ENROLLMENT COMPARISONSApril 20, 2006
Medical and Pharmacy
Medical or Pharmacy
*
Chart49
WHITE
BLACK
OTHER
0.8736032047
0.8595454545
0.8518518519
0.7849462366
0.6538461538
Sheet3
HIGHLIGHTS
TOTAL EXPENSES
98.0% of Members UNDER 65 have less than $25,000 incurred medical and pharmacy expenses with 69% of total paid.
97.5% OVER 65 have less than $25,000 incurred medical and pharmacy expenses with 62% of total paid.
The Over 65 SNP members incur more pharmacy and medical expenses per person over the $25,000 threshold.
MEDICAL EXPENSES
Females have a 17% higher PMPM than Males
Females have a 60% higher PMPM than males
Race
76% of the SNP population is white, with 18% as black.
76% of the SNP population is white, with 18% as black.
75% of the PMPM is attributable to the white population
75% of the PMPM is attributable to the white population
Financial Service
11% of PMPM is attributable to Outpatient Facility (ASC, ER)
9% of PMPM is attributable to Outpatient Facility (ASC, ER)
18% of PMPM is attributable to Medical Services and Supplies (DME, Home Care, Dialysis, Injectibles)
18% of PMPM is attributable to Medical Services and Supplies (DME, Home Care, Dialysis, Injectibles)
Inpatient Admits
Both behavioral health issue.
5 of Top 10 DRGs BH related
One Catastrophic Member drove PMPM ranking; #2 DRG - Organic Disturbances and Mental Retardation
3 of Top 10 DRGs BH related
PHARMACY
Higher PMPM than Over 65, fewer scripts per 1000 - drugs more expensive.
Lower PMPM, Higher Scripts per 1000 - drugs less expensive
ENROLL_TOTAL
UNIQUE MEMBERS
ENROLL_TOTAL
ENROLL_AGE
enroll_DATA
RISK_SCORE
Claims Stratification
First Quarter 2006
UNIQUE MEMBERS
7,267
58.4%
6,315
86.9%
4,827
66.4%
5,172
41.6%
4,597
88.9%
3,555
68.7%
2,077
28.6%
1,315
18.1%
1,396
27.0%
796
15.4%
Claims Stratification
% OF TOTAL
GENDER
Race
FSS
PMPM Chart
NO CLAIMS
952.00
575.00
6,315.00
4,597.00
1,315.00
796.00
2,077.00
1,396.00
7,267.00
5,172.00
4,827.00
3,555.00
First Quarter 2006
Source: CMS-MMR Report
AVERAGE RISK SCORE
Scripts PMPM
UNDER 65
OVER 65
AVERAGE RISK SCORE - SNP MEMBERS VS. ALL OTHER MEDICARE MEMBERS
G v B Payments
First Quarter 2006
UNDER 65
OVER 65
1,703
23.8%
86.6%
359,702
1.7%
100.0%
1,418
27.7%
88.5%
323,637
2.0%
100.0%
$0
961
13.4%
100.0%
0
0.0%
100.0%
587
11.5%
100.0%
0
0.0%
100.0%
Totals
7,149
100.0%
100.0%
$20,882,746
100.0%
100.0%
5,118
100.0%
100.0%
$16,071,583
100.0%
100.0%
&L&8&F /kas&CCONFIDENTIAL AND PROPRIETARY INFORMATION OF UPMC HEALTH PLAN&R&8Page &P &D
G v B Payments
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
RX_RACE
FEMALE
MALE
RX_GENDER
FEMALE
MALE
PMPM
TOP_25
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
TOP_25
MONTH_STRAT
MONTH_STRAT_AGE
Medical Expenses by Financial Service Category and by Age Grouping
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
MONTH_STRAT_AGE
BH EXPERIENCE
Sheet1
Per Member Per Month (PMPM) Payment
Comparison of SNP Program Allowed Payments to SSI and Medicare - Q1 2006 (On average, Total SNP Payments are 30% Higher)
286.28
531.4
388.42
171.25
269.53
93.25
94.16
93.63
44.56
76.88
6.22
6.34
6.27
5.63
5.54
83.35
107.46
93.39
41.97
89.45
27.89
47.2
35.93
12.09
33.83
76.88
92.98
83.58
46.86
91.29
158.21
166.22
161.55
181.76
95.34
103
17.17
67.23
2
5.22
347.12
222.45
295.17
234.64
101.31
1182.2
1285.38
1225.17
740.76
768.39
SNP
SSI
Medicare
Comparison of SNP, SSI and Medicare Scripts Per Member per Month - Q1 2006
2.7
2.3
0.9
2.2
1.4
0.7
4.9
3.7
1.6
race_data
SNP
SNP
SSI
SSI
Medicare
Medicare
% Generic
% Brand
Percentage of Scripts
Comparison of SNP, SSI and Medicare Generic versus Brand Utilization - Q1 2006
0.551
0.449
0.622
0.378
0.563
0.437
Percentage of Scripts
Comparison of SNP, SSI and Medicare Generic versus Brand Payments - Q1 2006
0.164
0.836
0.184
0.816
0.198
0.802
RX_DEMOG
First Quarter 2006
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
RX_DEMOG
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
UNDER 65
OVER 65
Unique Members Incurring Pharmacy Expenses by Race
Special Needs Population
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
FEMALE
MALE
PMPM
FEMALE
MALE
Top 25 Lists
2.24
0.8%
293.9
91.31
22
AVANDIA
2.76
1.0%
271.9
121.65
22
2.55
0.9%
405.9
75.36
23
ANTICOAGULANTS
2.10
0.7%
548.4
46.00
24
$ 234.42
81.6%
31,782.7
$ 88.51
52.74
18.4%
20,029.7
31.60
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
Special Needs Population - Pharmacy Utilization
TOP 5 THERAPY CLASSES BY MEMBER COUNT FOR MEMBERS UTILIZING > 6 DRUGS
RANK
Unique Members
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
Top 5 Therapy Classes for Members utilizing > 6 Drugs
Special Needs Population - Pharmacy Utilization
UTILIZING MEMBERS
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
Jan-06
Feb-06
Mar-06
Jan-06
Feb-06
Mar-06
PMPM
Jan-06
Feb-06
Mar-06
Special Needs Population - Pharmacy Utilization
Members Under 65 Years of Age v. Members Over 65 Years of Age
UTILIZING MEMBERS
UNDER 65
OVER 65
ALL SNP
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UNDER 65
OVER 65
UTILIZING MEMBERS BY NUMBER OF UNIQUE DRUGS - 1ST QUARTER 2006
UNDER 65
OVER 65
UNDER 65
OVER 65
PRESCRIPTIONS PER 1000 BY NUMBER OF UNIQUE DRUGS - 1ST QUARTER 2006
1
2
3
4
5
6
7
8
9
10
11
12
CATEGORY
SERVICE_DATE_YYYYMM
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
78,345.07
2.24
858.00
0.02
293.8691631465
91.3112703963
22.00
AVANDIA
96,588.05
2.76
794.00
271.95
271.9488526087
121.647418136
22.00
89,305.94
2.55
1,185.00
405.87
405.8682498002
75.3636624473
23.00
ANTICOAGULANTS
73,648.34
2.10
1,601.00
0.05
548.3502682955
46.0014615865
24.00
7,798.00
1.15
196,399.00
444,909.43
AGE_GROUP
CATEGORY
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
24,776.00
3.64
654,608.00
1,415,352.90
7,798.00
1.15
196,399.00
444,909.43
CATEGORY
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
AGE_GROUP
SERVICE_BEGIN_DATE_YYYYMM
MM
UNIQUE_MBRS
UNIQUE_DRUGS
RX_PAID
C_SVCS
SCRIPTS
C_ADMITS
C_PAID
MED_PMPM
RX_PMPM
TOT_PMPM
C_ADM_1000
C_CLMS_1000
SCRIPTS_1000
CLAIMS
AGE_GROUP
SERVICE_DATE_YYYYMM
MM
