ANAGED CARE DIGEST SERIES SI N C E 1 9 8 7 HOSPITALS ...€¦ · Kelvin Yamashita...

MANAGED CARE DIGEST SERIES®

H O S P I T A L S / S Y S T E M S D I G E S T P U B L I C P A Y E R D I G E S T H M O - P P O D I G E S TSINCE 1987

Health Care Data Summary|2014

NATIONAL

www.managedcaredigest.com

2 National Health Care Data Summary 2014 Managed Care digest series®

NATIONAL HEALTH CARE DATA SUMMARY

CONTACTS

CONTENTS

Amy Nguyen Howell, MD, MBA [email protected] Chief Medical Officer, CAPG

Kelvin Yamashita [email protected] Account Executive, Sanofi U.S.

Provided by Sanofi U.S.

Bridgewater, NJ

Developed and produced by Forte Information Resources LLC

Denver, CO

www.forteinformation.com

Data provided by IMS Health

Parsippany, NJ

www.managedcaredigest.com

MANAGED CARE DIGEST SERIES

®

SINCE 1987

West RegionHealth Plan Demographics. . . . . . . . . . . 3

HMO Measures . . . . . . . . . . . . . . . . . . . 4–9

Medical Groups . . . . . . . . . . . . . . . . 10–11

Hospital Utilization . . . . . . . . . . . . . . . . . 12

Central RegionHealth Plan Demographics. . . . . . . . . . 13

HMO Measures . . . . . . . . . . . . . . . . . 14–19

Medical Groups . . . . . . . . . . . . . . . . 20–21


East RegionHealth Plan Demographics. . . . . . . . . . 23

HMO Measures . . . . . . . . . . . . . . . . . 24–29

Medical Groups . . . . . . . . . . . . . . . . 30–31


Diabetes . . . . . . . . . . . . . . . . . . . . . . 33–35

ADA/EASD Guidelines . . . . . . . . . . . . . . 36

Regional Definitions: Pages 2–32Central Arkansas, Illinois, Iowa, Kansas, Michigan, Minnesota, Nebraska, North Dakota, Texas and

Wisconsin

East Florida, Georgia, Kentucky, New Jersey, New York, North Carolina, Ohio, Pennyslvania, South Carolina and Tennessee

West Alaska, Arizona, California, Colorado, Montana, Nevada, New Mexico, Oregon, Utah and Washington

Regional Definitions: Pages 33–35Midwest Iowa, Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, North Dakota, Nebraska, Ohio,

South Dakota, Wisconsin

Northeast Connecticut, Massachusetts, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont

South Alabama, Arkansas, Washington, D.C., Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennesseee, Texas, Virginia, West Virginia

West Nevada, Alaska, Arizona, California, Colorado, Hawaii, Idaho, Mountana, New Mexico, Oregon, Utah, Washington, Wyoming

IntroductionCAPG is the largest physician association in the country and the voice of physician

organizations practicing capitated, coordinated care. CAPG’s membership comprises more than

180 multi-specialty medical groups and independent practice associations (IPAs) across 30 states

and Puerto Rico. Our members provide comprehensive health care through coordinated and

accountable physician groups and IPAs, successfully practicing this model for many years and

deploying effective risk-based contracts in commercial and Medicare Advantage plans.

We strongly believe that patient-centered, primary care-focused, coordinated and

accountable care offers the highest quality, the most efficient delivery mechanism and the

greatest value for our patients. CAPG organizational members have successfully operated

under this budget-responsible model for over two decades. Together with its member groups

and strategic partners, CAPG will continue driving the evolution, quality and transformation of

healthcare delivery across the nation.

We are pleased to present, alongside Sanofi, the inaugural 2014 CAPG National Health Care Data Summary, an overview of demographic, financial, utilization and pharmacy measures for

health plans, hospitals and medical group practices in key states with a CAPG presence. The 2014

Summary also provides regional Type 2 diabetes benchmarks that can help payers and providers

identify better opportunities to serve the needs of their patients. Independent, third-party data

are drawn from the Sanofi Managed Care Digest Series®.

The Summary is designed to provide organizations and employers with key information about

health plans, hospitals and medical group practices, and to promote the cost-effective delivery

of quality health care to the benefit of local communities.

The data in this report were gathered by IMS Health, Parsippany, NJ, a recognized leader in

the health care information market, providing comprehensive profiling solutions to health care

marketing business problems.

A review process takes place, before and during production of this report, between IMS Health

and Forte Information Resources LLC.

Sanofi, as sponsor of this report, maintains an arm’s-length relationship with the organizations

that prepare the Summary and carry out the research. The desire of Sanofi is that the information

in the Summary be completely independent and objective.

Managed Care digest series® National Health Care Data Summary 2014 3

WEST REGION

HEALTH INSURANCE EXCHANGE ENROLLMENT, 20143

MARKET Unsubsidized Subsidized Total

Arizona 27,368 92,703 120,071

California4 154,047 1,250,817 1,405,102

Colorado 50,774 74,628 125,402

Montana 5,132 31,452 36,584

Nevada 8,092 37,298 45,390

New Mexico 6,686 25,376 32,062

Oregon 13,645 54,663 68,308

Utah 11,174 73,427 84,601

Washington 40,972 122,235 163,207

NATION4 1,201,105 6,670,458 8,019,763

HEALTH PLAN DEMOGRAPHICS

Data source: IMS Health © 2014

HMO ENROLLMENT REBOUNDS IN FIVE STATES AFTER REGION-WIDE DECLINES

Even though total HMO

enrollment declined in eight

of the nine featured West

region states from 2011 to

2012 (Nevada excepted),

HMOs serving five of these

states—Arizona, Colorado,

New Mexico, Oregon and

Washington—recovered

portions of their lost enrollment

the following year.

GOVERNMENT ENROLLMENT EXPANDS IN HMOs SERVING MOST WEST REGION STATES

Government enrollment in

HMOs grew in seven of the

eight featured West region

states, excepting California,

from 2012 to 2013. Growth

rates for this type of member

surpassed the national annual

rate of 6.0% in Colorado

(30.1%), Nevada (7.8%),

New Mexico (8.2%) and

Washington state (13.8%).

2+ MILLION WESTERNERS ENROLL IN HEALTH INSURANCE EXCHANGES

As of April 19, 2014, 2.1 million

individuals across the nine

profiled West region states

enrolled in a plan offered

by a state or federal health

insurance exchange (25.9%

of national health insurance

exchange enrollment). Of

these, 1.8 million (84.7%)

enrolled using subsidies.

HMO ENROLLMENT

MARKET

2011 2012 2013

Total # of Enrollees

Avg. # of Enrollees


Avg. # of Enrollees


Avg. # of Enrollees

Arizona 1,768,275 147,356.3 1,662,105 127,854.2 1,710,633 142,552.8

California 15,705,930 392,648.3 15,385,780 452,523.0 14,588,150 429,063.3

Colorado 1,445,501 120,458.4 1,261,148 114,649.8 1,363,014 123,910.4

Montana 183,327 45,831.8 59,637 29,818.5 — —

Nevada 572,066 71,508.3 576,866 72,108.3 477,772 68,253.1

New Mexico 725,054 120,842.3 633,608 126,721.6 669,828 167,457.0

Oregon 750,157 107,165.3 632,666 105,444.3 652,260 108,710.0

Utah 1,101,414 275,353.5 915,299 183,059.8 903,482 150,580.3

Washington 1,915,195 191,519.5 1,693,465 153,951.4 1,783,194 178,319.4

NATION 79,478,570 179,815.8 80,545,040 187,314.0 80,056,080 182,776.4

1 Federal Employees Health Benefit Program2 Government enrollees include Medicare Risk, Medicare Cost, Medicaid and Federal Employees Health Benefit Program

(FEHBP) members.3 Data are from the U.S. Department of Health and Human Services and reflect figures from October 1, 2013, through April 19, 2014.4 Total health insurance exchange enrollment includes individuals whose subsidy status is unknown.

NOTE: Throughout this Data Summary, data include all HMOs serving the profiled states. In some cases, HMOs did not report their data. There were no HMOs serving the state of Alaska, and some data were unavailable for the selected markets.

Data source: U.S. Department of Health and Human Services © 2014

ENROLLMENT OF HMOs WITH GOVERNMENT BENEFICIARIES

MARKET

Medicare Medicaid FEHBP1 Total Government Enrollees2

2012 2013 2012 2013 2012 2013 2012 2013

Arizona 511,935 499,054 339,748 408,763 23,226 18,693 874,909 926,510

California 1,838,243 2,014,867 4,396,457 4,047,805 333,135 315,402 6,567,835 6,378,074

Colorado 165,589 228,421 35,350 37,286 28,537 32,898 229,476 298,605

Nevada 120,321 152,568 172,660 191,576 38,711 13,260 331,692 357,404

New Mexico 59,869 59,472 382,827 422,895 25,283 24,117 467,979 506,484

Oregon 139,399 149,018 79,389 80,529 18,939 21,847 237,727 251,394

Utah 56,369 66,248 137,829 139,979 26,334 21,497 220,532 227,724

Washington 279,184 306,975 456,116 537,689 60,744 61,414 796,044 906,078

NATION 8,624,740 9,602,636 26,862,850 28,177,990 1,419,562 1,328,414 36,907,160 39,109,036

Health Insurance Exchanges


WEST REGION

UTILIZATION RATES FOR COMMERCIAL HMO/POS MEMBERS1

Hospital Admissions per 1,000 Members

Hospital Days per 1,000 Members

ALOS per Hospital

Admission

Physician Encounters

per Member

Ambulatory Visits per Member2

MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013

Arizona 57.1 55.8 226.1 227.2 3.9 4.1 4.0 5.3 1.8 2.3

California 56.7 58.2 205.1 210.3 3.6 3.6 3.7 4.3 1.5 2.1

Colorado 39.3 41.6 155.7 166.5 4.0 4.0 4.9 4.9 1.4 1.5

Nevada 56.5 57.2 215.4 199.9 3.7 3.5 5.5 4.5 1.9 0.9

New Mexico 63.7 61.3 275.0 279.6 3.9 4.1 5.2 5.0 2.7 2.5

Oregon 42.7 40.3 145.5 154.7 3.4 3.9 3.2 3.8 1.4 1.9

Utah 55.0 53.3 209.7 195.0 3.8 3.7 4.7 5.0 1.6 1.8

Washington 39.6 41.6 136.0 166.2 3.5 4.0 3.0 3.9 1.9 1.9

NATION 58.4 58.0 239.1 246.9 4.2 4.3 4.7 4.7 1.7 1.9

COMMERCIAL: HMO/HOSPITAL MEDICAL UTILIZATION

DAYS/1,000 COMMERCIAL MEMBERS RATIO IN THE WEST REGION LAGS THAT OF THE U.S.

For seven of the eight profiled

West region states (New

Mexico excluded), there were

fewer hospital days per 1,000

commercial members than

the corresponding national

average of 246.9 in 2013. This

occurred despite a minor

increase in this measure for

six of the eight profiled states

from 2012 to 2013.

ALOS IS LOW VS. U.S. AVG. FOR WEST REGION STATES

Average lengths of stay (ALOS)

per hospital admission for

commercial members of HMOs

serving any of the eight West

region states featured were

less than the national average

for such patients (4.3 days) in

2013. Nevada (3.5 days) plans

recorded the lowest average

among these states, followed

by California (3.6 days). Data source: IMS Health © 2014

NUMBER OF HOSPITAL ADMISSIONS PER 1,000 COMMERCIAL HMO/POS MEMBERS, 20131

Arizona California Colorado Nevada New Mexico Oregon Utah Washington Nation0

16

32

48

64

Ho

spita

l Ad

miss

ion

s

55.858.2

41.6

57.261.3

40.3

53.3

41.6

58.0

AVERAGE LENGTH OF STAY PER HOSPITAL ADMISSION, COMMERCIAL HMO/POS MEMBERS, 20131

1

2

3

4

5

Ave

rag

e L

en

gth

of S

tay

(Da

ys)

4.1

3.6

4.0

3.5

4.13.9

3.7

4.0

4.3

Arizona California Colorado Nevada New Mexico

Oregon Utah Washington Nation

1 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s office

that do not require the services of a physician. Such visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory.

NOTE: HMO hospital/medical utilization data were unavailable for Montana.


WEST REGION

0

2

4

6

8

Ave

rag

e L

en

gth

of S

tay

(Da

ys)

4.3 4.2

2.9

3.9

3.3

6.0

3.3

5.1

4.4



MEDICAID HOSPITAL ADMIT RATIOS ARE LOW FOR MOST WEST REGION STATES

In five of the eight profiled

states, the numbers of hospital

admissions per 1,000 Medicaid

HMO members were below

the national mean of 98.8 in

2013. Of these eight states,

Nevada HMOs recorded the

lowest hospital admissions ratio

in 2013, at 74.0, followed by

those serving California (81.1).

ALOS IS BELOW U.S. AVG. FOR MEDICAID HMO HOSPITAL ADMITS IN MOST WEST STATES

Average lengths of stay

(ALOS) for Medicaid member

hospital admissions were lower

than the overall national

average in 2013 for HMOs

serving six of the eight states

shown. For example, ALOS

per Medicaid HMO hospital

admission was 2.9 days in

Colorado, 34.1% lower than

the overall national average

of 4.4 days.


NUMBER OF HOSPITAL ADMISSIONS PER 1,000 MEDICAID HMO MEMBERS1

0

50

100

150

200

Ho

spita

l Ad

miss

ion

s

—186.7—

86.8 81.1

134.0 136.0

82.374.0

102.990.5

61.8

93.0

75.1

—

55.5

96.5 97.6 98.8

2012 2013

Arizona California Colorado Nevada New Mexico Oregon Utah Washington Nation

AVERAGE LENGTH OF STAY PER HOSPITAL ADMISSION, MEDICAID HMO MEMBERS, 20131

MEDICAID: HMO/HOSPITAL MEDICAL UTILIZATION

UTILIZATION RATES FOR MEDICAID HMO MEMBERS1



ALOS per Hospital

Admission


per Member


MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013

Arizona 186.7 186.7 — — 4.3 4.3 — — — —

California 86.8 81.1 296.2 325.0 3.9 4.2 3.6 4.0 1.2 1.8

Colorado 134.0 136.0 381.0 395.0 2.8 2.9 — — — —

Nevada 82.3 74.0 298.8 287.0 3.7 3.9 1.9 4.8 1.4 1.5

New Mexico 102.9 90.5 431.5 298.4 4.7 3.3 6.1 3.9 2.9 2.8

Oregon 61.8 93.0 249.5 551.2 4.0 6.0 2.0 — 1.3 3.8

Utah 75.1 — 270.3 534.3 3.6 3.3 4.0 5.0 2.6 3.1

Washington 55.5 96.5 221.1 498.8 4.1 5.1 2.6 4.9 1.7 3.7

NATION 97.6 98.8 380.5 395.3 4.2 4.4 4.4 4.6 2.3 2.6



NOTE: Some data were unavailable for the selected markets.


WEST REGION

MA ENROLLMENT EXPANDS AT A RAPID PACE IN WEST REGION STATES AND U.S.

In all 10 profiled states,

Medicare Advantage (MA)

enrollment expanded from

2011 to 2013; all but two

states—Arizona and Utah—

recorded double-digit growth

in this measure. Nationally, the

growth rate for MA enrollment

was 18.2% during this time, a

rate that was outstripped in

Alaska and New Mexico.

