing all claims data, it allows
for comparative analysis (e.g., benchmarking and trend analysis).
Co-payment: Flat rate that the member is responsible to pay for the claim
Cost Sharing Provisions: Provisions in which the subscriber, HCSC, Medicare or other carriers have responsibility for
a portion of the eligible charges.
Coverage Tier: Eligibility tiers which stratify enrollment data based on the employee and others enrolled under the
employee's coverage. Varying benefits can be assigned to tiers.
Covered Amount: Amount eligible for payment based on the terms of the medical/dental benefits agreement.
DAW/1: Indicates that the physician has specified 'do not substitute' on the prescription
Days: Count of days
Days/1000: Number of inpatient days per 1,000 members. It is calculated as: (Days / Member Months) * 1000 *
12
Deductible: Portion of annual deductible amount member is responsible to pay applied to the claim
Demographic Make-up: Derived from the age/gender mix of the account
Dental Loss Ratio: Calculated as the Dental Paid Claims Amount divided by the Billed Dental Premium Amount
10.2LAREDO TRANSIT MANAGEMENT, INC.: ALL
GLOSSARYGLOSSARY
Dental Paid Claims: An amount paid to cover the Health Plan's liability for dental services provided to members for
claims that have been processed and approved for payment
Detailed Service Type: Classification based on CPT -- detailed level
Diagnostic Radiology: Refers to radiology services used for diagnostic purposes, as opposed to therapeutic purposes
Discount: Amount of reduction from billed amount that has been negotiated with the provider
Discount %: For medical claims, the discount percent is calculated as Discount / Covered
Dispensing Rate: The proportion of total drugs claims a certain drug or drug type is being dispensed
Drug Type: An indicator on each Rx claim that tells whether a prescription is single source brand, multi-source
brand or generic item.
Effective Discount %: The effective discount percentage is calculated as: Discount / (Discount + Paid)
Fees and Credits: Includes all account-specific member and account level fees. Can include Specific Stop Loss,
Aggregate Stop Loss, Administration, Access Fees, ASO Adjustments (either debits or credits), Rx Credits and
other miscellaneous fees.
Females (20-44 years): The total number of members who are women between the ages of 20 and 44 years. The
proportion of females (20-44 years) is calculated as: Member Months for Women between 20-44 years /
Member Months
Formulary Compliance Rate: The percentage of drugs dispensed that were included in the formulary
Generic Dispensing Rate: Proportion of potential generic prescriptions that were filled as generic. It is calculated as:
Number of generic scripts / Number of scripts
Generic Drugs: A medication for which the patent has expired, allowing any manufacturer to produce and distribute
the product under the chemical name.
Generic Substitution Rate: The rate in which generics were dispensed when a generic was available. It is calculated
by Number of generic Rxs / (Number of generic Rxs + Number of multi-source brand Rxs)
Group Liability: Total Claim Expense plus Fees and Credits
HCC: High Cost Claimant, a claimant with total paid amount over a specified threshold (e.g., $30,000 or $50,000)
within the twelve month reporting period
HCPCS: Healthcare Common Procedure Coding System, a coding system comprised of CPT-4 (Current Procedural
Terminology, Version 4) codes used to identify medical services and procedures furnished by physicians and
other health care professionals and other products, supplies and services not included in the CPT-4 codes.
IBNR: An acronym for 'incurred but not reported'. IBNR claims are that group which are incurred before the fund
reserving date, but not reported until after that date.
Ingredient Cost: The cost of the drug minus any taxes or dispensing fees
In-Network Paid %: Percent of total paid expenses for in-network claims. It is calculated as: In-Network Paid / Paid
Inpatient Facility: Refers to Inpatient Facility claims
10.3LAREDO TRANSIT MANAGEMENT, INC.: ALL
GLOSSARYGLOSSARY
International Classification of Diseases (ICD-9): An official list of categories of diseases, physical and mental, issued
by the World Health Organization (WHO).
IP Paid PEPM: Inpatient facility paid amount per employee per month
IP Paid PMPM: Inpatient facility paid amount per member per month
Leading ICD-9 Diagnostic Category: For each patient, summarize total paid amount for each diagnosis and its
corresponding MDC. The MDC with the greatest paid amount for the patient becomes the Leading ICD-9
Diagnostic Category for the reporting period
MAC Program Savings: Savings achieved by using the MAC (maximum allowable cost) discount on generic
medications
Management Services: A combination of Capitation, Fees & Credits and Recoveries for medical services applied to
the Employer Group's account
MDC (DRG): Major Diagnostic Category based on DRG, available only in inpatient reports
Medical Paid Claims: An amount paid to cover the Health Plan's liability for medical (healthcare) services provided
to members for claims that have been processed and approved for payment
Medical/Pharmacy Loss Ratio: Calculated as the combined Medical and Pharmacy Paid Claims Amount plus
Capitation divided by the total Billed Premium Amount for Medical and Pharmacy, where appropriate
Member Months: Count of months of eligibility for members
Multi-Source Brand: Brand name medications with a generic equivalent
Network Indicator: An indicator that shows whether the claim was processed as in-network (e.g., in the Preferred
Provider Organization network) or out-of-network and paid accordingly
Network Savings Discount: The discount that is applied when a member receives services from a contract provider.
Non-acute: Refers to inpatient facility admissions for rehabilitation, skilled nursing facilities and hospice care
Not Covered: Amount considered not eligible for payment by the plan (excludes the discount amount)
Observation Room: A hospital room in an outpatient setting (less than 24 hours) that is necessary to
evaluate/monitor the patient's condition for possible inpatient admission.
