Get Full Government Meeting Transcripts, Videos, & Alerts Forever!
Get email alerts on the Claims Management topic
No spam. Unsubscribe anytime.
Claims rising slightly; pharmacy share and large claimants drive increases, consultant says
Summary
Consultant Chris reported trust claims running near budgeted levels but noted pharmacy costs are rising and a small number of large claimants account for a disproportionate share of paid claims. He highlighted utilization shifts tied to the district’s HealthiestU telehealth program.
Chris (consultant) delivered a claims update during the May 8 meeting, noting the trust’s most recent run rate and trends across plan tiers.
Chris said the trust is running at about 77% of expected liability year-to-date, similar to the prior year’s 78% at the same point. Pharmacy claims account for roughly 33% of total claims paid (up from 30% at the same time last year), which he attributed in part to certain high-cost specialty drugs returning to the plan. “We are seeing the claims cost for pharmacy go up…your pharmacy claims are accounting for about 33% of total claims paid right now,” Chris said.
Large claimants are a major driver of cost: 13 large claimants through March accounted for about 26% of total paid claims, with diagnoses including Crohn’s disease, arthritis and several cancer therapies including Humira-related regimens. Chris said these high-cost patients are largely responsible for the increases being seen in overall spend.
Chris reviewed plan-tier performance: the high-deductible plan is running higher as more members enroll in that tier; the lower-cost plan’s loss ratio has decreased. He also pointed to utilization indicators he associated with the HealthiestU telehealth program and Teladoc access: inpatient admissions and some utilization measures have declined, while pay-per-visit metrics for appropriate higher-cost settings rose (presented pay-per-visit increased from about $9 to $13.14). “I would argue that that is also because people are getting more appropriate care at the right place of service and not going to the ER because they have that option with HealthiestU and Teladoc,” Chris said.
Chris concluded with an explanation of pharmacy rebates and a note that a prior reconciliation produced an $83,000 payment related to contract guarantees; trustees asked no follow-up questions during the update.