MEDICARE ADVANTAGE PENETRATION, WEST REGION, 20131,2

Data source: Centers for Medicare and Medicaid Services and IMS Health © 2014

MEDICARE ADVANTAGE ENROLLMENT/PENETRATION1,2

2011 2012 2013

MARKET Enrollment Penetration Enrollment Penetration Enrollment Penetration

Alaska 41 0.1% 18 0.0% 79 0.1%

Arizona 359,889 37.2 378,636 37.4 391,070 37.0

California 1,766,531 35.5 1,899,968 36.7 2,032,183 38.0

Colorado 225,202 34.0 237,047 34.0 260,998 35.6

Montana 26,503 15.0 25,088 13.6 30,741 16.1

Nevada 118,696 31.5 121,819 30.7 133,754 32.1

New Mexico 88,062 26.9 95,079 27.9 106,103 30.1

Oregon 266,123 41.0 281,653 41.5 301,867 42.8

Utah 103,185 34.7 98,530 31.7 107,709 33.2

Washington 276,743 27.1 293,407 27.4 320,668 28.8

NATION 12,454,064 25.7% 13,278,369 26.4% 14,724,574 28.4%

HI45.3%AK

0.1%

CA38.0%

OR42.8%

WA28.8%

UT33.2%

MT16.1%

NATION: 28.4%

CO35.6%

AZ37.0% NM

30.1%

NV32.1%

South CentralRegion

CA38.0%

MD8.6%

MEDICARE ADVANTAGE

1 MA enrollment includes members of HMOs, PPOs, private fee-for-service (PFFS) plans and other plan types.2 The penetration rate reflects the percentage of the Medicare population enrolled in Medicare Advantage plans.


WEST REGION

HMO/HOSPITAL UTILIZATION AND COST MEASURES

Commercial HMO Hospital Days/1,000

Medicare HMO Hospital Days/1,000

Medicare Fee-for-Service

Discharges/1,0003


Hospital Days/1,0003

Medicare Fee-for-Service Payments per

Hospital Discharge3


Payments per Enrollee3

MARKET 2011 2012 2011 2012 2011 2012 2011 2012 2011 2012 2011 2012

Arizona 243 226 1,556 1,325 283 263 1,348 1,236 $10,844 $11,201 $2,967 $2,808

California 199 224 1,156 1,046 277 264 1,508 1,415 13,930 14,526 3,712 3,624

Colorado 175 156 1,155 1,082 256 240 1,193 1,124 10,179 10,716 2,553 2,502

Montana 194 — 1,830 2,312 202 196 942 926 10,115 10,621 1,966 1,949

Nevada 219 215 1,390 1,255 278 264 1,572 1,497 11,164 11,663 3,022 2,936

New Mexico 234 275 1,518 1,545 239 229 1,188 1,125 10,319 10,695 2,411 2,368

Oregon 165 146 1,035 840 208 200 955 902 11,352 11,679 2,337 2,248

Utah 176 210 2,223 1,406 238 233 1,020 982 9,847 10,089 2,259 2,230

Washington 157 136 891 1,043 238 233 1,130 1,099 11,047 11,527 2,601 2,616

NATION 236 239 1,643 1,602 323 307 1,734 1,634 $10,362 $10,674 $3,281 $3,176

MEDICARE MD UTILIZATION RATES RISE FOR MANY WEST REGION STATES IN 2013

In Arizona, Colorado,

Nevada, Oregon, Utah

and nationally, Medicare

HMO members visited their

physicians more often in 2013

than in 2012. Furthermore,

such members in Arizona,

Colorado, New Mexico and

Utah encountered physicians

more often than their peers

nationwide in 2013.

HOSPITAL UTILIZATION RATIOS ARE LOW FOR HMOs IN MUCH OF THE WEST REGION

Hospital admissions per 1,000

Medicare members ratios were

below the U.S. average of

275.6 for HMOs serving seven

of the eight profiled West

region states in 2013 (Nevada

excepted). Medicare hospital

days ratios for all of these

states were also low versus the

overall U.S. mean.

MEDICARE: HMO/HOSPITAL MEDICAL UTILIZATION


UTILIZATION RATES FOR MEDICARE MEMBERS1



ALOS per Hospital

Admission


per Member


MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013

Arizona 249.6 258.5 1,325.2 1,498.1 5.3 5.8 10.5 11.7 4.6 3.6

California 215.4 221.9 1,045.6 1,184.7 5.2 5.5 8.4 8.2 3.5 4.0

Colorado 182.9 193.2 1,082.1 1,347.3 5.9 6.8 10.8 12.2 3.1 4.5

Montana 262.7 — 2,311.8 — 8.8 — — — 6.8 —

Nevada 250.5 283.0 1,255.3 1,238.4 5.2 4.5 9.0 10.2 3.6 4.3

New Mexico 185.9 229.1 1,545.4 1,389.4 7.6 6.0 11.2 10.7 7.2 6.0

Oregon 193.3 183.6 839.8 958.2 4.5 5.1 6.4 7.3 3.5 3.9

Utah 225.8 230.4 1,406.4 1,496.2 6.1 6.3 11.5 11.8 7.7 7.6

Washington 203.6 201.1 1,042.8 1,160.4 4.7 5.2 8.5 8.5 4.6 3.5

NATION 265.8 275.6 1,602.4 1,727.1 6.1 6.3 9.9 10.4 4.4 4.5

NUMBER OF HOSPITAL ADMISSIONS PER 1,000 MEDICARE HMO MEMBERS, 20131


Oregon Utah Washington Nation0

75

150

225

300

Ho

spita

l Ad

miss

ion

s

258.5

221.9

193.2

283.0

229.1

183.6

230.4

201.1

275.6

Managed Care vs. Fee-for-Service MeasuresData source: IMS Health © 2014

1 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s office that do not require the services of a physician. Such

visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory.3 Discharges, hospital days per 1,000, payments per hospital discharge and payments per enrollee for Medicare fee-for-service come from the Medicare and Medicaid Research

Review Statistical Supplement.

NOTE: Some utilization data were unavailable for the selected markets.


WEST REGION


HMO PREMIUMS

INDIVIDUAL PREMIUMS TRAIL NATION IN AZ, CO, NM AND WA

Compared with the U.S.

average of $531.82, individual

premiums were lower at plans

serving Arizona, Colorado,

New Mexico and Washington.

Family premiums were below

the U.S. average in Colorado,

Nevada, New Mexico and

Utah. Premiums increased in

all markets (excepting New

Mexico) from 2011 to 2013.

CA HMO MEMBERS PAY LESS THAN U.S. AVG. FOR RX PREMIUMS

Individual ($34.56) and

family ($95.88) members of

HMOs serving the state of

California had lower monthly

premiums for outpatient

pharmacy benefits than such

members in plans across the

nation in 2013 ($40.71 and

$103.04, respectively).

Arizona California Colorado Montana Nevada New Mexico Oregon Utah Washington Nation$200

$315

$430

$545

$660

Avg

. In

div

idu

al P

rem

ium

($)

$468

$526$510

$595

$451

$491

$358

$587

$515

$557

$494 $494

$542

$592

$460

$552

$497

$527

$486

$532

2012 2013

AVERAGE INDIVIDUAL PREMIUM PER MONTH1

AVERAGE PREMIUM RATES PER MONTH1

Average Individual Premium Average Family Premium

MARKET 2011 2012 2013 2011 2012 2013

Arizona $446.44 $468.46 $526.11 $1,162.01 $1,192.80 $1,339.17

California 472.01 509.96 595.48 1,231.85 1,350.67 1,456.56

Colorado 451.16 450.64 491.38 1,151.41 1,143.52 1,209.37

Montana 521.98 357.50 587.00 1,282.98 1,327.00 1,327.00

Nevada 461.09 515.42 556.69 1,138.13 1,187.72 1,293.80

New Mexico 503.59 493.84 493.84 1,239.98 1,201.44 1,201.44

Oregon 473.95 541.79 591.62 1,237.62 1,396.47 1,367.88

Utah 452.37 459.61 551.86 1,026.35 1,048.54 1,194.24

Washington 433.96 497.01 526.91 1,170.72 1,349.29 1,332.14

NATION $464.75 $486.48 $531.82 $1,189.17 $1,237.31 $1,313.03

PREMIUMS PER MEMBER PER MONTH FOR OUTPATIENT PHARMACY BENEFITS


MARKET 2012 2013 2012 2013

Arizona $37.32 $37.32 $109.78 $109.78

California 34.56 34.56 95.88 95.88

Colorado 43.98 43.98 115.76 115.76

Nevada 47.29 48.63 116.72 133.07

New Mexico 37.00 37.00 117.50 117.50

Oregon 40.48 40.48 — —

Utah 44.62 44.62 100.36 100.36

Washington 50.74 50.74 184.00 184.00

NATION $40.21 $40.71 $101.80 $103.04

1 Averages represent the flat charge for medical health coverage and do not include charges for pharmacy, dental or other services. Also, employee contributions are not included. Numbers of options and levels of coverage may account for significant differences between an individual company’s premium rates and the average.

NOTE: Outpatient pharmacy premium data were unavailable for Montana; some data were unavailable for the selected markets.


WEST REGION

1 This average is derived by dividing HMO pharmacy expenses by the total number of prescriptions dispensed. Expenses do not include administration or copayment costs.

2 Rounded to the nearest dollar. Expenditures do not include administration and copayment costs.


HMO PHARMACY UTILIZATION AND EXPENDITURES

PRESCRIPTIONS DISPENSED PER COMMERCIAL HMO MEMBER PER YEAR

6

7

8

9

10

Ave

rag

e R

xs/P

MPY

8.88.6

—7.7—

8.58.4

—6.3—

8.4

8.1

—8.9—

8.1

7.8

8.6

8.38.1

7.8

9.1 9.0

2012 2013

Arizona California Colorado NevadaMontana New Mexico



INGREDIENT COSTS PER RX FALL IN MOST WEST REGION STATES, ARE LOWEST IN CA

From 2011 to 2013, average

ingredient costs for

prescriptions dispensed by

HMOs serving eight of the nine

profiled states (Washington

excepted) declined, and

were lowest, by state, in

California ($43.51) in 2013. Five

of the profiled states recorded

such costs that were below

the U.S. average in 2013.

RX FILL RATES DIP FOR COMMERCIAL HMOs IN MOST WEST REGION STATES

On average, commercial

members of HMOs serving

six of the nine profiled West

region states filled fewer

prescriptions in 2013 than they

did in 2012, while fill rates for

such members in the other

three states held steady.

In 2013, commercial HMO

members in Montana filled just

6.3 prescriptions per year.

RX COST PORTION OF HMO OPERATING EXPENSES IS LOW IN WEST REGION STATES

In 2013, the portions of

operating expenses devoted

to drug costs were lower

than the U.S. rate (14.7%) for

HMOs serving eight of the nine

profiled West region states

(Colorado excluded). From

2012 to 2013, per-member

per-year drug expenses fell

for HMOs serving California,

Montana and New Mexico.

PRESCRIPTIONS DISPENSED AND AVERAGE INGREDIENT COST1

Rxs Dispensed per Commercial HMO Member per Year Average Ingredient Cost

MARKET 2011 2012 2013 2011 2012 2013

Arizona 9.2 8.8 8.6 $60.29 $57.54 $55.32

California 8.5 7.7 7.7 51.10 43.26 43.51

Colorado 8.7 8.5 8.4 61.73 55.62 56.05

Montana 7.1 6.3 6.3 66.98 51.00 51.00

Nevada 8.7 8.4 8.1 63.49 58.09 58.17

New Mexico 9.1 8.9 8.9 60.56 54.63 54.63

Oregon 8.8 8.1 7.8 70.85 59.32 61.24

Utah 9.0 8.6 8.3 68.73 65.52 66.80

Washington 8.8 8.1 7.8 60.64 59.32 61.24

NATION 9.4 9.1 9.0 $58.95 $55.73 $56.70

HMO DRUG EXPENDITURES

Drug Costs as a Percentage of Operating Expenses

Expenditures per Member per Year for Drugs2

MARKET 2011 2012 2013 2011 2012 2013

Arizona 12.5% 12.2% 12.4% $511 $558 $671

California 12.8 12.4 12.4 518 578 531

Colorado 14.1 14.4 15.3 485 524 605

Montana 13.7 14.5 13.0 672 831 —

Nevada 13.7 13.9 14.3 546 576 654

New Mexico 11.3 11.8 13.0 436 474 411

Oregon 12.0 11.3 11.5 704 693 712

Utah 12.3 11.6 12.3 450 504 505

Washington 12.7 11.6 12.0 631 643 682

NATION 13.9% 14.5% 14.7% $578 $605 $609


WEST REGIONMEDICAL GROUPS: DEMOGRAPHICS


NUMBER OF MEDICAL GROUPS WITH FIVE OR MORE FTE PHYSICIANS, 2013

SIZE (# of MDs)Alaska Arizona Califor-

niaColo-rado Montana Nevada New

Mexico Oregon Utah Washing-ton NATION

5–6 7 89 499 106 25 32 42 94 41 169 5,729

7–9 14 43 339 61 16 32 20 87 26 97 3,266

10–14 4 20 222 29 15 12 14 36 20 66 1,786

15–19 3 11 81 9 3 6 5 7 9 25 630

20+ 2 16 233 32 4 10 3 36 14 57 1,478

TOTAL 30 179 1,374 237 63 92 84 260 110 414 12,889

SPECIALTY COMPOSITION

Single Specialty 15 100 545 161 23 50 41 150 48 222 7,161

Multispecialty 15 79 829 76 40 42 43 110 62 192 5,728

AVG. VISITS PER WEEK

Under 250 3 8 106 19 8 3 5 16 8 33 1,029

250–499 6 24 163 27 16 13 10 35 20 54 2,052

500–749 3 29 156 40 8 14 14 47 10 53 2,022

750+ 9 38 231 51 21 16 19 51 33 84 2,728

Unknown 9 79 697 100 9 46 34 110 38 180 4,932

TOTAL 30 179 1,374 237 63 92 84 260 110 414 12,889

PERCENTAGE OF MEDICAL GROUP PRACTICES BY AFFILIATION

Corporate Affiliation Independent

MARKET 2012 2013 2012 2013

Alaska 23.3% 23.3% 76.7% 76.7%

Arizona 29.2 29.1 70.8 70.9

California 43.1 43.4 56.9 56.6

Colorado 35.7 35.9 64.3 64.1

Montana 35.5 36.5 64.5 63.5

Nevada 29.3 29.3 70.7 70.7

New Mexico 51.8 51.2 48.2 48.8

Oregon 39.0 38.8 61.0 61.2

Utah 39.4 39.1 60.6 60.9

Washington 44.3 45.7 55.7 54.3

NATION 42.7% 42.7% 57.3% 57.3%

PERCENTAGE OF MEDICAL GROUP PRACTICES BY SPECIALTY, 2013

0%

20%

40%

60%

80%

Perc

en

tag

e o

f Gro

up

s

—50.0%—55.9%

44.1%39.7%

60.3%

67.9%

32.1%36.5%

63.5%

54.3%

45.7%

48.8%

51.2%

57.7%

42.3%

43.6%

56.4%53.6%

46.4%

55.6%

44.4%

Single Specialty Multispecialty

ArizonaAlaska Califor-nia

Colo-rado

NevadaMon-tana

New Mexico

Oregon Utah Wash-ington

Nation

WEST REGION GROUP PRACTICE SIZES MIRROR NATIONAL DISTRIBUTION

Apart from Alaska and

Nevada, medical group

practice sizes in the West

region, by number of FTE

physicians, followed the same

distribution as those of their

national counterparts. The

highest numbers of medical

groups in eight of 10 profiled

states were comprised of five

to six physicians, followed by

medical groups with seven to

nine physicians. Alaska was

the only state with more groups

of seven to nine physicians

than any other FTE range.