UNIQUE_MBRS
UNIQUE_DRUGS
RX_PAID
CLAIMS
C_SVCS
SCRIPTS
C_ADMITS
C_PAID
RX_PMPM
SCRIPTS_1000
AGE_GROUP
MM
UNIQUE_MEMBERS
ADMITS
MED_PAID
MED_CLAIMS
MED_SVCS
SCRIPTS
RX_PAID
UNIQUE_DRUGS
MED_PMPM
RX_PMPM
TOT_PMPM
SCRIPTS_1000
CLAIMS_1000
AGE_GROUP
MM
UNIQUE_MEMBERS
SCRIPTS
RX_PAID
UNIQUE_DRUGS
RX_PMPM
AGE_GROUP
MM
UNIQUE_MEMBERS
ADMITS
MED_PAID
MED_CLAIMS
MED_SVCS
MED_PMPM
CLAIMS_1000
ADMITS
164
277825.23
12.25
589
$13.59
7.19
345.86
29
22390.83
2.36
79
$1.53
1.94
64.93
193
300216.06
14.61
668
$8.57
5.00
228.79
230
231226.46
17.11
869
$11.31
10.05
510.28
42
142906.19
5.5
184
$9.79
4.52
151.23
272
374132.65
22.61
1053
$10.68
7.74
360.66
133
62999.28
4.17
271
$3.08
2.45
159.13
20
18906.61
4.17
29
$1.29
3.43
23.84
153
81905.89
8.34
300
$2.34
2.86
102.75
82
85768.4
11.14
258
4.20
6.5
151.5
780
39
24788.76
1.25
104
1.21
0.7
61.1
723
19
23924.58
0
52
1.17
0.0
30.5
414
10
19246.13
1.11
32
0.94
0.7
18.8
682
7
43540.27
9.89
16
2.98
8.1
13.2
428
4
10192.6
1.25
5
0.70
1.0
4.1
482
5
7229.76
1.11
10
0.50
0.9
8.2
719
8
7079
1.25
15
0.48
1.0
12.3
781
PMPM
ADM/1000
CLAIMS/1000
295
97
122962.54
31.59
255
6.02
18.5
149.7
307
13
43776.6
3.1
45
2.14
1.8
26.4
300
19
18184.42
3.36
40
0.89
2.0
23.5
305
PMPM
ADM/1000
CLAIMS/1000
294
6
4896.89
0
16
0.34
0.0
13.2
292
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
Special Needs Population - Behavioral Health Analysis
Pharmacy and Medical Claim Utilization - First Quarter 2006
IBNR applied to Medical Claims
Dental and Vision Claims not included
UNDER 65
OVER 65
Unique Members
Unique Members
Unique Members
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
UNDER 65
OVER 65
Behavioral Health Analysis
Dental and Vision Claims not included
UNDER 65
OVER 65
2,078
1,923
-7.5%
1,513
-27.2%
5,514
836
786
-6.0%
611
-26.9%
2,233
915
1,043
14.0%
1,726
88.6%
3,684
350
375
7.1%
648
85.1%
1,373
786
611
-22.3%
0
-100.0%
1,397
0
0
0.0%
0
0.0%
0
Behavorial Health Comorbidities
IBNR applied to Medical Claims
Dental and Vision Claims not included
UNDER 65
OVER 65
164
$13.59
7.2
345.9
29
$1.53
1.9
64.9
193
$8.57
5.0
228.8
230
$11.31
10.0
510.3
42
$9.79
4.5
151.2
272
$10.68
7.7
360.7
133
$3.08
2.4
159.1
20
$1.29
3.4
23.8
153
$2.34
2.9
102.8
UNDER 65
OVER 65
Unique Members
82
$4.20
6.5
151.5
7
$2.98
8.1
13.2
39
$1.21
0.7
61.1
19
$1.17
0.0
30.5
4
$0.70
1.0
4.1
10
$0.94
0.7
18.8
5
$0.50
0.9
8.2
8
$0.48
1.0
12.3
UNDER 65
OVER 65
Unique Members
97
$6.02
18.5
149.7
13
$2.14
1.8
26.4
6
$0.34
0.0
13.2
19
$0.89
2.0
23.5
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
MM JAN-MAR
3
41699.56
4.91
3
2.04
2.9
6
35592.4
11.92
6
1.74
7.0
538
Local Excis & Remov of Int Fix Dev Except Hip & Femur w/o CC
1
21369.04
4.39
1
1.05
2.6
2
17729.85
1.25
2
0.87
0.7
1
15414.78
5.64
2
0.75
3.3
1
14252.33
1.25
1
0.7
0.7
3
13949.05
6.98
4
0.68
4.1
1
13059.85
4.17
2
0.64
2.4
1
12426.62
1.25
1
0.61
0.7
1
11565.75
1.11
1
0.57
0.7
1
10833.71
1.11
1
0.53
0.7
1
10151.43
1.25
1
0.5
0.7
1
9625.6
1.25
1
0.47
0.7
2
9289.76
2.22
2
0.45
1.3
1
8734.81
1.11
1
0.43
0.7
2
8243.32
2.36
2
0.4
1.4
1
86067.24
4.39
1
5.9
3.6
3
45522.22
5.72
4
3.12
4.7
320
Kidney and Urinary Tract Infections, Age Greater than 17 with CC
2
39500.71
9.89
3
2.71
8.1
1
7633.06
8.35
2
0.52
6.9
Respiratory Infections and Inflammations, Age Greater than 17 with CC
1
7593.78
1.11
1
0.52
0.9
1
5198.28
1.11
1
0.36
0.9
1
4809.71
1.11
1
0.33
0.9
1
4367.85
1.25
1
0.3
1.0
296
Nutritional and Miscellaneous Metabolic Disorders, Age Greater than 17 with CC
1
3617.09
1.11
1
0.25
0.9
073
Other Ear, Nose, Mouth and Throat Diagnoses, Age Greater than 17
1
3580.04
1.25
1
0.25
1.0
1
1429.45
1.81
1
0.1
1.5
1
894.24
1.11
1
0.06
0.9
1
612.99
4.17
1
0.04
3.4
UNDER 65
OVER 65
1
$5.90
3.6
2
3
$3.12
4.70
3
14
$4.89
19.61
3
Kidney and Urinary Tract Infections, Age Greater than 17 with CC
2
$2.71
8.13
4
3
$2.04
2.88
4
Psychoses
6
$2.34
9.35
5
6
$1.74
7.00
5
3
$1.25
6.54
7
Rehabilitation
1
$0.53
1.03
8
Local Excis & Remov of Int Fix Dev Except Hip & Femur w/o CC
1
$1.05
2.58
8
1
$0.52
6.86
9
2
$0.87
0.73
9
Respiratory Infections and Inflammations, Age Greater than 17 with CC
1
$0.52
0.91
10
1
$0.75
3.31
10
1
$0.36
0.91
11
1
$0.70
0.73
12
3
$0.68
4.10
12
1
$0.33
0.91
13
1
$0.64
2.45
13
1
$0.61
0.73
14
1
$0.30
1.03
15
1
$0.57
0.65
16
Nutritional and Miscellaneous Metabolic Disorders, Age Greater than 17 with CC
1
$0.25
0.91
17
1
$0.56
0.91
17
Other Ear, Nose, Mouth and Throat Diagnoses, Age Greater than 17
1
$0.25
1.03
18
1
$0.53
0.65
18
1
$0.50
0.73
19
1
$0.10
1.49
20
1
$0.06
0.91
21
1
$0.47
0.73
21
1
$0.04
3.43
22
2
$0.45
1.30
22
1
$0.43
0.65
24
2
$0.40
1.39
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
MM JAN-MAR
Chart50
WHITE
BLACK
OTHER
0.532363483
0.5290909091
0.4722222222
0.4193548387
0.4230769231
Sheet3
HIGHLIGHTS
TOTAL EXPENSES
98.0% of Members UNDER 65 have less than $25,000 incurred medical and pharmacy expenses with 69% of total paid.
97.5% OVER 65 have less than $25,000 incurred medical and pharmacy expenses with 62% of total paid.
The Over 65 SNP members incur more pharmacy and medical expenses per person over the $25,000 threshold.
MEDICAL EXPENSES
Females have a 17% higher PMPM than Males
Females have a 60% higher PMPM than males
Race
76% of the SNP population is white, with 18% as black.
76% of the SNP population is white, with 18% as black.
75% of the PMPM is attributable to the white population
75% of the PMPM is attributable to the white population
Financial Service
11% of PMPM is attributable to Outpatient Facility (ASC, ER)
9% of PMPM is attributable to Outpatient Facility (ASC, ER)
18% of PMPM is attributable to Medical Services and Supplies (DME, Home Care, Dialysis, Injectibles)
18% of PMPM is attributable to Medical Services and Supplies (DME, Home Care, Dialysis, Injectibles)
Inpatient Admits
Both behavioral health issue.
5 of Top 10 DRGs BH related
One Catastrophic Member drove PMPM ranking; #2 DRG - Organic Disturbances and Mental Retardation
3 of Top 10 DRGs BH related
PHARMACY
Higher PMPM than Over 65, fewer scripts per 1000 - drugs more expensive.