Occupational Therapy: Therapy based on engagement in meaningful activities of daily life especially to enable
participation in such activities in spite of impairments or limitations in physical or mental functions.
OP Paid PEPM: Outpatient facility paid amount per employee per month
OP Paid PMPM: Outpatient facility paid amount per member per month
Other Adjustments: Minor payments or credits not captured in other specific expense measures
Other Payments: Combination of Blue Card access fees and surcharge expenses
Other Reductions: Combination of maximum reductions, penalties, workers compensation savings, and subrogation
savings
10.4LAREDO TRANSIT MANAGEMENT, INC.: ALL
GLOSSARYGLOSSARY
Out of Pocket: Total amount that is the responsibility of the claimant. It is calculated as: (Copay + Deductible +
Coinsurance)
Outpatient Facility: Refers to Outpatient Facility claims
Paid: Total amount paid by the plan, including access fees, adjustments, and surcharges
Paid + Recoveries: The total amount paid by the plan plus any amount recovered through subrogation.
Paid-Provider: Amount paid to the provider by the plan
Paid/Claimant: Amount paid to the provider by the plan per claimant. It is calculated as: Paid / Claimants
Paid/Day: Amount paid to the provider by the plan per inpatient day. It is calculated as: Paid / Days
Paid/Service: Amount paid to the provider by the plan per admission (inpatient facility), per visit (outpatient facility
and professional) or per script (prescription Rx). It is calculated as: Paid / Services
Paid/Visit: Amount paid to the plan per professional visit. It is calculated as: Paid / Visits
Paid PEPM: Amount paid to the provider by the plan per employee per month. It is calculated as: Paid / Subscriber
Member Months
Paid PMPM: Amount paid to the provider by the plan per member per month. It is calculated as: Paid / Member
Months
Penalty: Amount charged to the user of health care services for a non-approved contractual service
PEPM: Per employee per month
Pharmacy Discount %: For pharmacy claims, the discount percent is calculated as Discount / (Discount + Allowed)
Pharmacy Paid Claims: An amount paid to cover the Health Plan's liability for pharmacy services provided to
members for claims that have been processed and approved for payment
Pharmacy Tier: An indicator on each Rx claim that tells whether a prescription is generic, preferred brand,
non-preferred brand, specialty, or other
Physical Therapy: The treatment of injuries or disorder through physical activity with goals of restoring and/or
maintaining functional activities.
Place of Service: An indicator of whether the professional services were rendered during an inpatient admission,
outpatient visit, office visit, or other
Plan Eligibility: Eligibility derived directly from the plan's enrollment system. It excludes eligibility created during
data processing for claims without matching records in the enrollment system.
PMPM: Per member per month
PR Paid PEPM: Professional paid amount per employee per month
PR Paid PMPM: Professional paid amount per member per month
Premium: An agreed upon fee paid to the Health Plan for coverage of medical and/or dental benefits for an
established benefit period and set intervals
10.5LAREDO TRANSIT MANAGEMENT, INC.: ALL
GLOSSARYGLOSSARY
PT/OT/ST: See Physical Therapy, Occupational Therapy and Speech Therapy.
Recoveries: Subrogation and/or Reimbursements for claims that are included in BARS but not in HCSC's data
warehouse (since some of the reimbursements could be for members or claims that are no longer in our data
warehouse). Recoveries are loaded from the BARS System and included in Blue Insight for reconciliation
purposes.
Reporting Period: The date range for which the report was run. When data is not available for the complete reporting
period, partial totals will be displayed and comparisons may be inconclusive.
Rx Paid PEPM: Prescription drug paid amount per employee per month
Rx Paid PMPM: Prescription drug paid amount per member per month
Self-Administered Drugs: A drug furnished in an outpatient setting for therapeutic purposes which is usually
self-administered by the patient or caregiver.
Service Category: A classification based on claim type
Service Type: Classification based on principal diagnosis or ICD-9 Procedure Code
Services: Number of admissions (inpatient facility), number of visits (outpatient facility), number of claim lines
(professional), or number of scripts (prescription Rx)
Services/1000: Number of services per 1,000 members. It is calculated as: (Services / Member Months) * 1000 *
12
Services/Member: Number of services per member. It is calculated as: (Services / Member Months) * 12
Single Source Brand: Brand name medications with no generic equivalent
Specialty Drugs: Medications that generally have unique uses, require special dosing or administration, are typically
prescribed by a specialist provider and are significantly more costly than alternative drugs or therapies.
Speech Therapy: Corrective treatment of speech impairment which resulted from birth or from disease, injury or
prior medical treatment.
Subrogation Savings: Portion of amount eligible for payment originally paid by the plan but that has since been
recovered through a legal action
Surcharge: Amount charged as a tax by certain States on facility claims
Therapeutic Drug Class: Used to categorize or group prescription drugs which are considered similar by the disease
they treat or by the effect they have on the body
Total Paid: The total amount of medical, pharmacy and capitation dollars, where appropriate, paid to cover
healthcare services provided to members for claims that have been processed and approved for payment
Visits: Number of professional visits, where a visit is defined as a set of all professional services that occur on the
same date for the same claimant and the same professional provider. A visit relates to a physician interaction
with a patient and the place of service can be the office, inpatient facility or outpatient facility.
Visits/1000: Number of professional visits per 1,000 members. It is calculated as: (Visits / Member Months) *
1000 * 12
10.6LAREDO TRANSIT MANAGEMENT, INC.: ALL
GLOSSARYGLOSSARY
Workers Compensation Savings: Portion of amount eligible for payment that has been paid a third party Workers
Compensation carrier
10.7LAREDO TRANSIT MANAGEMENT, INC.: ALL