FOUR STATES HAVE LARGER SHARES OF MULTI- VERSUS SINGLE-SPECIALTY GROUPS

California, Montana, New

Mexico and Utah had higher

percentages of multispecialty

medical group practices

than single-specialty medical

group practices in 2013.

Nationally, 55.6% of medical

groups were single specialty.

HIGH SHARES OF WEST REGION PRACTICES ARE INDEPENDENT VS. U.S. AVG.

In 2013, the percentages

of medical group practices

with no corporate affiliation

were higher in Alaska (76.7%),

Arizona (70.9%), Colorado

(64.1%), Montana (63.5%),

Nevada (70.7%), Oregon

(61.2%) and Utah (60.9%) than

the national average of 57.3%.

New Mexico reported the

highest share of corporate-

affiliated practices (51.2%).

NOTE: IMS Health defines the medical groups represented on pages 10–11 of this Data Summary as those with five or more full-time equivalent (FTE) physicians whose primary business is seeing regularly scheduled patients for nonsurgical services other than imaging. Physicians must have a share in the practice and offer outpatient care, and the practice must be physically separate from a hospital. Anesthesiology and pathology groups are excluded.


WEST REGION

PERCENTAGE OF MEDICAL GROUPS, BY TYPE OF SERVICE

Groups That Perform Surgery (%)

Groups That Have Clinical Labs (%)

Groups That Offer Imaging Services (%)

MARKET 2012 2013 2012 2013 2012 2013

Alaska 58.6% 58.6% 68.2% 68.2% 64.3% 64.3%

Arizona 60.6 60.9 44.0 43.6 64.6 64.9

California 52.5 52.7 40.7 40.7 54.3 54.4

Colorado 67.3 67.3 47.5 47.5 62.8 62.8

Montana 61.4 62.1 69.4 67.6 78.0 78.4

Nevada 42.5 42.5 41.8 41.8 65.8 65.8

New Mexico 58.9 59.5 56.4 54.5 63.9 63.0

Oregon 65.5 65.7 56.9 57.1 64.5 64.6

Utah 77.3 77.6 62.7 61.9 65.9 66.3

Washington 67.8 68.1 58.5 58.8 69.3 69.7

NATION 54.7% 54.3% 49.8% 49.5% 64.5% 64.0%

SHARES OF GROUPS THAT PERFORM SURGERY ARE HIGH IN MOST WEST REGION STATES

The percentages of medical

group practices that perform

surgery were higher in eight of

10 profiled West region states

in 2013 than that of the nation

(54.3%). Utah state had the

highest share of such group

practices (77.6%), by profiled

West region state, followed

by Washington state (68.1%),

Colorado (67.3%) and

Oregon (65.7%).

MT HAS HIGHEST SHARE OF WEST REGION GROUP PRACTICES WITH RX SERVICES

Of the 10 profiled West region

states, Montana (73.0%)

had the highest share of

medical group practices with

pharmacy services in 2013,

while Nevada (37.7%) had the

lowest. Alaska (40.9%), Arizona

(45.5%) and Colorado’s (49.4%)

shares were also under 50%.

HIGH SHARES OF WEST REGION GROUPS OFFER FULL PHARMACY VS. NATION

In eight of 10 West region

states, higher percentages


offered full pharmacy services

than their counterparts

nationwide (18.9%) in 2013.

That year, medical group

practices in Alaska (44.4%)

and Arizona (44.0%) offered

such services at more than

double the national rate.

MEDICAL GROUPS: SERVICES

1 Medical groups with full pharmacies offer a complete range of medication types; those with limited pharmacy services offer a smaller range, often in particular therapeutic classes; others provide patients only with samples of medications.

NOTE: Some medical group practice data were unavailable for the selected states.


PERCENTAGE OF MEDICAL GROUPS, BY TYPE OF PHARMACY SERVICE1

Full Pharmacy Limited Pharmacy Samples

MARKET 2012 2013 2012 2013 2012 2013

Alaska 44.4% 44.4% 22.2% 22.2% 33.3% 33.3%

Arizona 44.9 44.0 6.1 8.0 51.0 52.0

California 33.4 33.1 17.5 17.9 51.3 51.2

Colorado 21.8 21.8 16.1 16.1 64.4 64.4

Montana 15.4 14.8 3.8 3.7 84.6 85.2

Nevada 15.0 15.0 10.0 10.0 80.0 80.0

New Mexico 34.5 35.7 17.2 14.3 51.7 53.6

Oregon 20.9 20.9 6.6 6.6 72.5 72.5

Utah 22.9 22.9 — — 77.1 77.1

Washington 32.7 32.9 8.0 7.9 61.3 61.2

NATION 18.4% 18.9% 9.7% 10.0% 75.0% 74.3%

0%

20%

40%

60%

80%

Perc

en

tag

e o

f Gro

up

s

—40.9%—45.0%

45.5% 50.4%50.5%

—49.4%—

72.2%73.0%

—37.7%—

51.8%50.0% 58.0%

57.6%58.5%

57.8%

53.0%53.3% 60.7%

60.2%

2012 2013

ArizonaAlaska Califor-nia

Colo-rado

NevadaMon-tana

New Mexico

Oregon Utah Wash-ington

Nation

PERCENTAGE OF MEDICAL GROUPS WITH PHARMACY SERVICES


WEST REGIONHOSPITAL UTILIZATION

SELECTED UTILIZATION STATISTICS FOR HOSPITALS, 20121

MEASUREAlaska Arizona Califor-

niaColo-rado

Mon-tana Nevada New

Mexico Oregon Utah Wash-ington NATION

Total Facility Admissions per Hospital

2,696 10,569 8,813 5,110 1,683 7,727 4,977 5,697 5,743 6,987 7,143

Total Facility Patient-Days per Hospital

18,360 44,743 43,482 26,325 7,803 37,269 24,325 22,490 22,546 28,755 35,791

Total FacilityALOS perHospital

10.9 4.1 5.6 6.2 3.6 4.2 4.2 3.3 3.8 3.6 5.3

Inpatient Surg./ Staffed Bed 10.9 17.0 11.5 10.4 11.5 13.3 12.1 17.2 12.0 14.5 11.8

Outpatient Surg. per Day 6.1 9.5 9.1 5.6 3.8 9.8 8.0 10.8 10.8 9.8 10.6

Outpatient Surg. as a Percentage of Total Surg.

77.1% 57.2% 56.8% 67.5% 75.9% 63.9% 68.6% 71.3% 73.9% 67.4% 70.9%

SELECTED FINANCIAL RATIOS FOR HOSPITALS (IN THOUSANDS), 2012MEASURE Alaska Arizona California Colorado Montana Nevada New Mexico Oregon Utah Washington NATION

Total Costs/Occupied Bed $1,726.8 $2,017.2 $1,926.9 $2,398.8 $3,048.1 $2,165.3 $2,369.8 $3,057.4 $2,188.5 $2,795.6 $1,847.4

Total Costs/Admission 36.9 19.5 24.1 30.3 34.7 23.2 25.3 29.5 20.6 26.7 22.3

Total Costs/ Patient-Day 4.7 5.5 5.3 6.6 9.2 5.9 6.5 8.7 6.5 7.8 5.2

Labor Costs/Patient-Day 1.9 2.3 2.5 2.6 3.0 2.1 2.5 3.5 2.3 3.1 2.1

Salary Costs/FTE4 66.8 65.9 83.4 61.6 54.9 67.8 61.5 72.5 54.9 68.8 57.4

Total Costs/FTE4 174.1 176.8 206.3 164.9 135.4 203.3 169.8 175.1 161.5 167.2 152.7


TOTAL FACILITY ADMITS FOR AZ, CA AND NV HOSPITALS EXCEED U.S. AVERAGE

Compared with the national

mean of 7,143, the average

hospital in Arizona (10,569),

California (8,813) and Nevada

(7,727) reported a higher

number of total facility

admissions per hospital in

2012. Of the 10 states profiled,

Montana reported the fewest

total facility admissions per

hospital in 2012, at 1,683,

less than a quarter of the

national average that year.

PATIENT-DAY AVERAGES TRAIL U.S. IN MOST OF THE PROFILED WEST REGION STATES

In seven of the 10 featured

West region states, hospitals

recorded fewer total facility

patient-days than the national

average of 35,791 in 2012.

ALOS TRAILS NATION FOR MOST WEST HOSPITALS

For 12 of the 14 West region

hospital systems shown,

average length of stay trailed

the national average of

5.3 days in 2012.

1 Total facility figures reflect all portions of the hospital’s occupancy.2 Hospital All-Cause Readmission Rate figures come from the Centers for Medicare and Medicaid Services Hospital Compare database and are measured from July 2012 through

June 2013. Unless otherwise noted, scores are averaged across all facilities within the specified system.3 The figures listed are for an individual hospital, rather than an average.4 “FTE” is full-time equivalent.

NOTE: Hospital utilization data represent patients of all payer types.

SELECTED UTILIZATION MEASURES, CAPG AND CATHOLIC HEALTH INITIATIVES AFFILIATES, 20121

SYSTEM NAME

Number of Staffed Beds

Average Number

of Hospital Admissions

Average Total Facility Occupancy

Average Length of

Stay (Days)

All-Cause Readmission

Rate2

Catholic Health Initiatives 131.6 6,808.1 50.3% 5.1 15.1%

Cedars-Sinai Medical Center3 957 49,190 76.2 5.4 16.3

Centura Health 93.0 5,184.0 55.2 4.2 14.1

Dignity Health 246.6 11,083.4 55.0 4.1 15.3

Franciscan Health System 132.8 9,810.6 65.9 3.3 15.2

MemorialCare 249.2 11,660.7 51.9 4.3 15.8

Orange Coast Memorial Medical Center3 218 12,326 56.4 3.6 16.1

Presbyterian Intercommunity Hospital3 444 18,991 52.0 4.1 15.0

Providence Health and Services 223.5 11,077.1 56.2 4.0 14.8

Scripps Health 272.2 14,279.6 64.9 4.2 14.7

Sharp HealthCare 395.7 15,351.7 67.5 4.8 15.6

St. Joseph Health System 195.7 8,926.8 49.3 4.8 14.9

Sutter Health 178.5 6,989.4 47.6 4.1 14.9

UCLA Healthcare 401.0 19,095.5 78.6 6.0 17.2

NATION 150.4 7,142.9 48.5% 5.3 15.6%


CENTRAL REGIONHEALTH PLAN DEMOGRAPHICS

HEALTH INSURANCE EXCHANGE ENROLLMENT, BY STATE, 20143


Arkansas 4,392 39,054 43,446

Illinois 49,307 168,185 217,492

Iowa 4,678 24,485 29,163

Kansas 12,144 44,869 57,013

Michigan 35,202 237,337 272,539

Minnesota — — 48,495

Nebraska 5,528 37,447 42,975

North Dakota 1,596 9,001 10,597

Texas 119,131 614,626 733,757

Wisconsin 12,824 126,991 139,815

NATION4 1,201,105 6,670,458 8,019,763


NUMBER OF HMO ENROLLEES INCREASES IN FOUR CENTRAL REGION STATES

From 2011 to 2013, the total

number of HMO enrollees

rose in four of the 10 profiled

states: Arkansas (0.9%),

Kansas (15.3%), North Dakota

(3.6%) and Wisconsin (31.4%).

Nationally, enrollment grew

0.7%. Minnesota recorded the

largest average number of

enrollees per plan in 2013, at

406,012.2; the smallest was in

Nebraska (76,065.0).

NUMBERS OF GOVERNMENT HMO ENROLLEES CLIMB IN SIX FEATURED STATES

Of the six profiled Central

region states that recorded

an increase in total HMO

government enrollees from

2012 to 2013, Arkansas noted

the largest rise (30.9%),

followed by Iowa (25.0%),

Wisconsin (15.1%), North

Dakota (5.6%), Michigan

(3.8%) and Texas (0.4%).

Nationally, the number of

HMO government enrollees

climbed 6.0%. Four states

recorded decreases in the

total number of government

HMO enrollees from 2012 to

2013: Illinois (15.5%), Kansas

(30.9%), Minnesota (3.9%)

and Nebraska (20.8%).

HMO ENROLLMENT

MARKET

2011 2012 2013


Avg. # of Enrollees


Avg. # of Enrollees


Avg. # of Enrollees

Arkansas 459,904 114,976.0 342,051 85,512.8 463,898 92,779.6

Illinois 2,200,647 104,792.7 2,359,665 117,983.3 2,194,005 121,889.2

Iowa 1,095,660 109,566.0 922,555 92,255.5 970,702 88,245.6

Kansas 919,599 102,177.7 1,337,784 133,778.4 1,060,184 151,454.9

Michigan 3,321,865 168,992.9 3,867,310 203,542.6 3,078,994 181,117.3

Minnesota 2,455,238 272,804.2 2,563,620 256,362.0 2,436,073 406,012.2

Nebraska 358,522 119,507.3 319,784 79,946.0 228,195 76,065.0

North Dakota 889,977 296,659.0 895,256 298,418.7 922,232 307,410.7

Texas 4,598,372 131,382.1 4,251,927 128,846.3 4,114,855 128,589.2

Wisconsin 3,409,547 162,359.4 4,279,480 203,784.8 4,481,408 213,400.4

NATION 79,478,570 179,815.8 80,545,040 187,314.0 80,056,080 182,776.4



MARKET


2012 2013 2012 2013 2012 2013 2012 2013

Arkansas 62,430 74,627 — — — 7,738 62,906 82,365

Illinois 278,201 187,898 198,548 219,341 28,368 19,703 505,117 426,942

Iowa 146,162 157,355 126,379 188,154 12,384 10,566 284,925 356,075

Kansas 65,009 62,653 501,250 324,808 14,054 13,431 580,313 400,892

Michigan 208,491 234,811 1,352,804 1,390,726 44,596 42,091 1,605,891 1,667,628

Minnesota 325,024 340,404 491,134 442,918 3,078 4,011 819,236 787,333

Nebraska 16,559 11,554 180,269 144,317 — — 196,828 155,871

North Dakota 142,853 158,574 113,436 112,034 146 152 256,435 270,760

Texas 533,244 595,093 2,429,209 2,379,699 18,806 17,508 2,981,259 2,992,300

Wisconsin 455,477 506,495 863,543 1,014,329 15,883 16,167 1,334,903 1,536,991

NATION 8,624,740 9,602,636 26,862,850 28,177,986 1,419,562 1,328,414 36,907,160 39,109,036


1 Federal Employees Health Benefit Program2 Government enrollees include Medicare

Risk, Medicare Cost, Medicaid and Federal Employees Health Benefit Program (FEHBP) members.

3 Data are from the Department of Health and Human Services and reflect figures from October 1, 2013, through April 19, 2014.

