City of Los Angeles 2016 Q3 Utilization Update Presented By: Justin Cao, MPH Executive Account Manager, Strategic Accounts Public Sector Michael Allard Underwriting Consultant, Public Sector California Mark Frey Director, Strategic Accounts Public Sector
Agenda Topic 1. Review the Objective & 2018 Renewal Considerations 2. Key Findings Summary 3. Review Utilization for Active Population Demographic Overview Total Paid Claims Overview Inpatient Paid Claims Overview Outpatient Paid Claims Overview Pharmacy Paid Claims Overview Pharmacy Brand Formulary Detail 4. Questions
Objective & 2018 Renewal Considerations Objective: The purpose of the following presentation is to provide the JLMBC with a preview of how City of Los Angeles utilization is trending through the first 9 months of 2016 (Q3 2016). This presentation compares the Q3 2016 claims to the claims used to calculate the 2017 renewal 2018 Renewal Considerations: The Q3 2016 utilization report includes 9 out of the 12 months of Paid Claims data that will be used for the 2018 renewal Three months of updated claims information is outstanding for the upcoming 2018 renewal. Rating Factors and Experience Adjustments for the 2018 Renewal will not be finalized until Spring 2017 Pooling Credit/Charges Conversion of Paid Claims to Incurred Claims Demographic Changes Rating Trend Retention ACA Fees
City of Los Angeles KEY FINDINGS SUMMARY Reports Referenced: Quarter 3 2016 Periodic Utilization Report KEY FINDING METRIC RELEVANCE Total Paid Claims PMPM increased by 6.4% through the first three quarters of 2016 Inpatient Claims PMPM increased by 2.28% Outpatient Claims PMPM increased by 12.51% Pharmacy Claims PMPM increased by 8.71% Total Paid Claims for the City of Los Angeles increased from $376.31 to $405.82.Total Paid Claims reflected within the report are unadjusted, which includes the impact of high cost claimants. Although the overall inpatient claims increase is low during this reporting period, the increase in claims cost for Inpatient Medical Services increased from $46.61 to $52.55. Outpatient Paid Claims PMPM increased from $140.40 to $157.96. Increases were seen in all three outpatient service categories: Emergency Room increased 14.6%, Outpatient Visits increased 14.2% and Surgical increased 12.3%. Pharmacy Paid Claims increased from $77.64 to $78.14, due to an 11.9% increase in Brand Formulary Drugs. While the City of Los Angeles utilization is increasing, it is increasing at a slower rates as compared to Kaiser Permanente s Southern California Health Plan Average. Additionally, the value of high cost claimants reflects $2.7M over the pooling point. The value of this pooling credit is approximately $7.05 PMPM Principle driver of cost within the Inpatient Medical Service category is due to neonates. Four of the top 10 Diagnosis Related Group (DRG) are newborn and neonatal conditions with claims totaling $5.5M. Hospital Admissions/1000 for the DRG s noted above increased from 21 to 44, with the Average Length of Stay remained flat at just over 15 days. Over the past three reporting periods, the City has experienced a proportionally higher increase in the Outpatient $/Visit as compared to the Outpatient Visits/1000 for Emergency Room. Many surgical services are moving to an outpatient setting, so members are encouraged to receive care in the proper setting. Additionally, Kaiser Permanente continues to expand the number of services available to members through a telephonic appointment (and soon to be coming are video visits). These services can help members seek more timely care, reduce member out-of-pocket costs as well as lower the outpatient utilization costs for the City. Generic Formulary prescribing patterns remain high and account for 94.2% of all prescription drug utilization. The Top 10 Brand Formulary Drugs cost increased by 14%, from $4.3M to $5.0M during this reporting period. Additionally, the number of scripts increased by 14%, from 961 to 1,100.