Lower PMPM, Higher Scripts per 1000 - drugs less expensive
ENROLL_TOTAL
UNIQUE MEMBERS
ENROLL_TOTAL
0
0
0
0
0
ENROLL_AGE
0
0
0
0
0
enroll_DATA
0
0
0
0
0
RISK_SCORE
0
0
0
0
0
Claims Stratification
First Quarter 2006
UNIQUE MEMBERS
7,267
58.4%
6,315
86.9%
4,827
66.4%
5,172
41.6%
4,597
88.9%
3,555
68.7%
2,077
28.6%
1,315
18.1%
1,396
27.0%
796
15.4%
Claims Stratification
GENDER
0
0
Race
0
0
FSS
0
0
PMPM Chart
NO CLAIMS
952.00
575.00
6,315.00
4,597.00
1,315.00
796.00
2,077.00
1,396.00
7,267.00
5,172.00
4,827.00
3,555.00
First Quarter 2006
Source: CMS-MMR Report
AVERAGE RISK SCORE
Scripts PMPM
AVERAGE RISK SCORE - SNP MEMBERS VS. ALL OTHER MEDICARE MEMBERS
G v B Payments
First Quarter 2006
UNDER 65
OVER 65
1,703
23.8%
86.6%
359,702
1.7%
100.0%
1,418
27.7%
88.5%
323,637
2.0%
100.0%
$0
961
13.4%
100.0%
0
0.0%
100.0%
587
11.5%
100.0%
0
0.0%
100.0%
Totals
7,149
100.0%
100.0%
$20,882,746
100.0%
100.0%
5,118
100.0%
100.0%
$16,071,583
100.0%
100.0%
&L&8&F /kas&CCONFIDENTIAL AND PROPRIETARY INFORMATION OF UPMC HEALTH PLAN&R&8Page &P &D
G v B Payments
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
RX_RACE
0
0
0
0
FEMALE
MALE
RX_GENDER
0
0
0
0
FEMALE
MALE
PMPM
TOP_25
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
TOP_25
0
0
0
0
0
0
0
0
0
0
0
0
MONTH_STRAT
0
0
0
0
0
0
MONTH_STRAT_AGE
Medical Expenses by Financial Service Category and by Age Grouping
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
MONTH_STRAT_AGE
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
BH EXPERIENCE
Sheet1
Per Member Per Month (PMPM) Payment
Comparison of SNP Program Allowed Payments to SSI and Medicare - Q1 2006 (On average, Total SNP Payments are 30% Higher)
286.28
531.4
388.42
171.25
269.53
93.25
94.16
93.63
44.56
76.88
6.22
6.34
6.27
5.63
5.54
83.35
107.46
93.39
41.97
89.45
27.89
47.2
35.93
12.09
33.83
76.88
92.98
83.58
46.86
91.29
158.21
166.22
161.55
181.76
95.34
103
17.17
67.23
2
5.22
347.12
222.45
295.17
234.64
101.31
1182.2
1285.38
1225.17
740.76
768.39
SNP
SSI
Medicare
Comparison of SNP, SSI and Medicare Scripts Per Member per Month - Q1 2006
2.7
2.3
0.9
2.2
1.4
0.7
4.9
3.7
1.6
race_data
SNP
SNP
SSI
SSI
Medicare
Medicare
% Generic
% Brand
Percentage of Scripts
Comparison of SNP, SSI and Medicare Generic versus Brand Utilization - Q1 2006
0.551
0.449
0.622
0.378
0.563
0.437
Percentage of Scripts
Comparison of SNP, SSI and Medicare Generic versus Brand Payments - Q1 2006
0.164
0.836
0.184
0.816
0.198
0.802
RX_DEMOG
First Quarter 2006
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
RX_DEMOG
0
0
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
UPMC For Life
Special Needs Population
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
0
0
0
0
FEMALE
MALE
PMPM
0
0
0
0
FEMALE
MALE
UPMC For Life
Top 25 Lists
2.24
0.8%
293.9
91.31
22
AVANDIA
2.76
1.0%
271.9
121.65
22
2.55
0.9%
405.9
75.36
23
ANTICOAGULANTS
2.10
0.7%
548.4
46.00
24
$ 234.42
81.6%
31,782.7
$ 88.51
52.74
18.4%
20,029.7
31.60
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
UPMC For Life
Special Needs Population - Pharmacy Utilization
TOP 5 THERAPY CLASSES BY MEMBER COUNT FOR MEMBERS UTILIZING > 6 DRUGS
RANK
Unique Members
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
0
0
0
0
0
UPMC For Life
UTILIZING MEMBERS
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Jan-06
Feb-06
Mar-06
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Jan-06
Feb-06
Mar-06
PMPM
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Jan-06
Feb-06
Mar-06
Special Needs Population - Pharmacy Utilization
Members Under 65 Years of Age v. Members Over 65 Years of Age
UTILIZING MEMBERS
UNDER 65
OVER 65
ALL SNP
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
0
0
0
0
0
0
0
0
0
0
UTILIZING MEMBERS BY NUMBER OF UNIQUE DRUGS - 1ST QUARTER 2006
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
UNDER 65
OVER 65
PRESCRIPTIONS PER 1000 BY NUMBER OF UNIQUE DRUGS - 1ST QUARTER 2006
1
2
3
4
5
6
7
8
9
10
11
12
CATEGORY
SERVICE_DATE_YYYYMM
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
78,345.07
2.24
858.00
0.02
293.8691631465
91.3112703963
22.00
AVANDIA
96,588.05
2.76
794.00
271.95
271.9488526087
121.647418136
22.00
89,305.94
2.55
1,185.00
405.87
405.8682498002
75.3636624473
23.00
ANTICOAGULANTS
73,648.34
2.10
1,601.00
0.05
548.3502682955
46.0014615865
24.00
7,798.00
1.15
196,399.00
444,909.43
AGE_GROUP
CATEGORY
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
24,776.00
3.64
654,608.00
1,415,352.90
7,798.00
1.15
196,399.00
444,909.43
CATEGORY
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
AGE_GROUP
SERVICE_BEGIN_DATE_YYYYMM
MM
UNIQUE_MBRS
UNIQUE_DRUGS
RX_PAID
C_SVCS
SCRIPTS
C_ADMITS
C_PAID
MED_PMPM
RX_PMPM
TOT_PMPM
C_ADM_1000
C_CLMS_1000
SCRIPTS_1000
CLAIMS
AGE_GROUP
SERVICE_DATE_YYYYMM
MM
UNIQUE_MBRS
UNIQUE_DRUGS
RX_PAID
CLAIMS
C_SVCS
SCRIPTS
C_ADMITS
C_PAID
RX_PMPM
SCRIPTS_1000
AGE_GROUP
MM
UNIQUE_MEMBERS
ADMITS
MED_PAID
MED_CLAIMS
MED_SVCS
SCRIPTS
RX_PAID
UNIQUE_DRUGS
MED_PMPM
RX_PMPM
TOT_PMPM
SCRIPTS_1000
CLAIMS_1000
AGE_GROUP
MM
UNIQUE_MEMBERS
SCRIPTS
RX_PAID
UNIQUE_DRUGS
RX_PMPM
AGE_GROUP
MM
UNIQUE_MEMBERS
ADMITS
MED_PAID
MED_CLAIMS
MED_SVCS
MED_PMPM
CLAIMS_1000
ADMITS
164
277825.23
12.25
589
$13.59
7.19
345.86
29
22390.83
2.36
79
$1.53
1.94
64.93
193
300216.06
14.61
668
$8.57
5.00
228.79
230
231226.46
17.11
869
$11.31
10.05
510.28
42
142906.19
5.5
184
$9.79
4.52
151.23
272
374132.65
22.61
1053
$10.68
7.74
360.66
133
62999.28
4.17
271
$3.08
2.45
159.13
20
18906.61
4.17
29
$1.29
3.43
23.84
153
81905.89
8.34
300
$2.34
2.86
102.75
82
85768.4
11.14
258
4.20
6.5
151.5
780
39
24788.76
1.25
104
1.21
0.7
61.1
723
19
23924.58
0
52
1.17
0.0
30.5
414
10
19246.13
1.11
32
0.94
0.7
18.8
682
7
43540.27
9.89
16
2.98
8.1
13.2
428
4
10192.6
1.25
5
0.70
1.0
4.1
482
5
7229.76
1.11
10
0.50
0.9
8.2
719
8
7079
1.25
15
0.48
1.0
12.3
781
PMPM
ADM/1000
CLAIMS/1000
295
97
122962.54
31.59
255
6.02
18.5
149.7
307
13
43776.6
3.1
45
2.14
1.8
26.4
300
19
18184.42
3.36
40
0.89
2.0
23.5
305
PMPM
ADM/1000
CLAIMS/1000
294
6
4896.89
0
16
0.34
0.0
13.2
292
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
UPMC For Life
Pharmacy and Medical Claim Utilization - First Quarter 2006
IBNR applied to Medical Claims
Dental and Vision Claims not included
UNDER 65
OVER 65
Unique Members
Unique Members
Unique Members
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
0
0
0
0
0
0
UPMC For Life
Behavioral Health Analysis
Dental and Vision Claims not included
UNDER 65
OVER 65
2,078
1,923
-7.5%
1,513
-27.2%
5,514
836
786
-6.0%
611
-26.9%
2,233
915
1,043
14.0%
1,726
88.6%
3,684
350
375
7.1%
648
85.1%
1,373
786
611
-22.3%
0
-100.0%
1,397
0
0
0.0%
0
0.0%
0
Behavorial Health Comorbidities
IBNR applied to Medical Claims
Dental and Vision Claims not included
UNDER 65
OVER 65
164
$13.59
7.2
345.9
29
$1.53
1.9
64.9
193
$8.57
5.0
228.8
230
$11.31
10.0
510.3
42
$9.79
4.5
151.2
272
$10.68
7.7
360.7
133
$3.08
2.4
159.1
20
$1.29
3.4
23.8
153
$2.34
2.9
102.8
UNDER 65
OVER 65
Unique Members
82
$4.20
6.5
151.5
7
$2.98
8.1
13.2
39
$1.21
0.7
61.1
19
$1.17
0.0
30.5
4
$0.70
1.0
4.1
10
$0.94
0.7
18.8
5
$0.50
0.9
8.2
8
$0.48
1.0
12.3
UNDER 65
OVER 65
Unique Members
97
$6.02
18.5
149.7
13
$2.14
1.8
26.4
6
$0.34
0.0
13.2
19
$0.89
2.0
23.5
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
MM JAN-MAR
3
41699.56
4.91
3
2.04
2.9
6
35592.4
11.92
6
1.74
7.0
538
Local Excis & Remov of Int Fix Dev Except Hip & Femur w/o CC
1
21369.04
4.39
1
1.05
2.6
2
17729.85
1.25
2
0.87
0.7
1
15414.78
5.64
2
0.75
3.3
1
14252.33
1.25
1
0.7
0.7
3
13949.05
6.98
4
0.68
4.1
1
13059.85
4.17
2
0.64
2.4
1
12426.62
1.25
1
0.61
0.7
1
11565.75
1.11
1
0.57
0.7
1
10833.71
1.11
1
0.53
0.7
1
10151.43
1.25
1
0.5
0.7
1
9625.6
1.25
1
0.47
0.7
2
9289.76
2.22
2
0.45
1.3
1
8734.81
1.11
1
0.43
0.7
2
8243.32
2.36
2
0.4
1.4
1
86067.24
4.39
1
5.9
3.6
3
45522.22
5.72
4
3.12
4.7
320
Kidney and Urinary Tract Infections, Age Greater than 17 with CC
2
39500.71
9.89
3
2.71
8.1
1
7633.06
8.35
2
0.52
6.9
Respiratory Infections and Inflammations, Age Greater than 17 with CC
1
7593.78
1.11
1
0.52
0.9
1
5198.28
1.11
1
0.36
0.9
1
4809.71
1.11
1
0.33
0.9
1
4367.85
1.25
1
0.3
1.0
296
Nutritional and Miscellaneous Metabolic Disorders, Age Greater than 17 with CC
1
3617.09
1.11
1
0.25
0.9
073
Other Ear, Nose, Mouth and Throat Diagnoses, Age Greater than 17
1
3580.04
1.25
1
0.25
1.0
1
1429.45
1.81
1
0.1
1.5
1
894.24
1.11
1
0.06
0.9
1
612.99
4.17
1
0.04
3.4
UNDER 65
OVER 65
1
$5.90
3.6
2
3
$3.12
4.70
3
14
$4.89
19.61
3
Kidney and Urinary Tract Infections, Age Greater than 17 with CC
2
$2.71
8.13
4
3
$2.04
2.88
4
Psychoses
6
$2.34
9.35
5
6
$1.74
7.00
5
3
$1.25
6.54
7
Rehabilitation
1
$0.53
1.03
8
Local Excis & Remov of Int Fix Dev Except Hip & Femur w/o CC
1
$1.05
2.58
8
1
$0.52
6.86
9
2
$0.87
0.73
9
Respiratory Infections and Inflammations, Age Greater than 17 with CC
1
$0.52
0.91
10
1
$0.75
3.31
10
1
$0.36
0.91
11
1
$0.70
0.73
12
3
$0.68
4.10
12
1
$0.33
0.91
13
1
$0.64
2.45
13
1
$0.61
0.73
14
1
$0.30
1.03
15
1
$0.57
0.65
16
Nutritional and Miscellaneous Metabolic Disorders, Age Greater than 17 with CC
1
$0.25
0.91
17
1
$0.56
0.91
17
Other Ear, Nose, Mouth and Throat Diagnoses, Age Greater than 17
1
$0.25
1.03
18
1
$0.53
0.65
18
1
$0.50
0.73
19
1
$0.10
1.49
20
1
$0.06
0.91
21
1
$0.47
0.73
21
1
$0.04
3.43
22
2
$0.45
1.30
22
1
$0.43
0.65
24
2
$0.40
1.39
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
MM JAN-MAR
Chart52
WHITE
BLACK
OTHER
0.1539110268
0.1781818182
0.1759259259
0.2150537634
0.3461538462
Sheet3
HIGHLIGHTS
TOTAL EXPENSES
98.0% of Members UNDER 65 have less than $25,000 incurred medical and pharmacy expenses with 69% of total paid.