4 Total health insurance exchange enrollment includes individuals whose subsidy status is unknown.

NOTE: Throughout this Data Summary, data include all HMOs serving the profiled states. In some cases, HMOs did not report their data. Some enrollment data were unavailable for the selected markets.


CENTRAL REGIONCOMMERCIAL: HMO/HOSPITAL MEDICAL UTILIZATION




ALOS per Hospital

Admission


per Member


MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013

Arkansas 58.8 58.8 230.5 235.7 3.9 4.0 3.2 3.1 1.3 1.8

Illinois 70.5 68.8 269.9 288.7 3.9 4.3 5.4 4.9 1.7 2.5

Iowa 50.1 50.9 203.1 213.0 4.2 4.2 3.3 3.8 1.3 1.7

Kansas 74.3 67.6 281.7 299.4 3.9 4.5 5.0 4.7 1.7 2.5

Michigan 64.9 71.9 282.8 293.8 4.2 4.0 5.2 4.8 1.9 1.5

Minnesota 58.2 54.4 210.7 204.7 3.6 3.8 4.2 5.1 1.8 1.7

Nebraska 42.8 48.0 183.8 212.8 4.4 4.4 3.4 4.8 0.8 1.6

North Dakota 54.6 59.1 178.3 213.5 3.0 3.5 2.0 3.7 1.5 1.6

Texas 45.7 48.7 206.0 230.3 4.4 4.9 3.5 3.9 1.7 1.6

Wisconsin 54.0 54.3 220.4 221.6 4.0 4.0 4.4 4.7 2.1 2.1

NATION 58.4 58.0 239.1 246.9 4.2 4.3 4.7 4.7 1.7 1.9

HOSPITAL DAYS RATIOS ARE LOW IN SEVEN PROFILED CENTRAL REGION STATES

In 2013, the number of hospital

days per 1,000 commercial

HMO members was lower

than that of the nation (246.9)

in Arkansas (235.7), Iowa

(213.0), Minnesota (204.7),

Nebraska (212.8), North

Dakota (213.5), Texas (230.3)

and Wisconsin (221.6). Of

the states that recorded a

higher-than-average number

of such days, Kansas had

the largest ratio (299.4).

AVERAGE LENGTH OF STAY IS LOWER THAN U.S. AVG. IN SIX CENTRAL REGION STATES

The average length of stay

(ALOS) per hospital admission

for commercial HMO/POS

members was lower than

that of the nation (4.3 days)

in Arkansas (4.0), Iowa (4.2),

Michigan (4.0), Minnesota

(3.8), North Dakota (3.5) and

Wisconsin (4.0) in 2013.



Arkansas Illinois Iowa Kansas Michigan Minnesota Nebraska North Dakota

Texas Wisconsin Nation0

20

40

60

80

Ho

spita

l Ad

miss

ion

s

58.8

68.8

50.9

67.671.9

54.4

48.0

59.1

48.7

54.358.0

AVERAGE LENGTH OF STAY PER HOSPITAL ADMISSION, COMMERCIAL HMO/POS MEMBERS, 20131

1

2

3

4

5

Ave

rag

e L

en

gth

of S

tay

(Da

ys)

4.04.3 4.2

4.5

4.03.8

4.4

3.5

4.9

4.04.3

Arkansas Illinois Iowa Kansas Michigan Minn-esota

Nebraska North Dakota

Texas Wisconsin Nation

1 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s

office that do not require the services of a physician. Such visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory.


CENTRAL REGIONMEDICAID: HMO/HOSPITAL MEDICAL UTILIZATION

0.0

1.5

3.0

4.5

6.0

Ave

rag

e L

en

gth

of S

tay

(Da

ys)

4.6

3.7

4.5

4.0

5.0

4.1

4.8 4.7

3.8

4.4

Illinois Iowa Kansas Michigan Minn-esota

Nebraska NorthDakota



HOSPITAL DAYS PER 1,000 MEDICAID HMO MEMBERS RATIO IS LOW IN SEVEN STATES

In 2013, the average number

of hospital days per 1,000

Medicaid HMO members

was lower than that of

the nation (395.3) in Illinois

(274.9), Iowa (360.1), Kansas

(277.9), Nebraska (329.5),

North Dakota (329.5), Texas

(393.1) and Wisconsin (304.7).



were lower than that of the

nation in four profiled states.

ALOS IS LOW VS. U.S. AVG. IN FOUR CENTRAL REGION STATES


(ALOS) per Medicaid HMO

hospital admission in Iowa

(3.7 days), Michigan (4.0),

Nebraska (4.1) and Wisconsin

(3.8) was lower than that

of the nation (4.4) in 2013.

Additionally, the number of

physician encounters per

Medicaid HMO member

decreased in five Central

region states from 2012 to 2013.


0

38

76

114

152

Ho

spita

l Ad

miss

ion

s

Illinois Iowa Kansas Michigan Minnesota Nebraska North Dakota Texas Wisconsin Nation

69.7

84.177.8

119.7111.2

—

110.5 111.6

145.1137.4

102.0

80.673.2

69.2

83.091.6

82.1

100.4 97.6 98.8

2012 2013

ALOS PER HOSPITAL ADMISSION, MEDICAID HMO MEMBERS, 20131




ALOS per Hospital

Admission


per Member


MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013

Illinois 69.7 84.1 287.1 274.9 4.6 4.6 3.8 3.7 1.2 2.1

Iowa 77.8 119.7 236.0 360.1 3.1 3.7 4.0 4.3 1.4 2.6

Kansas 111.2 — 333.5 277.9 3.0 4.5 5.4 4.2 2.6 —

Michigan 110.5 111.6 444.0 434.8 4.0 4.0 5.2 4.8 3.2 3.0

Minnesota 145.1 137.4 486.9 499.6 4.5 5.0 2.9 5.5 2.3 3.3

Nebraska 102.0 80.6 339.5 329.5 3.5 4.1 5.2 5.0 2.5 2.1

North Dakota 73.2 69.2 342.6 329.5 4.7 4.8 — — — —

Texas 83.0 91.6 331.1 393.1 4.3 4.7 4.4 4.3 2.2 2.4

Wisconsin 82.1 100.4 294.3 304.7 3.7 3.8 4.0 4.4 2.3 2.6

NATION 97.6 98.8 380.5 395.3 4.2 4.4 4.4 4.6 2.3 2.6

1 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s

office that do not require the services of a physician. Such visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory.



CENTRAL REGION

NJ14.1%

HI45.3%

NATION: 28.4%

RI35.7%

MA19.5%

NH6.1%

AR18.1%

IL11.6%

IA13.8%

MI28.1%

NE11.3%

ND13.1%

MN50.7%

KS12.7%

TX28.2%

WI34.4%

MEDICARE ADVANTAGE

MEDICARE ADVANTAGE PENETRATION, CENTRAL REGION, 20131,2


2011 2012 2013


Arkansas 85,514 15.5% 93,914 16.6% 104,854 18.1%

Illinois 183,983 9.7 201,007 10.3 232,238 11.6

Iowa 70,212 13.3 72,335 13.3 76,541 13.8

Kansas 51,736 11.6 51,619 11.2 59,838 12.7

Michigan 425,400 24.7 456,502 25.7 513,928 28.1

Minnesota 375,104 46.0 402,753 47.7 442,017 50.7

Nebraska 33,847 11.8 32,267 11.0 33,965 11.3

North Dakota 11,500 10.4 12,965 11.5 14,973 13.1

Texas 699,329 22.1 777,658 23.5 968,610 28.2

Wisconsin 295,741 31.4 311,907 32.0 346,161 34.4

NATION 12,454,064 25.7% 13,278,369 26.4% 14,724,574 28.4%

MA PENETRATION RISES IN MOST PROFILED CENTRAL REGION STATES

Medicare Advantage (MA)

penetration expanded in all

of the profiled Central region

states, except Nebraska,

as well as across the nation

between 2011 and 2013.

Minnesota (50.7%) and

Wisconsin (34.4%) had the

highest MA penetration in

2013, and both exceeded the

national average (28.4%).




CENTRAL REGIONMEDICARE: HMO/HOSPITAL MEDICAL UTILIZATION

UTILIZATION RATES FOR MEDICARE MEMBERS1



ALOS per Hospital

Admission


per Member


MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013

Arkansas 321.4 392.2 2,182.9 2,740.5 7.1 7.6 — 9.3 6.8 6.6

Illinois 268.4 260.2 1,702.6 1,642.6 6.2 6.5 8.9 7.8 3.5 3.5

Iowa 324.6 286.5 2,537.5 2,299.3 8.1 8.2 11.1 9.2 5.6 5.2

Kansas 386.0 399.3 2,089.5 3,336.0 6.5 — 10.0 9.3 6.3 7.3

Michigan 331.2 330.8 2,238.4 1,950.6 5.9 5.8 10.8 10.3 4.1 4.2

Minnesota 321.5 249.8 1,729.0 1,385.5 5.7 5.7 11.0 9.6 4.1 2.7

Nebraska 388.0 272.3 2,787.0 2,433.8 7.3 — 12.3 11.4 6.0 5.9

North Dakota 229.6 247.0 1,800.3 1,833.7 8.1 7.6 10.5 8.3 2.2 1.8

Texas 221.1 240.8 1,453.5 1,786.9 6.6 7.1 9.4 10.6 5.0 5.8

Wisconsin 252.6 271.3 1,519.7 1,798.3 6.1 6.7 11.4 10.6 4.7 4.6

NATION 265.8 275.6 1,602.4 1,727.1 6.1 6.3 9.9 10.4 4.4 4.5

HMO/HOSPITAL UTILIZATION AND COST MEASURES




Discharges/1,0003




Hospital Discharge3



MARKET 2011 2012 2011 2012 2011 2012 2011 2012 2011 2012 2011 2012

Arkansas 262 231 1,309 2,183 322 313 1,704 1,611 $8,560 $8,708 $2,715 $2,664

Illinois 268 270 1,473 1,703 364 341 1,871 1,738 9,829 10,092 3,521 3,378

Iowa 217 203 2,497 2,538 265 252 1,335 1,267 9,450 9,971 2,430 2,398

Kansas 294 282 2,394 2,090 286 275 1,468 1,388 9,265 9,580 2,584 2,531

Michigan 294 283 1,923 2,238 369 352 1,975 1,857 10,386 10,586 3,806 3,680

Minnesota 232 211 2,269 1,729 378 378 1,767 1,762 10,675 11,061 3,955 4,043

Nebraska 197 184 2,987 2,787 267 253 1,313 1,235 9,796 10,170 2,557 2,477

North Dakota 253 178 1,484 1,800 248 258 1,244 1,304 10,617 10,894 2,533 2,607

Texas 201 206 1,539 1,454 321 309 1,709 1,629 9,887 10,097 3,103 3,030

Wisconsin 229 220 1,716 1,520 276 270 1,354 1,288 10,207 10,356 2,789 2,732

NATION 236 239 1,643 1,602 323 307 1,734 1,634 $10,362 $10,674 $3,281 $3,176


180

240

300

360

420

Ho

spita

l Ad

miss

ion

s

392.2

260.2

286.5

399.3

330.8

249.8

272.3

247.0 240.8

271.3 275.6




Managed Care vs. Fee-for-Service Measures

Data source: Centers for Medicare and Medicaid Services and IMS Health © 20141 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s office that do not require the services of a physician.

Such visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory. 3 Discharges, hospital days per 1,000, payments per hospital discharge and payments per enrollee for Medicare fee-for-service come from the Medicare and Medicaid Research Review

Statistical Supplement.

NOTE: Some utilization data were unavailable for the selected markets.

ADMISSIONS PER 1,000 MEDICARE MEMBERS RISE IN FIVE OF 10 PROFILED STATES

From 2012 to 2013, the hospital

admissions per 1,000 Medicare

HMO members count

increased in five of the 10

profiled Central region states:

Arkansas (22.0%), Kansas

(3.4%), North Dakota (7.6%),

Texas (8.9%) and Wisconsin

(7.4%). Meanwhile, average

length of stay rose in five of the

profiled states and exceeded

the U.S. mean (6.3 days) in six.

HOSPITAL DAYS RATIO FOR MEDICARE HMO PATIENTS IS LOW IN THREE STATES

In 2012, the average number

of hospital days per 1,000

Medicare patients was lower

for those in HMO plans than

for those in fee-for-service

plans in Illinois, Minnesota,

Texas and across the nation.



CENTRAL REGIONHMO PREMIUMS

Arkansas Illinois Iowa Kansas Michigan Minnesota Nebraska North Dakota Texas Wisconsin Nation$200

$315

$430

$545

$660

Avg

. In

div

idu

al P

rem

ium

($)

$301

$338

$461

$535

$456

$501$472

$514

$484$511

$614

$644

$456

$498

$627$647

$460 $469 $468$488 $486

$532

2012 2013

INDIVIDUAL HMO PREMIUMS ARE LOW IN SEVEN PROFILED STATES

In 2013, average individual

HMO premiums per month


nation ($531.82) in Arkansas

($338.40), Iowa ($500.79),

Kansas ($513.84), Michigan

($510.63), Nebraska ($498.01),

Texas ($468.53) and Wisconsin

($487.63). Average family HMO

premiums were lower in eight

of the 10 Central region states.



RX BENEFIT PREMIUMS CHANGE LITTLE OR NOT AT ALL IN MOST FEATURED STATES

From 2012 to 2013, average

individual monthly premiums

for HMO outpatient pharmacy

benefits declined or were

unchanged in eight of the 10

featured Central region states.

In the case of family premiums,

seven states recorded lower

or unchanged premiums.

Nationally, such premiums

edged up 1.2% for individuals.



