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County health-plan report: paid claims slightly above premium, high-cost drugs flagged for 2025
Summary
A SEMCO representative presented Richland County’s health-plan fourth-quarter snapshot, reporting paid claims slightly above premiums, eight high-dollar claimants beyond the $150,000 pooling point, 107 potentially avoidable ER visits and plans to exclude two high-cost weight-loss drugs in 2025.
A representative from SEPCO/SEMCO presented Richland County’s fourth-quarter health-plan summary at the Feb. 27 commissioners meeting, reporting that paid claims for the past 12 months exceeded billed premiums and identifying high-cost claimants and prescription drivers.
Cindy Herring, filling the SEMCO presentation slot, told commissioners the county had “an overall loss ratio of a 2.3 last 12 months,” and that paid claims totaled about $10,900,000 compared with billed premium of about $10,600,000. Herring said eight claimants exceeded the county’s pooling point of $150,000; payments above that threshold are excluded from the county’s claims experience for rate-setting.
The presenter highlighted utilization details: inpatient costs declined in the current period compared with the prior period, while outpatient costs rose. Emergency-room utilization included 107 visits the report labeled “avoidable,” with an estimated potential savings of about $215,000; Herring cautioned that some ER visits that appear avoidable can be appropriate when symptoms are serious or occur outside other providers’ hours.
On prescription spending, SEMCO reported 86.3% of prescriptions were filled as generics; name-brand drugs accounted for roughly 91% of the nearly $2.7–$3 million in name‑brand spend. The report called out anti-diabetics and dermatologicals among the top drug categories and noted that Wegovy and Zepbound would be excluded from coverage in 2025, a change Herring said could reduce costs by about $350,000 for the year.
Herring recommended continued employee education about care options (primary care physician, MinuteClinic/retail clinics, urgent care, live‑health online) to reduce avoidable ER use and described county wellness resources such as the S.W.O.R.D. program for musculoskeletal prevention and rehabilitation.
Commissioners and staff asked clarifying questions about trend drivers and how claims older than June 2024 will roll off the experience window before renewal. The SEMCO representative provided detailed backup pages in the packet and left copies for county staff to review further.
No formal action or vote resulted from the presentation; commissioners recessed for an appointment and later returned to the meeting.