97.5% OVER 65 have less than $25,000 incurred medical and pharmacy expenses with 62% of total paid.
The Over 65 SNP members incur more pharmacy and medical expenses per person over the $25,000 threshold.
MEDICAL EXPENSES
Females have a 17% higher PMPM than Males
Females have a 60% higher PMPM than males
Race
76% of the SNP population is white, with 18% as black.
76% of the SNP population is white, with 18% as black.
75% of the PMPM is attributable to the white population
75% of the PMPM is attributable to the white population
Financial Service
11% of PMPM is attributable to Outpatient Facility (ASC, ER)
9% of PMPM is attributable to Outpatient Facility (ASC, ER)
18% of PMPM is attributable to Medical Services and Supplies (DME, Home Care, Dialysis, Injectibles)
18% of PMPM is attributable to Medical Services and Supplies (DME, Home Care, Dialysis, Injectibles)
Inpatient Admits
Both behavioral health issue.
5 of Top 10 DRGs BH related
One Catastrophic Member drove PMPM ranking; #2 DRG - Organic Disturbances and Mental Retardation
3 of Top 10 DRGs BH related
PHARMACY
Higher PMPM than Over 65, fewer scripts per 1000 - drugs more expensive.
Lower PMPM, Higher Scripts per 1000 - drugs less expensive
ENROLL_TOTAL
UNIQUE MEMBERS
ENROLL_TOTAL
ENROLL_AGE
enroll_DATA
RISK_SCORE
Claims Stratification
First Quarter 2006
UNIQUE MEMBERS
7,267
58.4%
6,315
86.9%
4,827
66.4%
5,172
41.6%
4,597
88.9%
3,555
68.7%
2,077
28.6%
1,315
18.1%
1,396
27.0%
796
15.4%
Claims Stratification
% OF TOTAL
GENDER
Race
FSS
PMPM Chart
NO CLAIMS
952.00
575.00
6,315.00
4,597.00
1,315.00
796.00
2,077.00
1,396.00
7,267.00
5,172.00
4,827.00
3,555.00
First Quarter 2006
Source: CMS-MMR Report
AVERAGE RISK SCORE
Scripts PMPM
UNDER 65
OVER 65
AVERAGE RISK SCORE - SNP MEMBERS VS. ALL OTHER MEDICARE MEMBERS
G v B Payments
First Quarter 2006
UNDER 65
OVER 65
1,703
23.8%
86.6%
359,702
1.7%
100.0%
1,418
27.7%
88.5%
323,637
2.0%
100.0%
$0
961
13.4%
100.0%
0
0.0%
100.0%
587
11.5%
100.0%
0
0.0%
100.0%
Totals
7,149
100.0%
100.0%
$20,882,746
100.0%
100.0%
5,118
100.0%
100.0%
$16,071,583
100.0%
100.0%
&L&8&F /kas&CCONFIDENTIAL AND PROPRIETARY INFORMATION OF UPMC HEALTH PLAN&R&8Page &P &D
G v B Payments
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
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RX_RACE
FEMALE
MALE
RX_GENDER
FEMALE
MALE
PMPM
TOP_25
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
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TOP_25
MONTH_STRAT
MONTH_STRAT_AGE
Medical Expenses by Financial Service Category and by Age Grouping
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
MONTH_STRAT_AGE
BH EXPERIENCE
Sheet1
Per Member Per Month (PMPM) Payment
Comparison of SNP Program Allowed Payments to SSI and Medicare - Q1 2006 (On average, Total SNP Payments are 30% Higher)
286.28
531.4
388.42
171.25
269.53
93.25
94.16
93.63
44.56
76.88
6.22
6.34
6.27
5.63
5.54
83.35
107.46
93.39
41.97
89.45
27.89
47.2
35.93
12.09
33.83
76.88
92.98
83.58
46.86
91.29
158.21
166.22
161.55
181.76
95.34
103
17.17
67.23
2
5.22
347.12
222.45
295.17
234.64
101.31
1182.2
1285.38
1225.17
740.76
768.39
SNP
SSI
Medicare
Comparison of SNP, SSI and Medicare Scripts Per Member per Month - Q1 2006
2.7
2.3
0.9
2.2
1.4
0.7
4.9
3.7
1.6
race_data
SNP
SNP
SSI
SSI
Medicare
Medicare
% Generic
% Brand
Percentage of Scripts
Comparison of SNP, SSI and Medicare Generic versus Brand Utilization - Q1 2006
0.551
0.449
0.622
0.378
0.563
0.437
Percentage of Scripts
Comparison of SNP, SSI and Medicare Generic versus Brand Payments - Q1 2006
0.164
0.836
0.184
0.816
0.198
0.802
RX_DEMOG
First Quarter 2006
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RX_DEMOG
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
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UNDER 65
OVER 65
Unique Members Incurring Pharmacy Expenses by Race
Special Needs Population
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
FEMALE
MALE
PMPM
FEMALE
MALE
Top 25 Lists
2.24
0.8%
293.9
91.31
22
AVANDIA
2.76
1.0%
271.9
121.65
22
2.55
0.9%
405.9
75.36
23
ANTICOAGULANTS
2.10
0.7%
548.4
46.00
24
$ 234.42
81.6%
31,782.7
$ 88.51
52.74
18.4%
20,029.7
31.60
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Special Needs Population - Pharmacy Utilization
TOP 5 THERAPY CLASSES BY MEMBER COUNT FOR MEMBERS UTILIZING > 6 DRUGS
RANK
Unique Members
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Top 5 Therapy Classes for Members utilizing > 6 Drugs
Special Needs Population - Pharmacy Utilization
UTILIZING MEMBERS
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Jan-06
Feb-06
Mar-06
Jan-06
Feb-06
Mar-06
PMPM
Jan-06
Feb-06
Mar-06
Special Needs Population - Pharmacy Utilization
Members Under 65 Years of Age v. Members Over 65 Years of Age
UTILIZING MEMBERS
UNDER 65
OVER 65
ALL SNP
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UNDER 65
OVER 65
UTILIZING MEMBERS BY NUMBER OF UNIQUE DRUGS - 1ST QUARTER 2006
UNDER 65
OVER 65
UNDER 65
OVER 65
PRESCRIPTIONS PER 1000 BY NUMBER OF UNIQUE DRUGS - 1ST QUARTER 2006
1
2
3
4
5
6
7
8
9
10
11
12
CATEGORY
SERVICE_DATE_YYYYMM
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
78,345.07
2.24
858.00
0.02
293.8691631465
91.3112703963
22.00
AVANDIA
96,588.05
2.76
794.00
271.95
271.9488526087
121.647418136
22.00
89,305.94
2.55
1,185.00
405.87
405.8682498002
75.3636624473
23.00
ANTICOAGULANTS
73,648.34
2.10
1,601.00
0.05
548.3502682955
46.0014615865
24.00
7,798.00
1.15
196,399.00
444,909.43
AGE_GROUP
CATEGORY
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
24,776.00
3.64
654,608.00
1,415,352.90
7,798.00
1.15
196,399.00
444,909.43
CATEGORY
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
AGE_GROUP
SERVICE_BEGIN_DATE_YYYYMM
MM
UNIQUE_MBRS
UNIQUE_DRUGS
RX_PAID
C_SVCS
SCRIPTS
C_ADMITS
C_PAID
MED_PMPM
RX_PMPM
TOT_PMPM
C_ADM_1000
C_CLMS_1000
SCRIPTS_1000
CLAIMS
AGE_GROUP
SERVICE_DATE_YYYYMM
MM
UNIQUE_MBRS
UNIQUE_DRUGS
RX_PAID
CLAIMS
C_SVCS
SCRIPTS
C_ADMITS
C_PAID
