Analysis of Incurred Claims Trend and Provider Payments

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1 Analysis of Incurred Claims Trend and Provider Payments Board of Trustees Meeting May 24, 2013

2 Presentation Overview Trends in Incurred Claims Paid through March 31, 2013 Per Member Per Month (PMPM) By Service Category State Health Plan Provider Rates Comparison to Medicare Provider Rates Comparison of Medicare and Medicaid Provider Rates 2

3 Per Member Per Month (PMPM) Claims Trends Using incurred claims data from BCBSNC, Segal analyzed trends in the Plan s claims costs paid through March 31, 2013 PMPM claims costs were down 1.4% from FY to FY , including negative trends for medical and pharmacy claims PMPM claims were down 0.5% from the first six months of FY to the first six months of FY A 1.2% decrease in PMPM medical claims was partially offset by a 1.3% increase in pharmacy claims 1.5% 1.0% 0.5% 0.0% -0.5% -1.0% -1.5% -2.0% SHP PMPM Cost Trends 1.3% -0.5% -1.4% -1.3% -1.2% -1.7% FY FY (thru December) Total Medical Pharmacy Source: BCBSNC; The Segal Company 3

4 PMPM Claims by Quarter Quarterly claims trends compare Plan costs in each quarter with costs from the same quarter of the prior year Quarterly claims show mostly negative trend over the last 18 months 8% 6% 7.2% 7.4% 4% 2% 3.3% 1.7% 2.0% 0% -2% -4% -6% -8% -0.2% -1.3% -1.4% -1.1% -2.0% -2.3% -2.8% -2.9% -4.3%-4.1% -4.9% -4.4% -6.3% FY12Q1 FY12Q2 FY12Q3 FY12Q4 FY13Q1 FY13Q2 (Jul-Sep 11) (Oct-Dec 11) (Jan-Mar 12) (Apr-Jun 12) (Jul-Sep 12) (Oct-Dec 12) Total Medical Pharmacy Source: BCBSNC; The Segal Company 4

5 Total Claims Cost Trends by Service Claims trends by category of service show some variation, but again, most of trends are negative 3.0% 2.5% 2.0% 1.8% 1.6% 1.4% 1.0% 0.0% -1.0% -2.0% -1.3% -0.3% -1.1% -1.5% -3.0% -2.2% -2.2% -4.0% -3.3% -3.6% -5.0% -4.4% -4.4% -6.0% Total Inpatient Facility Inpatient Professional Office Professional Outpatient Facility Outpatient Professional Pharmacy FY FY (thru Dec 2012) Source: BCBSNC; The Segal Company 5

6 Plan and Medicare Provider Rates: Professional Services Using data from BCBSNC, Segal analyzed 2012 Plan and Medicare provider rates for specific professional procedure codes Professional services were divided into five categories with Plan rates ranging from 127% to 159% of the corresponding Medicare provider rates SHP Professional Services Provider Rates as a Percent of Medicare Rates 180% 160% 140% 120% 100% 80% 60% 40% 20% 0% 130% 134% 132% Source: The Segal Company Professional fees also differ based on the location of the professional service being provided. The Plan pays: 143% of Medicare rates for professional services provided in facilities (generallyspeaking, hospitals), and 125% of Medicare rates for professional services provided in other settings (nonfacilities) In total, Segal concluded that the Plan pays 130% of Medicare for professional services 159% 147% 127% 125% 143% 6

7 Plan and Medicare Provider Rates: Hospital Services Segal also compared Plan provider rates for inpatient and outpatient hospital services using data from BCBSNC and the Healthcare Cost Report Information System (HCRIS) 250% 200% SHP Hospital Rates as a Percent of Medicare Rates 216% The Plan pays 129% of Medicare for inpatient care 150% 164% 129% Because Medicare pays for outpatient services at a significant discount, the Plan pays 216% of the Medicare rates 100% Overall, Segal found that the Plan pays 164% of Medicare rates for hospital services 50% 0% Total Hospital Inpatient Outpatient Source: The Segal Company 7

8 Plan and Medicare Provider Rates: Medical Services Combining professional and hospital rates, Segal concluded that the Plan pays providers at approximately 148% of Medicare rates 250% SHP Provider Rates as a Percent of Medicare Rates 216% 200% 150% 148% 130% 129% 100% 50% 0% Total Professional Inpatient Outpatient Source: The Segal Company 8

9 Comparing NC Medicare and Medicaid Provider Rates Physicians Medicaid pays 100% of Medicare rates for primary care physicians (PCPs) in For specialists, Medicaid pays 95% of Medicare rates for office visits and 86% of Medicare rates for procedures After 2014, PCPs will be reimbursed at the same percentages (95%/86%) as specialists Inpatient Hospital Medicaid has its own hospital rates that, in theory, pay 100% of Medicare rates after including supplemental payments However, these supplemental payments are funded through the imposition of hospital assessments that increase hospital costs The net effect of rates, supplemental payments, and assessments is that hospitals receive on average 75% to 95% of Medicare rates Outpatient Hospital Medicaid reimburses hospitals at 80% of cost, as reported by each hospital A later true up payment, funded with hospital assessments, gets the hospitals up to 100% of cost In general, Medicaid pays more than Medicare Note: This slide was prepared with the assistance of the Fiscal Research Division of the North Carolina General Assembly. 9

10 Comparison of Provider Rates Relative to Medicare Category Medicaid Medicare Plan Physician/Professional 86% - 100% 100% 130% Inpatient 75% - 95% 100% 129% Outpatient >100% 100% 216% Total Est. 90% 100% 148% If we estimate that, in total, Medicaid pays approximately 90% of the Medicare provider rates, the Plan s rates would be about 164% of Medicaid rates 10