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Presentation: DXCG risk scores show rising burden among early retirees and musculoskeletal conditions driving costs
Summary
SFHSS staff presented 2017–2018 DXCG risk scores showing rising concurrent risk across groups, higher prospective risk among early retirees (55–64) with roughly double PMPM spending, and musculoskeletal disorders and diabetes as top clinical drivers.
Marina Coleridge, enterprise systems and analytics manager for the Health Service System, presented diagnostic cost grouper (DXCG) risk scores for October 2017–September 2018 and compared them with the prior period. Coleridge said concurrent risk scores increased across active, early retiree and Medicare retiree groups while prospective risk improved slightly for the active population due to younger hires in recent years.
Key findings Coleridge highlighted: musculoskeletal disorders are the largest clinical driver of risk; diabetes is among the top three drivers and a high‑cost condition to manage; early retirees aged 55–64 show substantially higher illness burden and about twice the per‑member‑per‑month (PMPM) spend compared with active employees of the same age bracket.
Coleridge noted plan enrollment shifts—some healthier members moving to the Blue Shield Trio plan—affect the distribution of risk across plans. She also cautioned that the Trio baseline has limited data. The presentation described ‘‘dynamic adjustments’’ that scale spend relative to a 1.0 risk baseline to help compare plan performance on an adjusted basis.
Board members asked for more detail on the assumptions embedded in the dynamic adjustment, the potential role of coding differences between plans, and whether practice patterns (for example, frequency of preventive procedures) can change measured efficiency. Coleridge said staff will return with deeper analysis, including utilization and coding breakdowns, and acknowledged limitations when claims data do not include elements present only in electronic medical records.
Public comment: Claire Zavonsky, representing retired employee groups, praised the analysis and urged negotiation with carriers—particularly Blue Shield—over perceived rating and premium differences affecting early retirees.
Next steps: staff and the actuary will incorporate risk score findings into renewal negotiations and present follow‑up materials (methodology for the dynamic adjustment, six‑year utilization history, and benchmarking against external norms) at a future meeting.