RX_PMPM
SCRIPTS_1000
AGE_GROUP
MM
UNIQUE_MEMBERS
ADMITS
MED_PAID
MED_CLAIMS
MED_SVCS
SCRIPTS
RX_PAID
UNIQUE_DRUGS
MED_PMPM
RX_PMPM
TOT_PMPM
SCRIPTS_1000
CLAIMS_1000
AGE_GROUP
MM
UNIQUE_MEMBERS
SCRIPTS
RX_PAID
UNIQUE_DRUGS
RX_PMPM
AGE_GROUP
MM
UNIQUE_MEMBERS
ADMITS
MED_PAID
MED_CLAIMS
MED_SVCS
MED_PMPM
CLAIMS_1000
ADMITS
164
277825.23
12.25
589
$13.59
7.19
345.86
29
22390.83
2.36
79
$1.53
1.94
64.93
193
300216.06
14.61
668
$8.57
5.00
228.79
230
231226.46
17.11
869
$11.31
10.05
510.28
42
142906.19
5.5
184
$9.79
4.52
151.23
272
374132.65
22.61
1053
$10.68
7.74
360.66
133
62999.28
4.17
271
$3.08
2.45
159.13
20
18906.61
4.17
29
$1.29
3.43
23.84
153
81905.89
8.34
300
$2.34
2.86
102.75
82
85768.4
11.14
258
4.20
6.5
151.5
780
39
24788.76
1.25
104
1.21
0.7
61.1
723
19
23924.58
0
52
1.17
0.0
30.5
414
10
19246.13
1.11
32
0.94
0.7
18.8
682
7
43540.27
9.89
16
2.98
8.1
13.2
428
4
10192.6
1.25
5
0.70
1.0
4.1
482
5
7229.76
1.11
10
0.50
0.9
8.2
719
8
7079
1.25
15
0.48
1.0
12.3
781
PMPM
ADM/1000
CLAIMS/1000
295
97
122962.54
31.59
255
6.02
18.5
149.7
307
13
43776.6
3.1
45
2.14
1.8
26.4
300
19
18184.42
3.36
40
0.89
2.0
23.5
305
PMPM
ADM/1000
CLAIMS/1000
294
6
4896.89
0
16
0.34
0.0
13.2
292
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Special Needs Population - Behavioral Health Analysis
Pharmacy and Medical Claim Utilization - First Quarter 2006
IBNR applied to Medical Claims
Dental and Vision Claims not included
UNDER 65
OVER 65
Unique Members
Unique Members
Unique Members
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UNDER 65
OVER 65
Behavioral Health Analysis
Dental and Vision Claims not included
UNDER 65
OVER 65
2,078
1,923
-7.5%
1,513
-27.2%
5,514
836
786
-6.0%
611
-26.9%
2,233
915
1,043
14.0%
1,726
88.6%
3,684
350
375
7.1%
648
85.1%
1,373
786
611
-22.3%
0
-100.0%
1,397
0
0
0.0%
0
0.0%
0
Behavorial Health Comorbidities
IBNR applied to Medical Claims
Dental and Vision Claims not included
UNDER 65
OVER 65
164
$13.59
7.2
345.9
29
$1.53
1.9
64.9
193
$8.57
5.0
228.8
230
$11.31
10.0
510.3
42
$9.79
4.5
151.2
272
$10.68
7.7
360.7
133
$3.08
2.4
159.1
20
$1.29
3.4
23.8
153
$2.34
2.9
102.8
UNDER 65
OVER 65
Unique Members
82
$4.20
6.5
151.5
7
$2.98
8.1
13.2
39
$1.21
0.7
61.1
19
$1.17
0.0
30.5
4
$0.70
1.0
4.1
10
$0.94
0.7
18.8
5
$0.50
0.9
8.2
8
$0.48
1.0
12.3
UNDER 65
OVER 65
Unique Members
97
$6.02
18.5
149.7
13
$2.14
1.8
26.4
6
$0.34
0.0
13.2
19
$0.89
2.0
23.5
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MM JAN-MAR
3
41699.56
4.91
3
2.04
2.9
6
35592.4
11.92
6
1.74
7.0
538
Local Excis & Remov of Int Fix Dev Except Hip & Femur w/o CC
1
21369.04
4.39
1
1.05
2.6
2
17729.85
1.25
2
0.87
0.7
1
15414.78
5.64
2
0.75
3.3
1
14252.33
1.25
1
0.7
0.7
3
13949.05
6.98
4
0.68
4.1
1
13059.85
4.17
2
0.64
2.4
1
12426.62
1.25
1
0.61
0.7
1
11565.75
1.11
1
0.57
0.7
1
10833.71
1.11
1
0.53
0.7
1
10151.43
1.25
1
0.5
0.7
1
9625.6
1.25
1
0.47
0.7
2
9289.76
2.22
2
0.45
1.3
1
8734.81
1.11
1
0.43
0.7
2
8243.32
2.36
2
0.4
1.4
1
86067.24
4.39
1
5.9
3.6
3
45522.22
5.72
4
3.12
4.7
320
Kidney and Urinary Tract Infections, Age Greater than 17 with CC
2
39500.71
9.89
3
2.71
8.1
1
7633.06
8.35
2
0.52
6.9
Respiratory Infections and Inflammations, Age Greater than 17 with CC
1
7593.78
1.11
1
0.52
0.9
1
5198.28
1.11
1
0.36
0.9
1
4809.71
1.11
1
0.33
0.9
1
4367.85
1.25
1
0.3
1.0
296
Nutritional and Miscellaneous Metabolic Disorders, Age Greater than 17 with CC
1
3617.09
1.11
1
0.25
0.9
073
Other Ear, Nose, Mouth and Throat Diagnoses, Age Greater than 17
1
3580.04
1.25
1
0.25
1.0
1
1429.45
1.81
1
0.1
1.5
1
894.24
1.11
1
0.06
0.9
1
612.99
4.17
1
0.04
3.4
UNDER 65
OVER 65
1
$5.90
3.6
2
3
$3.12
4.70
3
14
$4.89
19.61
3
Kidney and Urinary Tract Infections, Age Greater than 17 with CC
2
$2.71
8.13
4
3
$2.04
2.88
4
Psychoses
6
$2.34
9.35
5
6
$1.74
7.00
5
3
$1.25
6.54
7
Rehabilitation
1
$0.53
1.03
8
Local Excis & Remov of Int Fix Dev Except Hip & Femur w/o CC
1
$1.05
2.58
8
1
$0.52
6.86
9
2
$0.87
0.73
9
Respiratory Infections and Inflammations, Age Greater than 17 with CC
1
$0.52
0.91
10
1
$0.75
3.31
10
1
$0.36
0.91
11
1
$0.70
0.73
12
3
$0.68
4.10
12
1
$0.33
0.91
13
1
$0.64
2.45
13
1
$0.61
0.73
14
1
$0.30
1.03
15
1
$0.57
0.65
16
Nutritional and Miscellaneous Metabolic Disorders, Age Greater than 17 with CC
1
$0.25
0.91
17
1
$0.56
0.91
17
Other Ear, Nose, Mouth and Throat Diagnoses, Age Greater than 17
1
$0.25
1.03
18
1
$0.53
0.65
18
1
$0.50
0.73
19
1
$0.10
1.49
20
1
$0.06
0.91
21
1
$0.47
0.73
21
1
$0.04
3.43
22
2
$0.45
1.30
22
1
$0.43
0.65
24
2
$0.40
1.39
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MM JAN-MAR
Chart51
WHITE
BLACK
OTHER
0.4389626818
0.4318181818
0.5
0.5806451613
0.5769230769
Sheet3
HIGHLIGHTS
TOTAL EXPENSES
98.0% of Members UNDER 65 have less than $25,000 incurred medical and pharmacy expenses with 69% of total paid.
97.5% OVER 65 have less than $25,000 incurred medical and pharmacy expenses with 62% of total paid.
The Over 65 SNP members incur more pharmacy and medical expenses per person over the $25,000 threshold.
MEDICAL EXPENSES
Females have a 17% higher PMPM than Males
Females have a 60% higher PMPM than males
Race
76% of the SNP population is white, with 18% as black.
76% of the SNP population is white, with 18% as black.
75% of the PMPM is attributable to the white population
75% of the PMPM is attributable to the white population
Financial Service
11% of PMPM is attributable to Outpatient Facility (ASC, ER)
9% of PMPM is attributable to Outpatient Facility (ASC, ER)
18% of PMPM is attributable to Medical Services and Supplies (DME, Home Care, Dialysis, Injectibles)
18% of PMPM is attributable to Medical Services and Supplies (DME, Home Care, Dialysis, Injectibles)
Inpatient Admits
Both behavioral health issue.
5 of Top 10 DRGs BH related
One Catastrophic Member drove PMPM ranking; #2 DRG - Organic Disturbances and Mental Retardation
3 of Top 10 DRGs BH related
PHARMACY
Higher PMPM than Over 65, fewer scripts per 1000 - drugs more expensive.