MARKET 2011 2012 2013 2011 2012 2013

Arkansas $310.78 $301.25 $338.40 $911.01 $984.28 $1,006.21

Illinois 460.05 460.51 534.91 1,138.67 1,125.24 1,270.08

Iowa 439.09 456.39 500.79 1,071.42 1,076.44 1,164.80

Kansas 416.90 472.22 513.84 1,058.99 1,157.72 1,226.19

Michigan 473.08 484.30 510.63 1,196.35 1,226.36 1,271.80

Minnesota 574.03 614.02 643.51 1,397.59 1,443.55 1,506.04

Nebraska 401.01 455.57 498.01 966.50 1,063.53 1,198.30

North Dakota 600.66 627.33 646.66 1,418.96 1,487.30 1,537.30

Texas 449.49 459.68 468.53 1,121.07 1,140.70 1,146.69

Wisconsin 453.81 468.06 487.63 1,158.14 1,183.83 1,231.25

NATION $464.75 $486.48 $531.82 $1,189.17 $1,237.31 $1,313.03

PREMIUMS PER MEMBER PER MONTH FOR OUTPATIENT PHARMACY BENEFITS1


MARKET 2012 2013 2012 2013

Arkansas $50.00 $34.00 $113.00 $77.50

Illinois 30.84 30.21 97.61 92.02

Iowa 34.07 34.07 82.81 82.81

Kansas 31.78 26.54 93.12 71.43

Michigan 45.37 49.49 126.09 139.78

Minnesota 37.83 20.74 137.25 —

Nebraska 37.86 — 78.99 —

North Dakota 41.83 41.83 105.38 105.38

Texas 41.73 41.73 103.89 103.89

Wisconsin 18.90 18.90 40.14 40.14

NATION $40.21 $40.71 $101.80 $103.04




CENTRAL REGIONHMO PHARMACY UTILIZATION AND EXPENDITURES



MARKET 2011 2012 2013 2011 2012 2013

Arkansas 9.3 8.9 8.7 $57.14 $52.32 $48.16

Illinois 9.6 9.4 9.3 63.77 60.16 60.03

Iowa 8.1 7.9 7.8 52.36 50.68 54.63

Kansas 9.6 9.4 9.2 59.87 57.46 56.58

Michigan 9.5 9.5 9.4 48.79 51.16 45.95

Minnesota 8.1 7.8 8.4 53.76 48.55 46.63

Nebraska 8.6 8.2 7.5 50.11 46.90 48.24

North Dakota 8.2 8.2 8.2 52.66 52.66 52.66

Texas 9.3 9.0 9.0 67.56 62.29 61.34

Wisconsin 8.8 9.0 8.9 43.11 44.18 44.48

NATION 9.4 9.1 9.0 $58.95 $55.73 $56.70


6

7

8

9

10

Ave

rag

e R

xs/P

MPY




8.98.7

9.4 9.3

7.9 7.8

9.49.2

9.5 9.4

7.8

8.48.2

7.5

—8.2—

—9.0— 9.08.9

9.1 9.0

2012 2013

HMO DRUG EXPENDITURESDrug Costs as a Percentage

of Operating ExpensesExpenditures per Member

per Year for Drugs2

MARKET 2011 2012 2013 2011 2012 2013

Arkansas 18.5% 16.0% 16.0% $690 $838 $733

Illinois 14.3 15.4 15.0 645 621 623

Iowa 13.7 13.8 14.8 403 494 428

Kansas 15.7 17.8 15.2 567 596 696

Michigan 13.1 14.0 13.1 467 550 509

Minnesota 12.1 12.2 11.2 608 826 649

Nebraska 11.0 12.0 — 227 339 209

North Dakota 12.0 12.0 12.5 424 683 563

Texas 12.3 13.8 14.5 608 548 524

Wisconsin 9.5 9.6 9.5 394 482 413

NATION 13.9% 14.5% 14.7% $578 $605 $609


NUMBERS OF RXs PER HMO MEMBER PER YEAR DECLINE IN SEVEN STATES

Between 2011 and 2013,

the numbers of prescriptions

dispensed per commercial

HMO member per year

decreased in seven of 10

profiled Central region states

and across the U.S. Of the

states that recorded declines,

Illinois (9.3), Kansas (9.2) and

Michigan (9.4) exceeded the

U.S. mean (9.0).

DRUG COSTS AS A SHARE OF OPERATING EXPENSES ARE LOW IN SIX FEATURED STATES

In 2013, HMO drug costs as

a percentage of operating

expenses were lower than

those nationally (14.7%) in

Michigan (13.1%), Minnesota

(11.2%), North Dakota (12.5%),

Texas (14.5%) and Wisconsin

(9.5%). This share was highest

among the Central region

states in Arkansas (16.0%).

RX COSTS PER HMO MEMBER ARE LOWER THAN U.S. AVG. IN FIVE PROFILED STATES

In Iowa ($428), Michigan

($509), Nebraska ($209),

North Dakota ($563), Texas

($524) and Wisconsin ($413),

average expenditures per

HMO member per year for

drugs were lower than those

nationally ($609) in 2013.

Furthermore, such expenses

decreased from 2012 to 2013

in eight of the 10 featured

Central region states.





CENTRAL REGIONMEDICAL GROUPS: DEMOGRAPHICS

DISTRIBUTION OF CENTRAL REGION GROUP PRACTICES, BY SIZE, IS SIMILAR TO U.S.’s

Across the Central region

states, medical group

practice sizes, by number

of FTE physicians, closely

followed the same distribution

as those of their national

counterparts in 2013.

The largest numbers of

medical groups in nine of

the 10 profiled states were

comprised of five to six

physicians. North Dakota was

the exception, where the

number of groups with seven

to nine physicians was the

same as those with five to six.

THREE STATES NOTE LARGER MULTISPECIALTY SHARES AMONG GROUPS

In 2013, of the profiled

Central region states and the

nation, only Illinois (57.6%),

North Dakota (55.1%) and

Wisconsin (59.7%) recorded

higher percentages of

multispecialty practices than

single-specialty practices.

SHARES OF GROUPS WITH CORPORATE TIES INCREASE SLIGHTLY IN FOUR STATES

In Arkansas (0.5 percentage

points), Illinois (0.2 points),

Michigan (0.2 points and

Texas (0.1 points), the

corporate-affiliated portion


rose fractionally. In Minnesota

(–0.9 percentage points) and

Wisconsin (–2.5 points), these

portions of corporate-affiliated

practices edged down.




MARKET 2012 2013 2012 2013

Arkansas 42.0% 42.5% 58.0% 57.5%

Illinois 51.2 51.4 48.8 48.6

Iowa 63.9 63.9 36.1 36.1

Kansas 30.2 30.2 69.8 69.8

Michigan 45.4 45.6 54.6 54.4

Minnesota 59.5 58.6 40.5 41.4

Nebraska 33.0 33.0 67.0 67.0

North Dakota 75.5 75.5 24.5 24.5

Texas 41.0 41.1 59.0 58.9

Wisconsin 70.5 68.0 29.5 32.0

NATION 42.7% 42.7% 57.3% 57.3%

0%

18%

36%

54%

72%

Perc

en

tag

e o

f Gro

up

s

61.1%

38.9%42.4%

57.6% 58.3%

41.7%

58.6%

41.4%

60.1%

39.9%

54.5%

45.5%

60.6%

39.4%44.9%

55.1% 57.6%

42.4%40.3%

59.7%55.6%

44.4%






SIZE (# of MDs)Arkan-

sas Illinois Iowa Kansas Michi-gan

Minne-sota

Ne-braska

North Dakota Texas Wiscon-

sin NATION

5–6 62 225 84 52 221 138 66 13 266 111 5,729

7–9 18 121 47 27 121 89 20 13 178 110 3,266

10–14 18 71 21 15 63 81 11 9 88 57 1,786

15–19 5 22 9 10 20 37 4 3 30 22 630

20+ 10 75 19 12 51 70 8 11 68 75 1,478

TOTAL 113 514 180 116 476 415 109 49 630 375 12,889



Multispecialty 44 296 75 48 190 189 43 27 267 224 5,728


Under 250 4 34 9 5 50 38 7 3 29 30 1,029

250–499 17 68 22 12 87 58 21 8 95 49 2,052

500–749 17 65 37 24 95 41 22 4 80 54 2,022

750+ 29 101 39 29 115 97 23 9 159 86 2,728

Unknown 45 236 73 46 127 177 36 25 262 151 4,932

TOTAL 113 514 180 116 476 415 109 49 630 375 12,889


NOTE: IMS Health defines the medical groups represented on pages 20–21 of this Data Summary as those with five or more full-time equivalent (FTE) physicians whose primary business is seeing regularly scheduled patients for nonsurgical services other than imaging. Physicians must have a share in the practice and offer outpatient care, and the practice must be physically separate from a hospital. Anesthesiology and pathology groups are excluded.


CENTRAL REGIONMEDICAL GROUPS: SERVICES





MARKET 2012 2013 2012 2013 2012 2013

Arkansas 55.0% 54.5% 51.8% 51.8% 74.5% 74.8%

Illinois 53.9 54.1 57.5 57.8 66.3 66.5

Iowa 67.7 67.7 69.2 69.2 70.2 70.2

Kansas 76.4 76.4 58.8 58.8 79.8 79.8

Michigan 55.0 54.9 44.1 44.1 67.3 67.2

Minnesota 71.2 70.1 66.0 69.1 75.8 74.7

Nebraska — — 61.0 61.0 68.1 68.1

North Dakota 80.4 80.4 86.1 86.1 88.9 88.9

Texas 47.6 47.6 52.7 52.8 64.0 64.0

Wisconsin 74.9 72.5 76.8 73.8 79.7 77.6

NATION 54.7% 54.3% 49.8% 49.5% 64.5% 64.0%

CENTRAL REGION GROUP PRACTICES ARE LIKELY TO OFFER IMAGING SERVICES

In 2013, the shares of medical

group practices in nine of

the 10 profiled Central region

states that offered imaging

services exceeded that of the

nation (64.0%). This portion

was highest in North Dakota

(88.9%). Also, in most of the

featured states, the portions

of practices that had clinical

labs or performed surgery

topped the U.S. averages.

MEDICAL GROUPS IN MOST PROFILED STATES ARE LIKELY TO HAVE PHARMACIES

In 2013, medical group

practices in Arkansas (65.9%),

Illinois (60.5%), Iowa (71.3%),

Kansas (72.5%), Michigan

(63.7%), Minnesota (64.8%),

Nebraska (63.0%), North

Dakota (77.8%) and Wisconsin

(79.7%) were more likely

than those nationally to

offer pharmacy services.

RATES OF FULL RX SERVICE AMONG GROUPS IN FIVE STATES TOP THE U.S. MEAN

The shares of medical group

practices in Illinois (23.2%),

Minnesota (23.9%), North

Dakota (35.7%), Texas (27.2%)

and Wisconsin (29.4%) that

offered full pharmacy services

exceeded that of the nation

(18.9%) in 2013. The provision

of samples was the most

common pharmacy service in

all 10 Central region states.






MARKET 2012 2013 2012 2013 2012 2013

Arkansas 3.7% 3.7% 1.9% 1.9% 98.1% 98.1%

Illinois 23.2 23.2 8.7 8.5 72.5 72.5

Iowa 17.2 17.2 1.1 1.1 82.8 82.8

Kansas 8.6 8.6 1.7 1.7 89.7 89.7

Michigan 15.0 14.9 5.9 5.9 83.4 83.5

Minnesota 22.7 23.9 4.2 4.9 74.8 73.5

Nebraska 9.8 9.8 3.9 3.9 92.2 92.2

North Dakota 35.7 35.7 7.1 7.1 71.4 71.4

Texas 26.9 27.2 13.7 13.6 64.6 64.3

Wisconsin 28.1 29.4 3.2 3.5 71.1 69.7

NATION 18.4% 18.9% 9.7% 10.0% 74.9% 74.3%

40%

50%

60%

70%

80%

Perc

en

tag

e o

f Gro

up

s

—65.9%—

60.6%60.5%

—71.3%— —72.5%—

63.8%63.7% 65.9%

64.8%

—63.0%—

—77.8%—

52.2%52.3%

77.4%79.7%

60.7%60.2%

2012 2013






CENTRAL REGIONHOSPITAL UTILIZATION


MEASUREArkan-

sas Illinois Iowa Kansas Michi-gan

Minne-sota

Ne-braska

North Dakota Texas Wiscon-

sin NATION


4,849 7,881 2,959 2,231 8,198 4,250 2,498 2,501 6,323 4,445 7,143


22,942 36,570 18,365 10,475 37,712 18,441 14,528 17,365 30,042 19,939 35,791


4.9 4.5 10.0 6.3 4.3 3.7 6.3 9.9 4.4 4.4 5.3




75.1% 71.1% 84.9% 82.9% 71.9% 78.8% 82.5% 86.0% 67.0% 77.1% 70.9%

AVERAGE TOTAL FACILITY OCCUPANCY, 20121

0%

15%

30%

45%

60%

Oc

cu

pa

nc

y (%

)

48.8% 51.3%

39.5%34.1%

41.0%

31.1% 31.5%37.1%

43.2%47.2% 48.5%




SELECTED FINANCIAL RATIOS FOR HOSPITALS (IN THOUSANDS), 2012

MEASUREArkansas Illinois Iowa Kansas Michigan Minnesota Nebraska North

Dakota Texas Wisconsin NATION

Total Costs/Occupied Bed $1,315.9 $1,965.4 $1,961.1 $1,818.8 $2,270.5 $2,866.3 $2,248.4 $1,825.3 $1,795.8 $2,779.2 $1,847.4

Total Costs/ Admission 15.7 22.1 29.1 23.6 25.1 29.9 28.4 28.2 20.2 30.1 22.3



Salary Costs/FTE3 46.5 55.6 50.6 48.5 56.5 60.3 51.0 47.8 53.8 62.5 57.4

Total Costs/FTE3 125.3 149.4 126.0 122.1 147.0 144.2 125.9 106.5 163.1 162.6 152.7

HOSPITAL FACILITY PATIENT-DAYS AND ADMISSIONS ARE HIGH IN MI

In 2012, Michigan recorded

the highest number of total

facility admissions (8,198)

and total facility patient-days

(37,712), per hospital, of the

10 Central region states.

Both also exceeded the U.S.

means (7,143 and 35,791,

respectively). The average

length of stay in Michigan

hospitals (4.3 days) was lower

than that of the nation (5.3).

TOTAL COSTS PER HOSPITAL ADMISSION IN WISCONSIN EXCEED THE NATIONAL AVG.

Total costs per hospital

admission in Wisconsin

($30,141) exceeded those

of the nine other states

listed and of the nation

($22,286) in 2012. However,

Texas hospitals recorded the

highest total costs per full-

time-equivalent employee

($163,103). Wisconsin had the

second-highest such costs

($162,594). Both topped the

national average ($152,715).

SELECTED UTILIZATION MEASURES, CATHOLIC HEALTH INITIATIVES AFFILIATES, 20121

SYSTEM NAME

Average Number of

Staffed Beds

Average Number



Average Length of

Stay (Days)


Rate2

Alegent Creighton Health 113.3 4,951.4 36.9% 5.7 15.3%

Mercy Health Network 139.7 7,245.6 49.3 6.0 15.4

St. Luke’s Health System 186.3 9,022.8 53.7 4.1 15.5

NATION 150.4 7,142.9 48.5% 5.3 15.6%

Data source: IMS Health © 20141 Total facility figures reflect all portions of the hospital’s occupancy.2 Hospital All-Cause Readmission Rate figures come from the Centers for Medicare and Medicaid Services Hospital Compare database and are measured from July 2012 through

June 2013. Unless otherwise noted, scores are averaged across all facilities within the specified system.3 “FTE” is full-time equivalent.



EAST REGIONHEALTH PLAN DEMOGRAPHICS

HEALTH INSURANCE EXCHANGE ENROLLMENT, 2013–20143


Florida 90,120 893,655 983,775

Georgia 41,165 275,378 316,543

Kentucky 22,994 59,753 82,747

New Jersey 25,484 136,291 161,775

New York 96,611 273,840 370,451

North Carolina 32,479 325,105 357,584

Ohio 23,153 131,515 154,668

Pennsylvania 59,622 258,455 318,077

South Carolina 14,691 103,633 118,324

Tennessee 30,787 120,565 151,352

NATION4 1,201,105 6,670,458 8,019,763


HMO ENROLLEE COUNT FALLS IN SEVEN EAST REGION STATES, RISES NATIONALLY


the total numbers of HMO

enrollees decreased in

Kentucky, New Jersey, New

York, North Carolina, Ohio,

Pennsylvania and Tennessee,

even as it increased by

nearly 600,000 nationally, to

80.1 million from 79.5 million.

However, between 2012 and

2013, the pattern was reversed,

with HMO enrollment rising

in six of the 10 profiled states

while falling 0.6% nationally.

NUMBERS OF GOVERNMENT BENEFICIARIES IN HMOs RISE IN SEVEN PROFILED STATES

The total number of Medicare,

Medicaid and FEHBP HMO

members increased in seven

of the 10 profiled East region

states from 2012 to 2013.