Demographic Overview City of Los Angeles 2014 2015 2016 Q3 Members 31,828 31,501 32,022 Subscribers 13,001 13,416 13,204 Average Contract Size 2.45 2.35 2.43 Average Age Male 35.7 36.0 35.9 Female 35.1 35.4 35.3 Total 35.4 35.7 35.6 % Distribution Male 49.7% 49.8% 50.0% Female 50.3% 50.2% 50.0% KP Southern California Regional Average 2014 2015 2016 Q3 Average Age Male 33.4 33.5 33.5 Female 34.2 34.2 34.2 Total 33.8 33.8 33.9 % Distribution Male 49.0% 49.1% 49.2% Female 51.0% 50.9% 50.8% 5 February 23, 2017 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Total Paid Claims Overview Total paid claims for City of LA increased 6.4% vs, 7.4% for KP regional average. The claims costs shown to the left are un-adjusted, which includes the impact of high cost claimants. The value of the $2.7M pooling credit described below is $7.05 (PMPM). In the most recent period, 7 individuals had claims that exceeded the pooling threshold of $650,000 totaling $2.7 million. In contrast to the prior period, which experienced 5 individuals with claims totaling $896K above the pooling threshold. 6 February 23, 2017 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Inpatient Overview Maternity Claims Cost: Increase $0.19 (1.7%) Surgical Claims Cost: Decrease $2.87 (-4.6%) Medical Claims Cost: Increase $5.94 (12.7%) Most significant change in Inpatient claims cost was focused primarily in the Medical Service Category o Principle driver of cost within the Medical service category was attributed to neonates (additional details regarding DRGs on following page). Not shown in chart above: Substance Abuse increased ~30% or $0.25 (PMPM), whereas Mental Heath costs decreased ~26% or $0.90 (PMPM) o For scale, Substance Abuse and Mental Health services combined account for ~3% of total Inpatient claims cost. 7 February 23, 2017 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Inpatient Detail - Medical The Top 10 Medical DRG claims cost is $9.8 million for 2016 Q3 vs. $5 million in the prior period, which is an increase of $4.7 million. o Admits for these DRG s increased 38%. o Average Length of Stay for these DRG s increased 27%. 4 of the Top 10 DRG s are Newborn and Neonatal conditions with claims totaling $5.5 million. 2 of the 7 High Cost Claimants for 2016 Q3 are Newborn related claims. o Admits for these DRG s increased from 21 to 44. o Average Length of Stay for these DRG s remained flat at just over 15 days. 8 February 23, 2017 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Outpatient Overview Outpatient Surgical Cost: Increase 12.3% ($4.89) KP Regional Avg Increase: 14.3% Emergency Room Cost: Increase 14.6% ($3.08) Outpatient Visits Cost: Increase 14.2% ($7.69) KP Regional Avg Increase: 8.0% KP Regional Avg Increase: 12.0% Emergency City of Los Angeles KP SoCal Regional Average 2014 2014-2015 2016 Q3 2014 2014-2015 2016 Q3 PMPM $18.48 $21.12 $24.20 $18.79 $20.76 $22.41 ER Visits/1000 166.9 172.5 178.8 174.1 178.8 183.6 % Change -4.1% 3.4% 3.6% -2.3% 2.7% 2.7% ER $/Visit $1,329.14 $1,469.18 $1,624.51 $1,295.22 $1,392.75 $1,464.35 % Change 6.2% 10.5% 10.6% 6.4% 7.5% 5.1% Over the past three reporting periods the City is experiencing a proportionally higher increase in the cost/er visit compared to the number of ER visits. This is both congruent to KP s regional average and characteristic of appropriate ER use. 9 February 23, 2017 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Pharmacy Overview City of Los Angeles KP SoCal Regional Average Scripts PMPY 2014 2014-2015 2016 Q3 2014 2014-2015 2016 Q3 Brand/Formulary 0.32 0.32 0.32 0.31 0.32 0.32 Generic/Formulary 5.16 5.29 5.28 4.59 4.63 4.67 $/Script 2014 2014-2015 2016 Q3 2014 2014-2015 2016 Q3 Brand/Formulary $786.04 $997.20 $1,121.28 $742.00 $937.33 $967.80 Generic/Formulary $23.47 $26.14 $26.51 $25.92 $29.06 $29.59 % of Total Scripts 2014 2014-2015 2016 Q3 2014 2014-2015 2016 Q3 Brand/Formulary 5.9% 5.8% 5.8% 6.3% 6.4% 6.3% Generic/Formulary 93.7% 94.2% 94.2% 92.5% 93.4% 93.6% % of Total Claims 2014 2014-2015 2016 Q3 2014 2014-2015 2016 Q3 Brand/Formulary 66.5% 70.1% 72.1% 64.5% 68.8% 68.7% Generic/Formulary 31.6% 29.9% 27.9% 32.9% 30.9% 31.1% Note: Both Generic and Brand non-formulary account for less than 100 th of one percent of total scripts 10 February 23, 2017 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Pharmacy Claims Cost Generic Formulary Cost: Increase 1.3% ($0.15 PMPM) Brand Formulary Cost: Increase 11.9% ($3.20 PMPM) 11 February 23, 2017 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Pharmacy Detail Treating HEP-C with Harvoni or a similar specialty drug typically costs between $70K-$100K for a course of treatment (cost varies depending on other medical factors) The Top 10 Brand Formulary drugs increased 14% ($4.3 million to $5.0 million) from the prior period. The number of Scripts increased 14% (961 to 1,100). Harvoni scripts increased from 120 to 137 The number of scripts for Truvada, Atripla, and Stribild increased 21% (326 to 395). These three drugs are non-specialty drugs and are used in the treatment of HIV. 12 February 23, 2017 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
APPENDIX
High-risk pregnancy management Pre-existing conditions or health factors can raise the risk of birth complications and costly treatments. The huge volume of maternity cases we handle more than 90,000 a year helps our doctors gain expertise in high-risk pregnancies. High-risk pregnancy care, management, and support at Kaiser Permanente includes: thorough prenatal screenings to identify risk factors and health problems early on electronic medical record alerts that trigger preventive measures
Expectant mothers with risk factors: member engagement Available tools and programs * Counseling for pre-existing health conditions Chronic condition classes and programs Available online and at facilities tools and programs * Hypertension and heart health online tools Variety of quit-smoking resources Comprehensive substance abuse intervention programs for pregnant members; includes counseling and treatment Numerous resources to help women suffering domestic abuse Behavioral health counseling and treatment * Programs and classes vary by region.