Lower PMPM, Higher Scripts per 1000 - drugs less expensive
ENROLL_TOTAL
UNIQUE MEMBERS
ENROLL_TOTAL
ENROLL_AGE
enroll_DATA
RISK_SCORE
Claims Stratification
First Quarter 2006
UNIQUE MEMBERS
7,267
58.4%
6,315
86.9%
4,827
66.4%
5,172
41.6%
4,597
88.9%
3,555
68.7%
2,077
28.6%
1,315
18.1%
1,396
27.0%
796
15.4%
Claims Stratification
% OF TOTAL
GENDER
Race
FSS
PMPM Chart
NO CLAIMS
952.00
575.00
6,315.00
4,597.00
1,315.00
796.00
2,077.00
1,396.00
7,267.00
5,172.00
4,827.00
3,555.00
First Quarter 2006
Source: CMS-MMR Report
AVERAGE RISK SCORE
Scripts PMPM
UNDER 65
OVER 65
AVERAGE RISK SCORE - SNP MEMBERS VS. ALL OTHER MEDICARE MEMBERS
G v B Payments
First Quarter 2006
UNDER 65
OVER 65
1,703
23.8%
86.6%
359,702
1.7%
100.0%
1,418
27.7%
88.5%
323,637
2.0%
100.0%
$0
961
13.4%
100.0%
0
0.0%
100.0%
587
11.5%
100.0%
0
0.0%
100.0%
Totals
7,149
100.0%
100.0%
$20,882,746
100.0%
100.0%
5,118
100.0%
100.0%
$16,071,583
100.0%
100.0%
&L&8&F /kas&CCONFIDENTIAL AND PROPRIETARY INFORMATION OF UPMC HEALTH PLAN&R&8Page &P &D
G v B Payments
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
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RX_RACE
FEMALE
MALE
RX_GENDER
FEMALE
MALE
PMPM
TOP_25
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
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TOP_25
MONTH_STRAT
MONTH_STRAT_AGE
Medical Expenses by Financial Service Category and by Age Grouping
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
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MONTH_STRAT_AGE
BH EXPERIENCE
Sheet1
Per Member Per Month (PMPM) Payment
Comparison of SNP Program Allowed Payments to SSI and Medicare - Q1 2006 (On average, Total SNP Payments are 30% Higher)
286.28
531.4
388.42
171.25
269.53
93.25
94.16
93.63
44.56
76.88
6.22
6.34
6.27
5.63
5.54
83.35
107.46
93.39
41.97
89.45
27.89
47.2
35.93
12.09
33.83
76.88
92.98
83.58
46.86
91.29
158.21
166.22
161.55
181.76
95.34
103
17.17
67.23
2
5.22
347.12
222.45
295.17
234.64
101.31
1182.2
1285.38
1225.17
740.76
768.39
SNP
SSI
Medicare
Comparison of SNP, SSI and Medicare Scripts Per Member per Month - Q1 2006
2.7
2.3
0.9
2.2
1.4
0.7
4.9
3.7
1.6
race_data
SNP
SNP
SSI
SSI
Medicare
Medicare
% Generic
% Brand
Percentage of Scripts
Comparison of SNP, SSI and Medicare Generic versus Brand Utilization - Q1 2006
0.551
0.449
0.622
0.378
0.563
0.437
Percentage of Scripts
Comparison of SNP, SSI and Medicare Generic versus Brand Payments - Q1 2006
0.164
0.836
0.184
0.816
0.198
0.802
RX_DEMOG
First Quarter 2006
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RX_DEMOG
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
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UNDER 65
OVER 65
Unique Members Incurring Pharmacy Expenses by Race
Special Needs Population
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
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FEMALE
MALE
PMPM
FEMALE
MALE
Top 25 Lists
2.24
0.8%
293.9
91.31
22
AVANDIA
2.76
1.0%
271.9
121.65
22
2.55
0.9%
405.9
75.36
23
ANTICOAGULANTS
2.10
0.7%
548.4
46.00
24
$ 234.42
81.6%
31,782.7
$ 88.51
52.74
18.4%
20,029.7
31.60
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Special Needs Population - Pharmacy Utilization
TOP 5 THERAPY CLASSES BY MEMBER COUNT FOR MEMBERS UTILIZING > 6 DRUGS
RANK
Unique Members
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Top 5 Therapy Classes for Members utilizing > 6 Drugs
Special Needs Population - Pharmacy Utilization
UTILIZING MEMBERS
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Jan-06
Feb-06
Mar-06
Jan-06
Feb-06
Mar-06
PMPM
Jan-06
Feb-06
Mar-06
Special Needs Population - Pharmacy Utilization
Members Under 65 Years of Age v. Members Over 65 Years of Age
UTILIZING MEMBERS
UNDER 65
OVER 65
ALL SNP
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UNDER 65
OVER 65
UTILIZING MEMBERS BY NUMBER OF UNIQUE DRUGS - 1ST QUARTER 2006
UNDER 65
OVER 65
UNDER 65
OVER 65
PRESCRIPTIONS PER 1000 BY NUMBER OF UNIQUE DRUGS - 1ST QUARTER 2006
1
2
3
4
5
6
7
8
9
10
11
12
CATEGORY
SERVICE_DATE_YYYYMM
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
78,345.07
2.24
858.00
0.02
293.8691631465
91.3112703963
22.00
AVANDIA
96,588.05
2.76
794.00
271.95
271.9488526087
121.647418136
22.00
89,305.94
2.55
1,185.00
405.87
405.8682498002
75.3636624473
23.00
ANTICOAGULANTS
73,648.34
2.10
1,601.00
0.05
548.3502682955
46.0014615865
24.00
7,798.00
1.15
196,399.00
444,909.43
AGE_GROUP
CATEGORY
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
24,776.00
3.64
654,608.00
1,415,352.90
7,798.00
1.15
196,399.00
444,909.43
CATEGORY
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
AGE_GROUP
SERVICE_BEGIN_DATE_YYYYMM
MM
UNIQUE_MBRS
UNIQUE_DRUGS
RX_PAID
C_SVCS
SCRIPTS
C_ADMITS
C_PAID
MED_PMPM
RX_PMPM
TOT_PMPM
C_ADM_1000
C_CLMS_1000
SCRIPTS_1000
CLAIMS
AGE_GROUP
SERVICE_DATE_YYYYMM
MM
UNIQUE_MBRS
UNIQUE_DRUGS
RX_PAID
CLAIMS
C_SVCS
SCRIPTS
C_ADMITS
C_PAID
RX_PMPM
SCRIPTS_1000
AGE_GROUP
MM
UNIQUE_MEMBERS
ADMITS
MED_PAID
MED_CLAIMS
MED_SVCS
SCRIPTS
RX_PAID
UNIQUE_DRUGS
MED_PMPM
RX_PMPM
TOT_PMPM
SCRIPTS_1000
CLAIMS_1000
AGE_GROUP
MM
UNIQUE_MEMBERS
SCRIPTS
RX_PAID
UNIQUE_DRUGS
RX_PMPM
AGE_GROUP
MM
UNIQUE_MEMBERS
ADMITS
MED_PAID
MED_CLAIMS
MED_SVCS
MED_PMPM
CLAIMS_1000
ADMITS
164
277825.23
12.25
589
$13.59
7.19
345.86
29
22390.83
2.36
79
$1.53
1.94
64.93
193
300216.06
14.61
668
$8.57
5.00
228.79
230
231226.46
17.11
869
$11.31
10.05
510.28
42
142906.19
5.5
184
$9.79
4.52
151.23
272
374132.65
22.61
1053
$10.68
7.74
360.66
133
62999.28
4.17
271
$3.08
2.45
159.13
20
18906.61
4.17
29
$1.29
3.43
23.84
153
81905.89
8.34
300
$2.34
2.86
102.75
82
85768.4
11.14
258
4.20
6.5
151.5
780
39
24788.76
1.25
104
1.21
0.7
61.1
723
19
23924.58
0
52
1.17
0.0
30.5
414
10
19246.13
1.11
32
0.94
0.7
18.8
682
7
43540.27
9.89
16
2.98
8.1
13.2
428
4
10192.6
1.25
5
0.70
1.0
4.1
482
5
7229.76
1.11
10
0.50
0.9
8.2
719
8
7079
1.25
15
0.48
1.0
12.3
781
PMPM
ADM/1000
CLAIMS/1000
295
97
122962.54
31.59
255
6.02
18.5
149.7
307
13
43776.6
3.1
45
2.14
1.8
26.4
300
19
18184.42
3.36
40
0.89
2.0
23.5
305
PMPM
ADM/1000
CLAIMS/1000
294
6
4896.89
0
16
0.34
0.0
13.2
292
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
Special Needs Population - Behavioral Health Analysis
Pharmacy and Medical Claim Utilization - First Quarter 2006
IBNR applied to Medical Claims
Dental and Vision Claims not included
UNDER 65
OVER 65
Unique Members
Unique Members
Unique Members
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
UNDER 65
OVER 65
Behavioral Health Analysis
Dental and Vision Claims not included
UNDER 65
OVER 65
2,078
1,923
-7.5%
1,513
-27.2%
5,514
836
786
-6.0%
611
-26.9%
2,233
915
1,043
14.0%
1,726
88.6%
3,684
350
375
7.1%
648
85.1%
1,373
786
611
-22.3%
0
-100.0%
1,397
0
0
0.0%
0
0.0%
0
Behavorial Health Comorbidities
IBNR applied to Medical Claims