Nationally, the number of

these beneficiaries in HMOs

climbed 6.0%, to 39.1 million

from 36.9 million the prior year.

SUBSIDIZED SHARES OF EXCHANGE ENROLLEES IN EAST REGION STATES TOP U.S.

The percentages of health

insurance exchange enrollees

in 2014 whose coverage was

subsidized led that of the

nation (83.2%) in six of the 10

profiled East region states.

HMO ENROLLMENT

MARKET

2011 2012 2013


Avg. # of Enrollees


Avg. # of Enrollees


Avg. # of Enrollees

Florida 5,028,438 128,934.3 4,980,528 134,608.9 5,050,417 136,497.8

Georgia 2,406,419 200,534.9 3,418,517 310,774.3 3,443,647 313,058.8

Kentucky 2,218,127 170,625.2 2,031,073 156,236.4 1,860,966 186,096.6

New Jersey 3,552,849 355,284.9 3,109,606 345,511.8 3,479,925 347,992.5

New York 6,974,744 268,259.4 7,819,855 300,763.7 6,220,602 259,191.8

North Carolina 1,064,066 133,008.3 914,538 130,648.3 961,118 137,302.6

Ohio 4,034,270 201,713.5 3,913,500 195,675.0 3,427,300 214,206.3

Pennsylvania 4,080,913 194,329.2 3,825,633 191,281.7 4,026,262 201,313.1

South Carolina 943,908 104,878.7 794,594 99,324.3 957,478 119,684.8

Tennessee 1,873,419 187,341.9 1,488,670 165,407.8 1,475,397 184,424.6

NATION 79,478,570 179,815.8 80,545,040 187,314.0 80,056,080 182,776.4

1 Federal Employees Health Benefit Program2 Government enrollees include Medicare

Risk, Medicare Cost, Medicaid and Federal Employees Health Benefit Program (FEHBP) members.

3 Data are from the Department of Health and Human Services and reflect figures from October 1, 2013, through April 19, 2014.

4 Total health insurance exchange enrollment includes individuals whose subsidy status is unknown.

NOTE: Data include all HMOs serving the profiled states. Some data were unavailable for the selected states.


MARKET


2012 2013 2012 2013 2012 2013 2012 2013

Florida 836,417 947,373 1,138,778 1,229,813 17,832 17,053 1,993,027 2,194,239

Georgia 65,599 96,432 979,529 971,601 39,076 37,419 1,084,204 1,105,452

Kentucky 132,530 132,370 730,229 546,097 1,354 2,036 864,113 680,503

New Jersey 288,636 369,406 1,517,366 2,133,221 13,545 11,607 1,819,547 2,514,234

New York 874,836 886,400 2,419,010 1,968,100 101,446 66,536 3,395,292 2,921,036

North Carolina 183,946 212,853 — — — — 183,946 212,853

Ohio 454,053 370,881 1,875,902 1,719,948 36,233 10,984 2,366,188 2,101,813

Pennsylvania 606,230 641,127 1,083,692 1,337,390 35,157 27,013 1,725,079 2,005,530

South Carolina 58,493 57,254 457,708 609,808 — — 516,201 667,062

Tennessee 228,315 255,804 1,166,235 1,149,726 4,179 2,687 1,398,729 1,408,217

NATION 8,624,740 9,602,636 26,862,850 28,177,986 1,419,562 1,328,414 36,907,160 39,109,036




EAST REGIONCOMMERCIAL: HMO/HOSPITAL MEDICAL UTILIZATION




ALOS per Hospital

Admission


per Member


MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013

Florida 47.3 52.8 189.4 212.2 3.9 4.1 5.2 4.2 1.4 1.3

Georgia 45.7 43.1 203.5 190.7 4.5 4.5 5.4 5.7 1.5 1.1

Kentucky 53.1 52.3 211.9 218.1 4.0 4.2 4.5 4.7 2.8 2.5

New Jersey 65.1 63.7 326.9 289.4 5.0 4.4 6.5 5.3 2.5 1.8

New York 64.9 75.2 287.0 318.0 4.5 4.4 5.5 5.7 1.7 1.9

North Carolina 47.3 44.0 197.9 190.6 4.3 4.4 4.6 4.5 1.3 0.9

Ohio 64.0 64.3 323.7 293.8 4.8 4.5 4.8 4.5 2.2 2.2

Pennsylvania 58.8 58.2 268.2 273.5 4.5 4.6 5.5 5.5 2.0 2.2

South Carolina 54.2 46.4 277.0 187.6 4.9 4.1 5.2 3.7 1.0 1.0

Tennessee 91.9 56.0 229.5 266.8 5.0 4.9 5.4 5.5 1.8 1.2

NATION 58.4 58.0 239.1 246.9 4.2 4.3 4.7 4.7 1.7 1.9

HOSPITAL ADMISSIONS PER 1,000 HMO MEMBERS ARE DOWN IN SEVERAL STATES

Between 2012 and 2013, the

number of hospital admissions

per 1,000 commercial HMO

members decreased in seven

of 10 profiled states. This

measure dropped 39.1% in

Tennessee (the most of any of

the featured states) and 14.4%

in South Carolina. New York

reported the highest number

of hospital admissions per 1,000

HMO members (75.2) in 2013.

ALOS CONTRACTS IN FIVE FEATURED STATES


(ALOS) per hospital admission

dropped for commercial HMO

members in New Jersey (to 4.4

from 5.0), New York (to 4.4 from

4.5), Ohio (to 4.5 from 4.8),

South Carolina (to 4.1 from 4.9)

and Tennessee (to 4.9 from 5.0)

from 2012 to 2013.



50

40

60

70

80

Ho

spita

l Ad

miss

ion

s

52.8

43.1

52.3

63.7

75.2

44.0

64.3

58.2

46.4

56.058.0

Florida Georgia Kentucky New Jersey New York North Carolina

Ohio Pennsylvania South Carolina

Tennessee Nation

ALOS PER HOSPITAL ADMISSION, COMMERCIAL HMO/POS MEMBERS, 20131

1

2

3

4

5

Ave

rag

e L

en

gth

of S

tay

(Da

ys)

4.1

4.5

4.24.4 4.4 4.4 4.5 4.6

4.1

4.9

4.3

Florida Georgia Ken-tucky

NewJersey

NewYork

North Carolina

Ohio Penn-sylvania

South Carolina

Tenn-essee

Nation




EAST REGIONMEDICAID: HMO/HOSPITAL MEDICAL UTILIZATION


0

2

4

6

8

Ave

rag

e L

en

gth

of S

tay

(Da

ys)

4.1

4.75.0 4.9

4.64.9

4.44.8

6.3

4.4

Florida Georgia Kentucky NewJersey

New York Ohio Pennsylvania South Carolina

Tennessee Nation

MEDICAID HMO ADMISSIONS PER 1,000 MEMBERS DECLINE



decreased in nine of 10 East

region states from 2012 to

2013 (Tennessee excepted).

However, in 2013 this ratio

remained higher than that of

the nation (98.8) in Kentucky

(117.4), New York (123.5), Ohio

(106.0), Pennsylvania (119.4),

South Carolina (114.9) and

Tennessee (100.3).

MEDICAID HMO HOSPITAL DAYS RATIO CLIMBS IN FIVE PROFILED STATES

From 2012 to 2013, hospital

days per 1,000 Medicaid

HMO members grew in five

of the nine profiled East

region states for which data

were available: Georgia (to

320.7), Kentucky (587.7), Ohio

(508.4), Pennsylvania (489.0)

and South Carolina (510.7).


0

40

80

120

160

Ho

spita

l Ad

miss

ion

s

79.472.0 70.1 68.1

120.4 117.4

83.5

74.1

139.8

123.5

110.1106.0

128.2119.4

133.2

114.9

99.9 100.3 97.6 98.8

2012 2013

Florida Georgia Kentucky New Jersey New York Ohio Pennsylvania South Carolina

Tennessee Nation

ALOS PER HOSPITAL ADMISSION, MEDICAID HMO MEMBERS, 20131




ALOS per Hospital

Admission


per Member


MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013

Florida 79.4 72.0 310.4 292.2 3.9 4.1 4.0 3.4 2.2 2.2

Georgia 70.1 68.1 310.9 320.7 4.5 4.7 3.7 4.3 1.7 1.9

Kentucky 120.4 117.4 526.9 587.7 4.4 5.0 6.1 6.1 5.3 4.3

New Jersey 83.5 74.1 518.2 367.0 5.4 4.9 5.4 5.6 6.7 4.8

New York 139.8 123.5 624.0 518.8 4.5 4.6 6.6 6.5 2.9 3.7

Ohio 110.1 106.0 494.8 508.4 4.6 4.9 5.1 5.4 3.2 3.7

Pennsylvania 128.2 119.4 487.6 489.0 4.7 4.4 4.3 5.0 2.1 2.2

South Carolina 133.2 114.9 445.2 510.7 4.4 4.8 6.4 5.8 1.6 1.5

Tennessee 99.9 100.3 567.1 552.9 6.6 6.3 5.3 6.4 2.7 3.4

NATION 97.6 98.8 380.5 395.3 4.2 4.4 4.4 4.6 2.3 2.6



NOTE: HMO/hospital medical utilization data were unavailable for North Carolina.


EAST REGIONMEDICARE ADVANTAGE


2011 2012 2013


Florida 1,170,000 33.4% 1,284,469 35.3% 1,400,809 37.1%

Georgia 298,426 22.8 331,923 24.2 302,804 21.1

Kentucky 128,838 16.3 119,860 14.7 196,234 23.5

New Jersey 190,967 13.9 215,529 15.2 203,522 14.1

New York 983,196 31.9 1,036,867 32.7 1,136,877 35.1

North Carolina 290,165 18.6 317,551 19.6 464,028 27.6

Ohio 690,094 35.2 732,376 36.2 782,196 37.7

Pennsylvania 900,995 38.5 922,040 38.3 962,954 39.2

South Carolina 139,954 17.2 156,452 18.4 186,830 21.1

Tennessee 293,760 26.7 326,218 28.5 368,202 31.2

NATION 12,454,064 25.7% 13,278,369 26.4% 14,724,574 28.4%

HI45.3%

NATION: 28.4%

South CentralRegion

VT6.5%

PA39.2% NJ

14.1%

NY35.1%

OH37.7%

NC27.6%

SC21.1%

FL 37.1%

GA21.1%

TN31.2%

KY23.5%

Data source: IMS Health and Centers for Medicare and Medicaid Services © 2014

MA ENROLLMENT AND PENETRATION CLIMB

From 2011 to 2013, enrollment

in Medicare Advantage

(MA) plans grew in all 10

profiled East region states,

and MA penetration rose in

nine (Georgia excepted).

MA penetration led that

of the nation (28.4%) in

Florida (37.1%), New York

(35.1%), Ohio (37.7%),

Pennsylvania (39.2%) and

Tennessee (31.2%) in 2013.

MEDICARE ADVANTAGE PENETRATION, EAST REGION, 20131



EAST REGIONMEDICARE HMO/HOSPITAL MEDICAL UTILIZATION


0

125

250

375

500

Ho

spita

l Ad

miss

ion

s

266.2 257.5

359.9

301.3326.1

261.8

391.5

352.1

451.9

331.3

275.6

Florida Georgia Ken-tucky

NewJersey

NewYork

NorthCarolina

Ohio Penn-sylvania

South Carolina

Tenn-essee

Nation

UTILIZATION RATES FOR MEDICARE HMO/POS MEMBERS1



ALOS per Hospital

Admission


per Member


MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013

Florida 226.1 266.2 1,264.2 1,429.5 5.4 5.4 11.6 11.2 3.7 3.8

Georgia 237.2 257.5 1,485.8 2,002.6 6.1 7.1 9.9 10.3 4.3 3.9

Kentucky 327.6 359.9 1,634.7 2,246.5 5.8 6.2 11.9 11.0 7.1 4.4

New Jersey 333.3 301.3 2,472.7 2,150.2 6.8 7.2 14.1 12.3 5.6 5.0

New York 302.9 326.1 1,983.6 2,305.0 7.0 7.3 11.7 12.2 4.2 4.1

North Carolina 323.9 261.8 2,694.1 2,002.1 8.4 6.9 — 10.3 5.4 5.1

Ohio 368.1 391.5 2,410.9 2,146.3 6.5 6.3 9.4 10.2 4.6 4.9

Pennsylvania 368.3 352.1 2,236.3 2,264.0 7.3 7.3 12.7 13.6 4.4 4.3

South Carolina 262.7 451.9 2,311.8 2,408.9 8.8 6.8 — 11.4 6.8 4.3

Tennessee 276.0 331.3 1,740.1 1,938.2 6.2 6.8 11.4 13.9 5.6 5.4

NATION 265.8 275.6 1,602.4 1,727.1 6.1 6.3 9.9 10.4 4.4 4.5

HMO/HOSPITAL UTILIZATION AND COST MEASURES, BY REGION AND STATE1




Discharges/1,0003




Hospital Discharge3



MARKET 2011 2012 2011 2012 2011 2012 2011 2012 2011 2012 2011 2012Florida 191 189 1,205 1,264 349 338 1,885 1,803 $9,129 $9,290 $3,127 $3,026Georgia 201 204 1,497 1,486 315 300 1,699 1,602 9,425 9,650 2,915 2,800Kentucky 216 212 2,187 1,635 365 345 1,890 1,777 8,910 9,232 3,224 3,126

New Jersey 268 327 2,313 2,473 344 321 2,023 1,868 11,170 11,437 3,760 3,572New York 293 287 2,255 1,984 348 329 2,349 2,199 12,941 13,212 4,442 4,229North Carolina 199 198 2,729 2,694 315 302 1,664 1,582 10,128 10,292 3,132 3,004

Ohio 344 324 2,335 2,411 374 358 1,892 1,788 9,203 9,404 3,416 3,306Pennsylvania 247 268 2,151 2,236 360 337 1,979 1,828 9,753 10,084 3,466 3,315South Carolina 278 277 — 2,312 305 287 1,727 1,592 9,878 10,075 2,963 2,804Tennessee 240 230 1,912 1,740 347 332 1,846 1,757 8,584 8,837 2,911 2,819

NATION 236 239 1,643 1,602 323 307 1,734 1,634 $10,362 $10,674 $3,281 $3,176

HOSPITAL ADMISSION RATES ARE RELATIVELY HIGH FOR EASTERN MEDICARE HMOs

With the exception of those

serving Florida (266.2), Georgia

(257.5) and North Carolina

(261.8), HMOs operating in

any of the other profiled East

region states reported higher

numbers of hospital admissions

per 1,000 Medicare members

than the national mean of

275.6 in 2013. Florida also had

a lower hospital-days ratio

than the U.S. average in 2013.

HOSPITAL-DAYS RATIO TRAILS FFS AVG. FOR MEDICARE HMOs IN SOME EAST STATES

In 2012, Medicare HMOs in

Florida, Georgia, Kentucky,

New York, Tennessee and

nationally reported fewer

hospital days per 1,000

members than Medicare

fee-for-service plans in

those states. This ratio fell in

five of 10 featured East region

states from 2011 to 2012.

Data source: IMS Health and Centers for Medicare and Medicaid Services © 2014

1 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s office that do not require the services of a physician. Such

visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory.3 Discharges, hospital days per 1,000, payments per hospital discharge and payments per enrollee for Medicare fee-for-service come from the Medicare and Medicaid Research Review

Statistical Supplement.