Prenatal and postpartum care: member engagement Available tools and programs Self-referral for pregnancy test Pregnancy education, exercise, and wellness classes Healthy Beginnings prenatal newsletters Details what to expect at next office visit and at each phase of pregnancy KP My Baby & Me app Email your doctor and view select test results at kp.org kp.org/maternity In-depth tools and resources include podcasts, virtual labor and delivery room tours, and your personal health record
THE CARE YOU NEED, WHEN YOU NEED IT. ROUTINE NONURGENT CARE OTHER NONURGENT CARE URGENT CARE EMERGENCY CARE WHAT IS IT FOR? An expected care need, like a recommended preventive screening or a visit for a health issue currently being treated. A new health concern or a change in an existing health condition that is not an urgent care need. An illness or injury that requires prompt medical attention, but is not an emergency medical condition. A medical or psychiatric condition that requires immediate medical attention to prevent serious jeopardy to your health.* WHAT SHOULD YOU KNOW? Examples of routine nonurgent care needs include: Physical exams Pre-travel exams Pap tests Well-child checkups Medication checkups Follow-up visits You can schedule an appointment online with your personal physician or ob-gyn. If your doctor isn t available within a time frame that works for you, call us to request an appointment with another available physician. Examples of other nonurgent care needs include: Trouble sleeping General digestion problems Gradual skin changes Joint stiffness Ongoing anxiety issues Weight loss or gain Schedule an appointment online with your personal physician, or call us to request the next available appointment in the primary care department you need. Examples of urgent care needs include: Minor injuries, including accidents and falls Sprains and cuts needing stitches Backaches Headaches High fever Mild breathing issues Sore throats Coughs, upper respiratory symptoms Earaches An urgent care need may also include situations where you are experiencing new or worsening symptoms, or have concerns about your medication. Symptoms that may indicate an emergency medical condition include: Chest pain or pressure that may radiate to the arm, neck, back, shoulder, jaw, or wrist Sudden onset of severe abdominal pain Severe shortness of breath Sudden decrease in or loss of consciousness Sudden inability to talk or to move one side of the body, or sudden slurred speech Severe, persistent bleeding that cannot be stopped Major injuries like gunshot or stab wounds or severe injuries from a vehicle accident Active labor when there isn t time for a safe transfer to a designated hospital before delivery WHAT DO YOU DO? Make an appointment: Online through My Health Manager at kp.org Call our appointment and advice line. Make an appointment: Online through My Health Manager at kp.org Call our appointment and advice line. Call for advice: If you have an urgent care need, call our appointment and advice line. We can even schedule a same-day or next-day appointment with your physician in most cases, if appropriate. If you reasonably believe you have an emergency medical condition, call 911 or go to the nearest hospital. Call our appointment and advice line If you have an illness or injury and you re not sure what kind of care you need, our advice nurses can help. With access to your electronic health record, they can assess your situation, help determine what type of care is most appropriate for your condition or symptoms, and even help you handle the problem at home until your next appointment. * An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a reasonable person would have believed that the absence of immediate medical attention would result in any of the following: (1) placing the person s health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. A mental health condition is an emergency medical condition when it meets the requirements of the paragraph above or, for members who are not enrolled in Kaiser Permanente Senior Advantage, when the condition manifests itself by acute symptoms of sufficient severity such that either of the following is true: The person is an immediate danger to himself or herself or to others, or the person is immediately unable to provide for or use food, shelter, or clothing due to the mental disorder.