Dental and Vision Claims not included
UNDER 65
OVER 65
164
$13.59
7.2
345.9
29
$1.53
1.9
64.9
193
$8.57
5.0
228.8
230
$11.31
10.0
510.3
42
$9.79
4.5
151.2
272
$10.68
7.7
360.7
133
$3.08
2.4
159.1
20
$1.29
3.4
23.8
153
$2.34
2.9
102.8
UNDER 65
OVER 65
Unique Members
82
$4.20
6.5
151.5
7
$2.98
8.1
13.2
39
$1.21
0.7
61.1
19
$1.17
0.0
30.5
4
$0.70
1.0
4.1
10
$0.94
0.7
18.8
5
$0.50
0.9
8.2
8
$0.48
1.0
12.3
UNDER 65
OVER 65
Unique Members
97
$6.02
18.5
149.7
13
$2.14
1.8
26.4
6
$0.34
0.0
13.2
19
$0.89
2.0
23.5
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
MM JAN-MAR
3
41699.56
4.91
3
2.04
2.9
6
35592.4
11.92
6
1.74
7.0
538
Local Excis & Remov of Int Fix Dev Except Hip & Femur w/o CC
1
21369.04
4.39
1
1.05
2.6
2
17729.85
1.25
2
0.87
0.7
1
15414.78
5.64
2
0.75
3.3
1
14252.33
1.25
1
0.7
0.7
3
13949.05
6.98
4
0.68
4.1
1
13059.85
4.17
2
0.64
2.4
1
12426.62
1.25
1
0.61
0.7
1
11565.75
1.11
1
0.57
0.7
1
10833.71
1.11
1
0.53
0.7
1
10151.43
1.25
1
0.5
0.7
1
9625.6
1.25
1
0.47
0.7
2
9289.76
2.22
2
0.45
1.3
1
8734.81
1.11
1
0.43
0.7
2
8243.32
2.36
2
0.4
1.4
1
86067.24
4.39
1
5.9
3.6
3
45522.22
5.72
4
3.12
4.7
320
Kidney and Urinary Tract Infections, Age Greater than 17 with CC
2
39500.71
9.89
3
2.71
8.1
1
7633.06
8.35
2
0.52
6.9
Respiratory Infections and Inflammations, Age Greater than 17 with CC
1
7593.78
1.11
1
0.52
0.9
1
5198.28
1.11
1
0.36
0.9
1
4809.71
1.11
1
0.33
0.9
1
4367.85
1.25
1
0.3
1.0
296
Nutritional and Miscellaneous Metabolic Disorders, Age Greater than 17 with CC
1
3617.09
1.11
1
0.25
0.9
073
Other Ear, Nose, Mouth and Throat Diagnoses, Age Greater than 17
1
3580.04
1.25
1
0.25
1.0
1
1429.45
1.81
1
0.1
1.5
1
894.24
1.11
1
0.06
0.9
1
612.99
4.17
1
0.04
3.4
UNDER 65
OVER 65
1
$5.90
3.6
2
3
$3.12
4.70
3
14
$4.89
19.61
3
Kidney and Urinary Tract Infections, Age Greater than 17 with CC
2
$2.71
8.13
4
3
$2.04
2.88
4
Psychoses
6
$2.34
9.35
5
6
$1.74
7.00
5
3
$1.25
6.54
7
Rehabilitation
1
$0.53
1.03
8
Local Excis & Remov of Int Fix Dev Except Hip & Femur w/o CC
1
$1.05
2.58
8
1
$0.52
6.86
9
2
$0.87
0.73
9
Respiratory Infections and Inflammations, Age Greater than 17 with CC
1
$0.52
0.91
10
1
$0.75
3.31
10
1
$0.36
0.91
11
1
$0.70
0.73
12
3
$0.68
4.10
12
1
$0.33
0.91
13
1
$0.64
2.45
13
1
$0.61
0.73
14
1
$0.30
1.03
15
1
$0.57
0.65
16
Nutritional and Miscellaneous Metabolic Disorders, Age Greater than 17 with CC
1
$0.25
0.91
17
1
$0.56
0.91
17
Other Ear, Nose, Mouth and Throat Diagnoses, Age Greater than 17
1
$0.25
1.03
18
1
$0.53
0.65
18
1
$0.50
0.73
19
1
$0.10
1.49
20
1
$0.06
0.91
21
1
$0.47
0.73
21
1
$0.04
3.43
22
2
$0.45
1.30
22
1
$0.43
0.65
24
2
$0.40
1.39
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
MM JAN-MAR
7,267
58.4%
6,315
86.9%
4,827
66.4%
5,172
41.6%
4,597
88.9%
3,555
68.7%
2,077
28.6%
1,315
18.1%
1,396
27.0%
796
15.4%
Chart11
% OF TOTAL
0.868996835
0.8888244393
Sheet3
HIGHLIGHTS
TOTAL EXPENSES
98.0% of Members UNDER 65 have less than $25,000 incurred medical and pharmacy expenses with 69% of total paid.
97.5% OVER 65 have less than $25,000 incurred medical and pharmacy expenses with 62% of total paid.
The Over 65 SNP members incur more pharmacy and medical expenses per person over the $25,000 threshold.
MEDICAL EXPENSES
Females have a 17% higher PMPM than Males
Females have a 60% higher PMPM than males
Race
76% of the SNP population is white, with 18% as black.
76% of the SNP population is white, with 18% as black.
75% of the PMPM is attributable to the white population
75% of the PMPM is attributable to the white population
Financial Service
11% of PMPM is attributable to Outpatient Facility (ASC, ER)
9% of PMPM is attributable to Outpatient Facility (ASC, ER)
18% of PMPM is attributable to Medical Services and Supplies (DME, Home Care, Dialysis, Injectibles)
18% of PMPM is attributable to Medical Services and Supplies (DME, Home Care, Dialysis, Injectibles)
Inpatient Admits
Both behavioral health issue.
5 of Top 10 DRGs BH related
One Catastrophic Member drove PMPM ranking; #2 DRG - Organic Disturbances and Mental Retardation
3 of Top 10 DRGs BH related
PHARMACY
Higher PMPM than Over 65, fewer scripts per 1000 - drugs more expensive.
Lower PMPM, Higher Scripts per 1000 - drugs less expensive
ENROLL_TOTAL
UNIQUE MEMBERS
ENROLL_TOTAL
0
0
0
0
0
ENROLL_AGE
0
0
0
0
0
enroll_DATA
0
0
0
0
0
RISK_SCORE
0
0
0
0
0
Claims Stratification
First Quarter 2006
UNIQUE MEMBERS
7,267
58.4%
6,315
86.9%
4,827
66.4%
5,172
41.6%
4,597
88.9%
3,555
68.7%
2,077
28.6%
1,315
18.1%
1,396
27.0%
796
15.4%
Claims Stratification
GENDER
0
0
Race
0
0
FSS
0
0
PMPM Chart
NO CLAIMS
952.00
575.00
6,315.00
4,597.00
1,315.00
796.00
2,077.00
1,396.00
7,267.00
5,172.00
4,827.00
3,555.00
First Quarter 2006
Source: CMS-MMR Report
AVERAGE RISK SCORE
Scripts PMPM
AVERAGE RISK SCORE - SNP MEMBERS VS. ALL OTHER MEDICARE MEMBERS
G v B Payments
First Quarter 2006
UNDER 65
OVER 65
1,703
23.8%
86.6%
359,702
1.7%
100.0%
1,418
27.7%
88.5%
323,637
2.0%
100.0%
$0
961
13.4%
100.0%
0
0.0%
100.0%
587
11.5%
100.0%
0
0.0%
100.0%
Totals
7,149
100.0%
100.0%
$20,882,746
100.0%
100.0%
5,118
100.0%
100.0%
$16,071,583
100.0%
100.0%
&L&8&F /kas&CCONFIDENTIAL AND PROPRIETARY INFORMATION OF UPMC HEALTH PLAN&R&8Page &P &D
G v B Payments
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
TOP_25
0
0
0
0
FEMALE
MALE
Ther_combo
0
0
0
0
FEMALE
MALE
PMPM
MONTH_STRAT
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
MONTH_STRAT
0
0
0
0
0
0
0
0
0
0
0
0
data
0
0
0
0
0
0
BH EXPERIENCE
Medical Expenses by Financial Service Category and by Age Grouping
First Quarter 2006
Dental and Vision Claims not included
UNDER 65
OVER 65
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
BH EXPERIENCE
BH dx
race_data
Per Member Per Month (PMPM) Payment
Comparison of SNP Program Allowed Payments to SSI and Medicare - Q1 2006 (On average, Total SNP Payments are 30% Higher)
286.28
531.4
388.42
171.25
269.53
93.25
94.16
93.63
44.56
76.88
6.22
6.34
6.27
5.63
5.54
83.35
107.46
93.39
41.97
89.45
27.89
47.2
35.93
12.09
33.83
76.88
92.98
83.58
46.86
91.29
158.21
166.22
161.55
181.76
95.34
103
17.17
67.23
2
5.22
347.12
222.45
295.17
234.64
101.31
1182.2
1285.38
1225.17
740.76
768.39
SNP
SSI
Medicare
Comparison of SNP, SSI and Medicare Scripts Per Member per Month - Q1 2006
2.7
2.3
0.9
2.2
1.4
0.7
4.9
3.7
1.6
RX_RACE
SNP
SNP
SSI
SSI
Medicare
Medicare
% Generic
% Brand
Percentage of Scripts
Comparison of SNP, SSI and Medicare Generic versus Brand Utilization - Q1 2006
0.551
0.449
0.622
0.378
0.563
0.437
RX_DEMOG
SNP
SNP
SSI
SSI
Medicare
Medicare
% Generic
% Brand
Percentage of Scripts
Comparison of SNP, SSI and Medicare Generic versus Brand Payments - Q1 2006
0.164
0.836
0.184
0.816
0.198
0.802
RX_GENDER
First Quarter 2006
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
RX_GENDER