NOTE: Some HMO/hospital medical utilization data were unavailable for the selected markets.

Managed Care vs. Fee-for-Service MeasuresData source: IMS Health © 2014


EAST REGIONHMO PREMIUMS



MARKET 2011 2012 2013 2011 2012 2013

Florida $486.00 $505.47 $551.53 $1,174.88 $1,228.62 $1,426.56

Georgia 474.41 479.33 582.62 1,155.73 1,175.76 1,277.16

Kentucky 481.09 511.74 493.58 1,115.63 1,281.29 1,272.65

New Jersey 528.51 546.87 612.43 1,319.47 1,399.11 1,502.07

New York 547.84 573.75 595.46 1,372.98 1,488.95 1,515.36

North Carolina 369.12 383.42 506.15 1,032.30 1,106.81 1,241.14

Ohio 512.46 521.15 603.09 1,269.69 1,373.32 1,456.93

Pennsylvania 498.06 507.26 555.14 1,322.91 1,351.20 1,378.71

South Carolina 351.40 370.71 448.75 1,022.48 1,084.91 1,335.67

Tennessee 401.48 375.10 455.03 1,111.84 1,069.77 1,363.82

NATION $464.75 $486.48 $531.82 $1,189.17 $1,237.31 $1,313.03

Florida Georgia Kentucky New Jersey New York North Carolina

Ohio Pennsylvania South Carolina

Tennessee Nation$300

$400

$500

$600

$700

Avg

. In

div

idu

al P

rem

ium

($)

$505

$552

$479

$583

$512$494

$547

$612

$574$595

$383

$506$521

$603

$507

$555

$371

$449

$375

$455

$486

$532

2012 2013


PREMIUMS PER MEMBER PER MONTH FOR OUTPATIENT PHARMACY BENEFITS


MARKET 2012 2013 2012 2013

Florida $37.24 $39.76 $109.23 $109.23

Georgia 38.84 38.84 126.54 126.54

Kentucky 34.77 34.77 79.04 79.04

New Jersey 44.84 39.88 126.69 102.27

New York 63.09 61.21 141.81 133.50

North Carolina 43.84 43.84 136.02 136.02

Ohio 49.77 54.92 142.36 170.45

Pennsylvania 33.21 33.21 72.26 72.26

South Carolina 21.33 25.00 75.00 120.00

Tennessee 47.18 47.18 131.02 131.02

NATION $40.21 $40.71 $101.80 $103.04


INDIVIDUAL RX PREMIUMS ARE BELOW U.S. AVG. IN MANY EASTERN STATES

Average monthly individual

pharmacy benefit premiums

in Florida ($39.76), Georgia

($38.84), Kentucky ($34.77),

New Jersey ($39.88),

Pennsylvania ($33.21) and

South Carolina ($25.00) were

all below that of the nation

($40.71) in 2013. Conversely,

such premiums were higher

in New York ($61.21), Ohio

($54.92), Tennessee ($47.18)

and North Carolina ($43.84).

INDIVIDUAL AND FAMILY PREMIUMS ARE LOWER IN KY AND NC THAN U.S. OVERALL

Of the 10 East region states

profiled, only Kentucky

($493.58 and $1,272.65) and

North Carolina ($506.15 and

$1,241.14) reported both

individual and family average

monthly HMO premiums

that were lower than the

corresponding national

rates ($531.82 and $1,313.03,

respectively) in 2013.



EAST REGIONHMO PHARMACY UTILIZATION AND EXPENDITURES




MARKET 2011 2012 2013 2011 2012 2013

Florida 9.7 9.3 9.3 $63.52 $63.79 $65.24

Georgia 9.8 9.6 9.5 70.05 68.69 69.22

Kentucky 10.3 10.2 9.7 59.99 57.53 61.66

New Jersey 10.7 10.6 9.5 74.26 70.33 62.91

New York 10.1 9.9 9.8 55.17 53.54 51.87

North Carolina 10.2 10.0 9.8 68.18 63.03 63.80

Ohio 9.6 9.6 9.9 61.13 58.98 62.21

Pennsylvania 8.8 8.6 8.4 56.04 52.67 53.22

South Carolina 8.3 7.7 7.6 50.49 39.23 43.84

Tennessee 9.5 9.1 9.2 71.62 66.05 63.18

NATION 9.4 9.1 9.0 $58.95 $55.73 $56.70


0

3

6

9

12

Ave

rag

e R

xs/P

MPY

—9.3— 9.6 9.510.2

9.7

10.6

9.59.9 9.8 10.0 9.8 9.6 9.9

8.6 8.47.7 7.6

9.1 9.2 9.1 9.0

2012 2013


New York NorthCarolina

Ohio Penn-sylvania

SouthCarolina

Tennessee Nation

HMO DRUG EXPENDITURES

Drug Costs as a Percentage of Operating Expenses

Expenditures per Member per Year for Drugs2

MARKET 2011 2012 2013 2011 2012 2013

Florida 14.2% 14.1% 15.3% $691 $576 $642

Georgia 14.5 15.2 15.6 480 505 501

Kentucky 16.6 15.3 16.3 586 589 618

New Jersey 13.0 14.1 13.7 552 588 682

New York 13.8 15.1 15.5 707 751 820

North Carolina 14.7 16.6 16.7 615 673 733

Ohio 13.9 15.4 15.0 548 719 603

Pennsylvania 14.8 15.8 16.1 626 708 729

South Carolina 15.1 15.3 15.4 562 635 579

Tennessee 15.5 15.1 17.7 692 768 621

NATION 13.9% 14.5% 14.7% $578 $605 $609

PMPY COMMERCIAL RXs DECLINE IN SEVEN OF 10 PROFILED STATE MARKETS

From 2012 to 2013, the

numbers of prescriptions

dispensed per commercial

HMO member per year

(PMPY) dropped in seven

of 10 profiled East region

states, Ohio and Tennessee

excepted, and remained the

same in Florida. The largest

declines were reported in

New Jersey (to 9.5 PMPY from

10.6) and Kentucky (to 9.7

from 10.2).

DRUG COST SHARES OF OPERATING EXPENSES RISE ACROSS PROFILED MARKETS

The percentages of annual

HMO operating expenses

represented by drug spending

grew in all but two profiled

East region states from 2012

to 2013. The exceptions were

New Jersey (to 13.7% from

14.1%) and Ohio (to 15.0% from

15.4%), which both reported

a 0.4-percentage-point

decline. Nationally, drug costs

accounted for 14.7% of HMO

operating expenses in 2013.

PMPY HMO DRUG SPENDING FALLS IN GA, OH, SC AND TN

HMO PMPY expenditures for

prescription drugs decreased

in Georgia (0.8%), Ohio

(16.1%), South Carolina

(8.8%) and Tennessee (19.1%)

between 2012 and 2013.

Meanwhile, PMPY drug

spending across the nation

increased 0.7%, to $609 in

2013 from $605 in 2012.




EAST REGIONMEDICAL GROUP: DEMOGRAPHICS



MARKET 2012 2013 2012 2013

Florida 36.7% 37.1% 63.3% 62.9%

Georgia 47.2 47.4 52.8 52.6

Kentucky 29.0 29.3 71.0 70.7

New Jersey 30.5 30.6 69.5 69.4

New York 38.1 36.7 61.9 63.3

North Carolina 48.5 48.5 51.5 51.5

Ohio 47.9 48.3 52.1 51.7

Pennsylvania 40.9 41.1 59.1 58.9

South Carolina 47.3 47.3 52.7 52.7

Tennessee 38.2 37.7 61.8 62.3

NATION 42.7% 42.7% 57.3% 57.3%


0%

20%

40%

60%

80%

Perc

en

tag

e o

f Gro

up

s

53.0%47.0%

64.4%

35.6%

59.8%

40.2%

64.4%

35.6%

54.2%

45.8%

70.7%

29.3%

57.6%

42.4%

63.1%

36.9%

74.7%

25.3%

61.2%

38.8%

55.6%

44.4%




Ohio Penn-sylvania

South Carolina

Tennessee Nation



SIZE (# of MDs)Florida Georgia

Ken-tucky

New Jersey

New York

North Carolina

OhioPenn-

sylvaniaSouth

CarolinaTenn-essee

NATION

5–6 295 177 89 155 308 223 231 354 98 124 5,729

7–9 156 104 55 69 153 127 113 185 56 70 3,266

10–14 70 54 21 41 80 51 63 82 13 39 1,786

15–19 21 20 5 4 33 17 18 32 10 11 630

20+ 62 33 14 15 75 29 59 68 5 37 1,478

TOTAL 604 388 184 284 649 447 484 721 182 281 12,889



Multispecialty 284 138 74 101 297 131 205 266 46 109 5,728


Under 250 59 28 17 35 51 26 47 98 14 16 1,029

250–499 95 80 36 75 118 71 85 148 35 43 2,052

500–749 98 73 20 47 107 96 81 122 39 38 2,022

750+ 128 94 48 35 131 131 106 121 40 72 2,728

Unknown 219 111 62 90 236 122 159 223 54 110 4,932

TOTAL 604 388 184 284 649 447 484 721 182 281 12,889

HALF OF EAST REGION STATES HAVE LESS THAN 100 GROUPS WITH 750+ VISITS PER WEEK

In five of the 10 profiled

East region states in 2013,

there were more than 100

medical group practices that

recorded 750 or more patient

visits per week. New York and

North Carolina each reported

131 such medical groups,

followed by Florida (128),

Pennsylvania (121) and Ohio

(106). New Jersey reported

the lowest number of medical

group practices in the

750-or-more-visits range (35),

followed by South Carolina

(40) and Kentucky (48).

MORE THAN 70% OF NC AND SC GROUP PRACTICES ARE SINGLE SPECIALTY

Medical group practices in all

but two profiled East region

states were more likely to be

single specialty than their

national counterparts (55.6%)

in 2013. The single-specialty

share was highest, of these

states, in South Carolina and

North Carolina in 2013.

INDEPENDENT GROUP SHARES ARE HIGH IN EAST REGION STATES

In 2013, the independent

percentages of medical group

practices were higher than

that of the nation (57.3%)

in six of the 10 profiled East

region states. Georgia (52.6%),

South Carolina (52.7%), Ohio

(51.7%) and North Carolina

(51.5%) reported the lowest

independent group practice

shares that year.

NOTE: IMS Health defines the medical groups represented on pages 30-31 of this Data Summary as those with five or more FTE physicians whose primary business is seeing regularly scheduled patients for nonsurgical services other than imaging. Physicians must have a share in the practice and offer outpatient care, and the practice must be physically separate from a hospital. Anesthesiology and pathology groups are excluded.


EAST REGIONMEDICAL GROUPS: SERVICES





MARKET 2012 2013 2012 2013 2012 2013

Florida 48.2% 48.4% 41.4% 41.3% 67.9% 68.0%

Georgia 53.1 53.1 43.3 43.5 72.4 72.6

Kentucky 48.3 48.0 51.1 51.1 59.6 59.9

New Jersey 38.0 37.7 32.6 32.5 56.0 55.7

New York 43.1 41.7 42.2 44.4 65.6 64.4

North Carolina 54.9 55.0 50.0 50.0 66.6 66.7

Ohio 47.3 47.5 42.1 42.2 57.6 57.5

Pennsylvania 49.8 49.7 38.9 38.9 52.2 52.1

South Carolina 52.0 52.0 41.0 41.0 61.8 61.8

Tennessee 52.1 52.3 48.4 49.0 66.1 66.2

NATION 54.7% 54.3% 49.8% 49.5% 64.5% 64.0%





MARKET 2012 2013 2012 2013 2012 2013

Florida 17.4% 17.2% 27.3% 27.3% 63.2% 63.7%

Georgia 12.5 12.5 9.7 9.7 84.0 84.0

Kentucky 10.4 10.4 4.2 4.2 87.5 87.5

New Jersey 9.6 9.6 16.9 16.9 75.9 75.9

New York 19.4 20.8 12.8 14.2 69.9 67.2

North Carolina 5.7 5.7 3.1 3.1 92.2 92.2

Ohio 17.6 17.3 3.2 3.1 84.2 84.5

Pennsylvania 10.2 10.4 10.2 10.1 84.2 84.0

South Carolina 5.2 5.2 10.3 10.3 86.2 86.2

Tennessee 9.7 9.6 11.5 11.3 82.3 82.6

NATION 18.4% 18.9% 9.7% 10.0% 75.0% 74.3%

20%

35%

50%

65%

80%

Perc

en

tag

e o

f Gro

up

s 69.9%70.1%

67.3%67.0%

—73.3%—

44.1%43.9%

51.7%49.6%

—59.8%—

69.5%69.8%

—60.7%—

—55.2%—59.8%

60.2%60.7%

60.2%

2012 2013



Ohio Penn-sylvania

South Carolina

Tennessee Nation


LOW PERCENTAGES OF PRACTICES IN EAST REGION STATES PERFORM SURGERY

In nine of 10 profiled East

region states, medical group

practices were less likely to

perform surgery than their

national counterparts in both

2012 and 2013 (54.7% and

54.3%, respectively). Only in

North Carolina did the share

of medical groups performing

surgery (54.9% in 2012 and

55.0% in 2013) exceed that of

the nation in either year.

SHARES OF MEDICAL GROUPS WITH RX SERVICES ARE MIXED IN EAST REGION STATES

In 2013, the percentages of

medical group practices in

the profiled East region states

offering pharmacy services

varied from a low of 43.9% in

New Jersey to a high of 73.3%

in Kentucky. More than 50%

of medical groups offered

pharmacy services in eight of

the 10 profiled states.

PORTIONS OF MEDICAL GROUPS WITH FULL RX TRAIL U.S. IN EAST REGION STATES

Among medical group

practices with any pharmacy

services, the shares of those

offering full pharmacy service

were lower in nine of 10

profiled East region states

than the national portion

(18.9%) in 2013. Meanwhile,

the percentages of medical

groups that offered samples

were higher in eight of these

states than the U.S. average.