PEACE OF MIND MAY BE JUST A PHONE CALL AWAY. Get medical advice when you need it. Sometimes it s difficult to know what type of medical care you need. That s why we have telephone advice nurses available to help you. Our advice nurses are registered nurses who are specially trained to help assess medical problems and provide advice over the phone, when medically appropriate. They can often resolve a minor concern or advise you on what to do next, including making a same-day or next-day appointment. We believe your concerns shouldn t go unanswered. Call our telephone advice nurses anytime you need advice, 24 hours a day. To reach an advice nurse, call one of the following appointment and advice numbers in your area, Monday through Friday, 7 a.m. to 7 p.m. For after-hours care, call 1-888-KPONCALL (1-888-576-6225). Anaheim Medical Center 1-888-988-2800 Antelope Valley area 1-877-554-4404 Baldwin Park Medical Center 1-800-780-1277 Coachella Valley area 1-866-984-7483 Downey Medical Center 1-800-823-4040 Fontana Medical Center 1-888-750-0036 Irvine Medical Center 1-888-988-2800 Kern County area 1-661-328-9831 Los Angeles Medical Center 1-800-954-8000 Moreno Valley area 1-866-984-7483 Ontario Medical Center 1-888-750-0036 Otay Mesa Outpatient Medical Center 1-800-290-5000 Panorama City Medical Center 1-888-778-5000 Riverside Medical Center 1-866-984-7483 San Diego Medical Center 1-800-290-5000 South Bay Medical Center 1-800-780-1230 West Los Angeles Medical Center 1-800-954-8000 Western Ventura County area 1-888-515-3500 Woodland Hills Medical Center 1-888-515-3500 TTY for the hearing/speech impaired 1-888-880-0833 kp.org Please recycle. 88702 September 2013
Telephone appointments now available 42-28751849_Corbis_RF_HiRes_DG_CMYK.tif Now, you can get care from a doctor wherever you are Do you have a minor health condition? If it doesn t require an in-person medical exam, you may be able to address it with a doctor by phone. You ll get great care, and you ll save time. Some examples of conditions:* Allergies Colds and coughs Some follow-up visits Upper respiratory infections When you call us, we will: Make sure you re 18 and over Confirm you ve had at least 1 face-to-face visit with us Schedule a 1-hour window for the doctor to call you (continues on back) Need to make an appointment? Find phone numbers and hours on the back side of this page. * Telephone appointments are not appropriate for emergency conditions, such as severe shortness of breath, severe abdominal pain, severe bleeding, or urgent conditions like sprains, falls, or cuts needing stitches. If you reasonably believe you have an emergency medical condition, call 911 or go to the nearest emergency department. An emergency medical condition is a medical or psychiatric condition that requires immediate medical attention to prevent serious jeopardy to your health. For the complete definition of an emergency medical condition, please refer to your Evidence of Coverage. kp.org
(continued from front) Call for care at a location near you Baldwin Park, Downey, and South Bay Baldwin Park Medical Center 1-800-780-1277 Downey Medical Center Sat Sun, 7 a.m. to 1 p.m. 1-800-823-4040 South Bay Medical Center 7 days, 24 hours 1-800-780-1230 Inland Empire and Coachella Valley Fontana Medical Center Sat, 7 a.m. to 3:30 p.m 1-888-750-0036 Moreno Valley Medical Center Sat, 7 a.m. to 3 p.m. 1-866-984-7483 Ontario Medical Center Sat, 7 a.m. to 3:30 p.m. 1-888-750-0036 Riverside Medical Center Sat, 7 a.m. to 3:30 p.m. 1-866-984-7483 Kern County, Valleys, Western Ventura Antelope Valley Service Area 1-877-554-4404 Kern County Service Area 1-877-524-7373 Panorama City Medical Center 1-888-778-5000 Woodland Hills Medical Center 1-888-515-3500 Los Angeles Los Angeles Medical Center 1-800-954-8000 West Los Angeles Medical Center 1-800-954-8000 Orange County Orange County Anaheim Medical Center 1-888-988-2800 Orange County Irvine Medical Center 1-888-988-2800 San Diego San Diego Medical Center 7 days a week, 7 a.m. to 7 p.m. 1-800-290-5000 For T TY, all locations call 711. Please recycle. 60525427 October 2016