0
0
Top 25 Lists
2.24
0.8%
293.9
91.31
22
AVANDIA
2.76
1.0%
271.9
121.65
22
2.55
0.9%
405.9
75.36
23
ANTICOAGULANTS
2.10
0.7%
548.4
46.00
24
$ 234.42
81.6%
31,782.7
$ 88.51
52.74
18.4%
20,029.7
31.60
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
UPMC For Life
Special Needs Population - Pharmacy Utilization
TOP 5 THERAPY CLASSES BY MEMBER COUNT FOR MEMBERS UTILIZING > 6 DRUGS
RANK
Unique Members
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
0
0
0
0
0
UPMC For Life
UTILIZING MEMBERS
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Jan-06
Feb-06
Mar-06
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Jan-06
Feb-06
Mar-06
PMPM
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Jan-06
Feb-06
Mar-06
Special Needs Population - Pharmacy Utilization
Members Under 65 Years of Age v. Members Over 65 Years of Age
UTILIZING MEMBERS
UNDER 65
OVER 65
ALL SNP
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
0
0
0
0
0
0
0
0
0
0
UTILIZING MEMBERS BY NUMBER OF UNIQUE DRUGS - 1ST QUARTER 2006
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
UNDER 65
OVER 65
PRESCRIPTIONS PER 1000 BY NUMBER OF UNIQUE DRUGS - 1ST QUARTER 2006
1
2
3
4
5
6
7
8
9
10
11
12
CATEGORY
SERVICE_DATE_YYYYMM
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
78,345.07
2.24
858.00
0.02
293.8691631465
91.3112703963
22.00
AVANDIA
96,588.05
2.76
794.00
271.95
271.9488526087
121.647418136
22.00
89,305.94
2.55
1,185.00
405.87
405.8682498002
75.3636624473
23.00
ANTICOAGULANTS
73,648.34
2.10
1,601.00
0.05
548.3502682955
46.0014615865
24.00
7,798.00
1.15
196,399.00
444,909.43
AGE_GROUP
CATEGORY
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
24,776.00
3.64
654,608.00
1,415,352.90
7,798.00
1.15
196,399.00
444,909.43
CATEGORY
UTILIZING_MEMBERS
UTILIZED_DRUGS
INGR_COST
DISP_FEE
PAID_AMT
PMPM
SCRIPTS
SCRIPTS_1000
DAYS_SUPPLY
QUANTITY
AGE_GROUP
SERVICE_BEGIN_DATE_YYYYMM
MM
UNIQUE_MBRS
UNIQUE_DRUGS
RX_PAID
C_SVCS
SCRIPTS
C_ADMITS
C_PAID
MED_PMPM
RX_PMPM
TOT_PMPM
C_ADM_1000
C_CLMS_1000
SCRIPTS_1000
CLAIMS
AGE_GROUP
SERVICE_DATE_YYYYMM
MM
UNIQUE_MBRS
UNIQUE_DRUGS
RX_PAID
CLAIMS
C_SVCS
SCRIPTS
C_ADMITS
C_PAID
RX_PMPM
SCRIPTS_1000
AGE_GROUP
MM
UNIQUE_MEMBERS
ADMITS
MED_PAID
MED_CLAIMS
MED_SVCS
SCRIPTS
RX_PAID
UNIQUE_DRUGS
MED_PMPM
RX_PMPM
TOT_PMPM
SCRIPTS_1000
CLAIMS_1000
AGE_GROUP
MM
UNIQUE_MEMBERS
SCRIPTS
RX_PAID
UNIQUE_DRUGS
RX_PMPM
AGE_GROUP
MM
UNIQUE_MEMBERS
ADMITS
MED_PAID
MED_CLAIMS
MED_SVCS
MED_PMPM
CLAIMS_1000
ADMITS
164
277825.23
12.25
589
$13.59
7.19
345.86
29
22390.83
2.36
79
$1.53
1.94
64.93
193
300216.06
14.61
668
$8.57
5.00
228.79
230
231226.46
17.11
869
$11.31
10.05
510.28
42
142906.19
5.5
184
$9.79
4.52
151.23
272
374132.65
22.61
1053
$10.68
7.74
360.66
133
62999.28
4.17
271
$3.08
2.45
159.13
20
18906.61
4.17
29
$1.29
3.43
23.84
153
81905.89
8.34
300
$2.34
2.86
102.75
82
85768.4
11.14
258
4.20
6.5
151.5
780
39
24788.76
1.25
104
1.21
0.7
61.1
723
19
23924.58
0
52
1.17
0.0
30.5
414
10
19246.13
1.11
32
0.94
0.7
18.8
682
7
43540.27
9.89
16
2.98
8.1
13.2
428
4
10192.6
1.25
5
0.70
1.0
4.1
482
5
7229.76
1.11
10
0.50
0.9
8.2
719
8
7079
1.25
15
0.48
1.0
12.3
781
PMPM
ADM/1000
CLAIMS/1000
295
97
122962.54
31.59
255
6.02
18.5
149.7
307
13
43776.6
3.1
45
2.14
1.8
26.4
300
19
18184.42
3.36
40
0.89
2.0
23.5
305
PMPM
ADM/1000
CLAIMS/1000
294
6
4896.89
0
16
0.34
0.0
13.2
292
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
UPMC For Life
Pharmacy and Medical Claim Utilization - First Quarter 2006
IBNR applied to Medical Claims
Dental and Vision Claims not included
UNDER 65
OVER 65
Unique Members
Unique Members
Unique Members
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
0
0
0
0
0
0
UPMC For Life
Behavioral Health Analysis
Dental and Vision Claims not included
UNDER 65
OVER 65
2,078
1,923
-7.5%
1,513
-27.2%
5,514
836
786
-6.0%
611
-26.9%
2,233
915
1,043
14.0%
1,726
88.6%
3,684
350
375
7.1%
648
85.1%
1,373
786
611
-22.3%
0
-100.0%
1,397
0
0
0.0%
0
0.0%
0
Behavorial Health Comorbidities
IBNR applied to Medical Claims
Dental and Vision Claims not included
UNDER 65
OVER 65
164
$13.59
7.2
345.9
29
$1.53
1.9
64.9
193
$8.57
5.0
228.8
230
$11.31
10.0
510.3
42
$9.79
4.5
151.2
272
$10.68
7.7
360.7
133
$3.08
2.4
159.1
20
$1.29
3.4
23.8
153
$2.34
2.9
102.8
UNDER 65
OVER 65
Unique Members
82
$4.20
6.5
151.5
7
$2.98
8.1
13.2
39
$1.21
0.7
61.1
19
$1.17
0.0
30.5
4
$0.70
1.0
4.1
10
$0.94
0.7
18.8
5
$0.50
0.9
8.2
8
$0.48
1.0
12.3
UNDER 65
OVER 65
Unique Members
97
$6.02
18.5
149.7
13
$2.14
1.8
26.4
6
$0.34
0.0
13.2
19
$0.89
2.0
23.5
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
MM JAN-MAR
3
41699.56
4.91
3
2.04
2.9
6
35592.4
11.92
6
1.74
7.0
538
Local Excis & Remov of Int Fix Dev Except Hip & Femur w/o CC
1
21369.04
4.39
1
1.05
2.6
2
17729.85
1.25
2
0.87
0.7
1
15414.78
5.64
2
0.75
3.3
1
14252.33
1.25
1
0.7
0.7
3
13949.05
6.98
4
0.68
4.1
1
13059.85
4.17
2
0.64
2.4
1
12426.62
1.25
1
0.61
0.7
1
11565.75
1.11
1
0.57
0.7
1
10833.71
1.11
1
0.53
0.7
1
10151.43
1.25
1
0.5
0.7
1
9625.6
1.25
1
0.47
0.7
2
9289.76
2.22
2
0.45
1.3
1
8734.81
1.11
1
0.43
0.7
2
8243.32
2.36
2
0.4
1.4
1
86067.24
4.39
1
5.9
3.6
3
45522.22
5.72
4
3.12
4.7
320
Kidney and Urinary Tract Infections, Age Greater than 17 with CC
2
39500.71
9.89
3
2.71
8.1
1
7633.06
8.35
2
0.52
6.9
Respiratory Infections and Inflammations, Age Greater than 17 with CC
1
7593.78
1.11
1
0.52
0.9
1
5198.28
1.11
1
0.36
0.9
1
4809.71
1.11
1
0.33
0.9
1
4367.85
1.25
1
0.3
1.0
296
Nutritional and Miscellaneous Metabolic Disorders, Age Greater than 17 with CC
1
3617.09
1.11
1
0.25
0.9
073
Other Ear, Nose, Mouth and Throat Diagnoses, Age Greater than 17
1
3580.04
1.25
1
0.25
1.0
1
1429.45
1.81
1
0.1
1.5
1
894.24
1.11
1
0.06
0.9
1
612.99
4.17
1
0.04
3.4
UNDER 65
UNDER 65
1
$5.90
3.6
2
3
$3.12
4.70
3
14
$4.89
19.61
4
Kidney and Urinary Tract Infections, Age Greater than 17 with CC
2
$2.71
8.13
5
3
$2.04
2.88
5
Psychoses
6
$2.34
9.35
6
6
$1.74
7.00
6
3
$1.25
6.54
8
Rehabilitation
1
$0.53
1.03
9
Local Excis & Remov of Int Fix Dev Except Hip & Femur w/o CC
1
$1.05
2.58
9
1
$0.52
6.86
10
2
$0.87
0.73
10
Respiratory Infections and Inflammations, Age Greater than 17 with CC
1
$0.52
0.91
11
1
$0.75
3.31
11
1
$0.36
0.91
12
1
$0.70
0.73
12
1
$0.33
0.91
13
3
$0.68
4.10
13
1
$0.64
2.45
14
1
$0.30
1.03
15
1
$0.61
0.73
15
1
$0.58
1.47
16
Nutritional and Miscellaneous Metabolic Disorders, Age Greater than 17 with CC
1
$0.25
0.91
17
1
$0.57
0.65
17
Other Ear, Nose, Mouth and Throat Diagnoses, Age Greater than 17
1
$0.25
1.03
18
1
$0.53
0.65
19
1
$0.10
1.49
20
1
$0.50
0.73
20
1
$0.06
0.91
21
1
$0.04
3.43
22
1
$0.47
0.73
22
2
$0.45
1.30
24
1
$0.43
0.65
25
2
$0.40
1.39
&C&"Times New Roman,Regular"&11Confidential and Proprietary Information of UPMC Health Plan
UPMC For Life
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