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HSS dashboard: specialty drugs and high-cost claimants drive nearly half of spending
Summary
The Health Service System's Q2 2019 dashboard shows specialty drugs dominate prescription spending and high-cost claimants (>$50,000 threshold) account for roughly 45.9% of total spend; staff flagged rising Medicare utilization and unusual outpatient costs in the UHC PPO plan.
Marina Coleridge, enterprise systems and analytics manager, presented the Q2 2019 cost, utilization and quality dashboard derived from the system's all-payer claims database covering April 2018–March 2019 (paid through June). "13 of our top 15 are in fact specialty drugs," Coleridge said, and specialty drug costs continue to rise.
The dashboard uses an industry threshold of $50,000 to identify high-cost claimants. Coleridge told commissioners that "45.9% of spend, total spend results from high cost claimants," underscoring that a relatively small group of patients accounts for a large portion of total dollars.
Plan-level and Medicare trends: Coleridge said UnitedHealthcare's city PPO population (about 3,000 lives) shows higher outpatient facility costs than inpatient costs — a departure from typical patterns — with outpatient facility costs called out as driven by injectable specialty drugs. On the Medicare side (about 28,543 lives), she said admits, length of stay and prescription volumes are increasing and that the online dashboard will be corrected to reflect those trends.
Board follow-up and methodology: commissioners asked about the risk-score and demographic displays and about the methodology for identifying avoidable admissions. Coleridge agreed to document the specific criteria and return with a written report so the board could review the definitions underlying the quality markers and avoidable-admission counts.
Next steps: staff will correct the online dashboard notes and provide a written methodology for avoidable admissions and related quality markers at a subsequent meeting.
