UMR presentation shows high-cost claimants drive a large share of Sunnyside plan spend
Summary
UMR analysts told trustees that 21 high-cost claimants account for roughly 32.6% of total medical cost, MSK and digestive diagnoses drove spending increases, and utilization measures show 81.9% of members used medical benefits during the period reviewed.
UMR’s data-analytics team presented the trust with a multi-slide review of enrollment, utilization and cost drivers for the plan’s experience period.
Heather Liglerhoppe introduced Carissa Daniels as the designated analyst. Carissa said enrollment rose about 4.3% versus the prior year and reported a paid PMPM of about $361.98 (up roughly 2%). "About 81.9% of your members are actually utilizing their medical benefits," she said, noting that figure is above the book-of-business norm of 74.7%.
Carissa flagged diagnostic drivers and high-cost claimants as major cost contributors: she reported a 93% increase in musculoskeletal (MSK) costs in the experience period and said the plan defined high-cost claimants as members with claims of $50,000 or more. "Your total high cost payments are 21% and across those 21 high cost payments, you pay about $2,040,000," she said, estimating that represented about 32.6% of total cost.
On inpatient and emergency care, UMR said total inpatient dollars fell about 7.2% (roughly a $102,000 decline) and that ER utilization decreased about 7% while paid-per-visit rose 39.9%, driven in part by fewer potentially avoidable visits and higher-cost true emergencies.
Carissa also described chronic-condition trends (metabolic conditions and type 2 diabetes) and said behavioral-health spending improved, with reduced inpatient behavioral-health dollars and lower out-of-network spend.
UMR offered appendix slides and follow-up data for trustees who requested further detail.