EAST REGIONHOSPITAL UTILIZATION

SELECTED UTILIZATION MEASURES, CATHOLIC HEALTH INITIATIVES AFFILIATES, 20121

SYSTEM NAME

Average Number of

Staffed Beds

Average Number



Average Length of

Stay (Days)


Rate2

KentuckyOne Health 152.5 7,300.8 56.1% 4.2 15.6%

TriHealth 439.5 28,769.5 74.3 4.1 15.3

NATION 150.4 7,142.9 48.5% 5.3 15.6%


MEASUREFlorida Geor-

giaKen-tucky

New Jersey

New York

North Caro-lina

OhioPenn-sylva-

nia

South Caro-lina

Tennes-see NATION


12,754 6,570 5,769 14,441 14,207 8,857 8,775 9,619 7,188 6,211 7,143


61,707 31,579 27,049 70,210 94,147 45,800 37,161 48,197 34,423 31,445 35,791


5.0 5.3 4.4 5.0 7.6 4.9 4.1 5.0 4.4 5.2 5.3




58.9% 73.8% 74.4% 61.6% 73.6% 69.7% 73.0% 70.3% 68.4% 72.2% 70.9%

AVERAGE TOTAL FACILITY OCCUPANCY, 20121

0%

20%

40%

60%

80%

Oc

cu

pa

nc

y (%

)


NewYork

NorthCarolina

Ohio Penn-sylvania

SouthCarolina

Tenn-essee

Nation

60.3%

49.6% 46.3%

62.6%67.0%

55.1%46.8%

54.7%45.5%

49.6% 48.5%

SELECTED FINANCIAL RATIOS FOR HOSPITALS (IN THOUSANDS), 2012

MEASURE Florida Georgia Kentucky New Jersey New York North Carolina Ohio Penn-

sylvaniaSouth

Carolina Tennessee NATION

Total Costs/ Occupied Bed $1,312.0 $1,700.4 $1,692.3 $1,570.3 $1,158.0 $1,664.6 $2,057.9 $1,609.7 $1,909.6 $1,455.9 $1,847.4

Total Costs/ Admission 16.1 20.3 19.0 19.3 20.4 20.4 21.9 20.0 22.0 17.5 22.3



Salary Costs/FTE3 58.0 51.6 48.1 66.0 63.1 52.9 53.8 55.7 53.2 49.0 57.4

Total Costs/FTE3 169.3 137.6 135.8 162.2 140.2 140.0 160.7 167.0 153.1 141.6 152.7


EAST REGION HOSPITALS ADMIT LARGE NUMBERS OF INPATIENTS IN 2012

On average, hospitals in seven

of the 10 profiled East region

states reported higher numbers

of total facility admissions in

2012 than the national mean

of 7,143. This number was

highest, among the profiled

East region states, in New

Jersey, at 14,441, followed

by New York (14,207). New

York hospitals recorded

the highest number of

patient-days in 2012, at 94,147.

Total facility patient-days per

hospital trailed the U.S. rate

of 35,791 in four East region

states that year: Georgia

(31,579), Kentucky (27,049),

South Carolina (34,423) and

Tennessee (31,445).

IN NY HOSPITALS, MORE THAN TWO-THIRDS OF STAFFED BEDS ARE OCCUPIED

In 2012, hospitals in the

state of New York operated

at 67.0% occupancy, the

highest rate of the 10 profiled

East region states, and well

above the overall national

average rate of 48.5%.

1 Total facility figures reflect all portions of the hospital’s occupancy.2 Hospital All-Cause Readmission Rate figures come from the Centers for Medicare and Medicaid Services Hospital Compare database and are measured from July 2012 through June

2013. Unless otherwise noted, scores are averaged across all facilities within the specified system.3 “FTE” is full-time equivalent.



DIABETESDIABETES: DEMOGRAPHICS


Inpatient Outpatient0

8

16

24

32

Nu

mb

er o

f Ca

ses

(in M

illio

ns)

6.3 6.4 6.2

23.1

25.628.0

2010 2011 2012

TOTAL NUMBER OF INPATIENT AND OUTPATIENT CASES, NATION, DIABETES MELLITUS (IN MILLIONS)1

PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY AGE, 20132

REGION 0–17 18–35 36–64 65–79 80+

West 0.4% 3.0% 44.2% 38.6% 13.8%

Midwest 0.5 3.1 46.2 36.8 13.4

Northeast 0.4 2.8 45.4 36.8 14.6

South 0.4 2.8 45.5 39.1 12.2

NATION 0.4% 2.9% 45.4% 38.1% 13.2%

PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY TYPE OF COMPLICATION, 20132,3

REGIONCardiovascular

Disease Neuropathy Nephropathy Retinopathy Hypoglycemia

West 51.2% 32.8% 33.6% 17.9% 8.4%

Midwest 56.5 32.2 29.9 18.1 8.1

Northeast 60.2 31.1 26.0 23.2 7.6

South 58.5 33.5 32.9 16.6 7.8

NATION 57.4% 32.7% 31.0% 18.5% 7.9%

West Midwest Northeast South Nation0%

10%

20%

30%

40%

Perc

en

tag

e o

f Pa

tien

ts

25.0% 26.1% 26.0% 26.9%

30.2% 31.1%29.5%

31.1%28.1% 29.4%

2012 2013

PERCENTAGE OF TYPE 2 DIABETES PATIENTS WITH TWO OR MORE COMPLICATIONS2,3

1 Inpatient/outpatient case count data come from IMS Health’s Hospital Procedure/Diagnosis (HPD) database and are current as of calendar year 2012.

2 On pages 33–35, the percentages are representative of the universe of Type 2 diabetes patients on whom claims data have been collected in a given year.

3 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy and retinopathy.

OUTPATIENT DIABETES MELLITUS CASE COUNT EXPANDS BY MORE THAN 21%


the number of diabetes

mellitus cases nationally that

were treated in the hospital

outpatient setting climbed

21.2%, to 28.0 million from

23.1 million. Meanwhile, such

cases treated in the inpatient

setting declined 1.6%, to

6.2 million from 6.3 million.

PERCENTAGES OF TYPE 2 DIABETES PTS. WITH TWO OR MORE COMPLICATIONS RISE

The shares of Type 2 diabetes

patients with two or more

complications grew in every

region from 2012 to 2013. The

rates of such patients were

highest in the Northeast and

South regions (both 31.1%),

and lowest in the West region

(26.1%). In 2013, among

Type 2 diabetes patients with

complications, cardiovascular

(CV) disease was the most

common, affecting 57.4%

nationally. In the Northeast,

60.2% of such patients had

CV disease, the highest

percentage of all regions.

TYPE 2 DIABETES PATIENTS ARE APT TO BE WORKING AGE

In 2013, Type 2 diabetes

patients across all regions

were most likely to be

18–64 years old, followed by

those 65–79 years old and

those 80-plus years old. The

share of Type 2 diabetes

patients who were 18–64

was highest in the Midwest.


DIABETESDIABETES: USE OF SERVICES


PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY SERVICE

A1c Test1Blood

Glucose Test

Serum Cholesterol

Test

Ophthalmologic Exam

Urine Microalbumin

Test

REGION 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013

West 73.7% 73.8% 87.1% 87.1% 84.4% 84.5% 68.0% 67.8% 70.2% 70.1%

Midwest 77.1 77.3 86.1 86.2 84.2 84.2 69.5 69.6 73.5 73.5

Northeast 75.3 75.4 89.1 89.0 87.9 87.9 71.3 71.2 78.5 78.4

South 72.0 72.1 85.7 85.7 82.6 82.6 69.5 69.4 67.6 67.5

NATION 74.1% 74.2% 86.7% 86.8% 84.4% 84.4% 69.6% 69.6% 71.5% 71.5%

West Midwest Northeast South Nation60%

66%

72%

78%

84%

Perc

en

tag

e o

f Pa

tien

ts

75.7%74.7%

71.3%

80.7%

79.2%

72.9%

77.1%78.3%

71.9%

75.8%

74.5%

67.9%

77.1% 76.7%

70.3%

Commercial Insurance2 Medicaid Medicare

PERCENTAGE OF TYPE 2 DIABETES PATIENTS RECEIVING A1c TESTS, BY PAYER TYPE, 20131

PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY A1c LEVEL RANGE1

≤7.0% 7.1–7.9% 8.0–9.0% >9.0%

REGION 2012 2013 2012 2013 2012 2013 2012 2013

West 51.4% 51.6% 20.2% 20.4% 12.9% 12.8% 15.5% 15.2%

Midwest 50.6 47.7 21.1 21.5 12.9 13.9 15.4 16.9

Northeast 50.7 50.0 21.4 20.9 12.8 13.1 15.1 16.0

South 50.3 49.1 20.5 20.8 13.0 13.6 16.2 16.5

NATION 50.6% 49.5% 20.6% 20.8% 13.0% 13.4% 15.9% 16.3%

1 The A1c test measures the amount of glucose present in the blood during the past 2–3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year.

2 Includes HMOs, PPOs, point-of-service plans and exclusive provider organizations.

NOTE: Medicare data include both fee-for-service and Medicare managed care.

TYPE 2 DIABETES PATIENTS IN THE SOUTH ARE LESS APT TO HAVE CERTAIN TESTS DONE

In 2013, Type 2 diabetes

patients in the South region

were less likely than their

peers nationally to receive

any one of five tests. For

instance, 72.1% of such

patients in the South had

an A1c test, compared with

74.2% nationally, and 67.5%

in the South had a urine

microalbumin test versus 71.5%

across the U.S. Meanwhile,

of Type 2 diabetes patients

who received an A1c test in

2013, those in the Northeast

region were most apt to

be covered by Medicaid

(78.3%) instead of commercial

insurance (77.1%) or Medicare

(71.9%). In all other regions

and nationally, such patients

were more likely to have

commercial insurance.

TYPE 2 DIABETES PATIENTS IN THE MIDWEST AND SOUTH HAVE HIGH A1c LEVELS

In 2013, the percentages

of Type 2 diabetes patients

in the Midwest and South

regions who had A1c levels

of 8.0% to 9.0% or above 9.0%

exceeded those of the nation.

For instance, 16.9% of such

patients in the Midwest and

16.5% in the South had A1c

levels above 9.0%, versus 16.3%

of such patients across the U.S.


DIABETESDIABETES: PHARMACOTHERAPY


PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, 20131

Any Insulin Products

Long-Acting Insulin Short-Acting Insulin Rapid-Acting Insulin Mixed Insulin

REGION Pens Vials Pens Vials Pens Vials Pens Vials

West 35.4% 15.7% 13.9% 9.3% 11.4% 9.3% 9.6% 1.7% 2.6%

Midwest 36.2 18.9 10.7 12.0 9.6 12.0 8.1 2.4 2.6

Northeast 32.3 18.1 8.0 10.6 7.1 10.6 6.0 3.0 2.3

South 33.7 16.4 9.8 9.3 8.7 9.3 7.0 2.9 3.8

NATION 34.3% 17.2% 10.3% 10.1% 9.0% 10.1% 7.5% 2.6% 3.0%

PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING NON-INSULIN ANTIDIABETIC THERAPIES1

Any Non-InsulinAntidiabetic

ProductSulfonylureas DPP-4 Inhibitors Insulin Sensitizing

AgentsGLP-1 Receptor

Agonists

REGION 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013

West 84.4% 84.3% 34.5% 33.5% 12.6% 12.7% 9.3% 7.3% 4.7% 5.1%

Midwest 82.9 83.0 34.8 33.7 10.8 10.8 6.7 5.4 4.8 5.2

Northeast 85.8 85.8 35.6 34.9 15.8 15.6 6.9 5.0 4.5 4.8

South 84.8 85.2 33.6 32.9 12.2 12.1 6.4 5.0 5.4 5.8

NATION 84.6% 84.7% 34.4% 33.6% 12.8% 12.7% 7.1% 5.5% 4.9% 5.3%

1 Patients who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa.

2 Figures reflect the percentages of Type 2 diabetes patients who were readmitted to an inpatient facility in the three-year period between 2011 and 2013. These percentages include patients who filled multiple prescriptions. Readmissions are not necessarily due to Type 2 diabetes.

Dipeptidyl Peptidase 4 (DPP-4) Inhibitors Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels.

GLP-1 Receptor Agonists Used in conjunction with oral agents; increase glucose-dependent insulin secretion and pancreatic beta-cell sensitivity, reduce glucagon production, slow rate of absorption of glucose in the digestive tract by slowing gastric emptying, and suppress appetite.

Insulin Sensitizing Agents Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose.

Sulfonylureas Stimulate the release of insulin in the pancreas.

INSULIN USE IN SOUTH, NORTHEAST REGIONS TRAILS NATIONAL AVG.

The percentages of Type 2

diabetes patients dispensed

any insulin products in 2013


nation (34.3%) in the South

(33.7%) and Northeast (32.3%)

regions. The South (16.4%)

and West (15.7%) regions also

recorded lower portions of

Type 2 diabetes patients who

received long-acting insulin

pens than the U.S. rate of

17.2%. Meanwhile, the shares

of such patients dispensed

any non-insulin antidiabetic

product were higher than

that of the U.S. (84.7%) in the

Northeast and South regions.

READMIT RATES ARE LOW IN SEVERAL REGIONS FOR TYPE 2 PTS. PRESCRIBED INSULIN PENS

In the Mid-Atlantic, Midwest

and Northeast regions, three-

and 30-day readmission rates

for Type 2 diabetes patients

treated in the inpatient

hospital setting were lowest for

those prescribed insulin pens

than any other profiled insulin

or non-insulin antidiabetic

therapy in the three years

from 2011 to 2013. In the

Pacific region, the three-day

readmit rate was lower for

such patients dispensed insulin

pens than any other insulin

or non-insulin therapy shown,

and the 30-day rates were the

same for insulin pens and vials.

READMISSION RATES FOR PATIENTS DIAGNOSED WITH TYPE 2 DIABETES, BY TYPE OF THERAPY, 2011–20131,2

REGION

Three-Day Readmissions 30-Day Readmissions


InsulinPens

InsulinVials

Three Non-Insulin Products


Insulin Pens

InsulinVials

Three Non-Insulin Products

Mid-Atlantic 10.2% 7.7% 10.4% 13.9% 19.4% 16.1% 19.0% 25.0%

Midwest 9.4 5.5 9.6 11.4 19.4 15.2 19.4 21.6

Northeast 10.2 6.0 10.5 13.8 20.2 15.2 20.1 24.9

Pacific 8.4 6.8 8.2 11.7 16.5 15.5 15.5 22.0

Southeast 10.0 9.9 9.3 13.9 18.9 18.5 17.6 23.6

Southwest 9.7 11.8 7.2 14.8 17.9 19.6 14.8 24.7

NATION 9.9% 9.0% 9.3% 13.6% 18.9% 17.6% 17.8% 23.9%


915 Wilshire Boulevard, Suite 1620 Los Angeles, CA 90017(213) 624-CAPG

© 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY US.NMH.15.01.106

Initial drugmonotherapy Efficacy (�HbA1c) Hypoglycemia Weight Side Effects Costs

Two-drugcombinationsa

Efficacy (�HbA1c) Hypoglycemia Weight Major Side Effect(s) Costs

Three-drugcombinations

More complexinsulin strategies

Healthy eating, weight control, increased physical activity

Metforminhigh

low riskneutral/loss

GI/lactic acidosislow

If needed to reach individualized HbA1c target after ≈3 months, proceed to two-drug combination(order not meant to denote any specific preference):

Metformin+

Sulfonylureab

highmoderate risk

gainhypoglycemiac

low

Metformin+

Thiazolidinedione

highlow risk

gainedema, HF, Fxsc

high

Metformin+

DPP-4 Inhibitor

intermediatelow riskneutralrarec

high

Metformin+

GLP-1 Receptor Agonist

highlow risk

lossGIc

high

Metformin+

Insulin (Usually Basal)

highesthigh risk

gainhypoglycemiac

variable

If needed to reach individualized HbA1c target after ≈3 months, proceed to three-drug combination(order not meant to denote any specific preference):

Metformin+

Sulfonylureab

+TZD

or DPP-4or GLP-1-RAor Insulind

Metformin+

Thiazolidinedione+

Sulfonylureab

or DPP-4or GLP-1-RAor Insulind

Metformin+

DPP-4 Inhibitor+

Sulfonylureab

or TZDor Insulind

Metformin+

GLP-1 Receptor Agonist+

Sulfonylureab

or TZDor Insulind

Metformin+

Insulin (Usually Basal)+

TZDor DPP-4

or GLP-1-RA

If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3–6 months,proceed to a more complex insulin strategy, usually in combination with one or two non-insulin agents:

Insuline

(multiple daily doses)

Antihyperglycemic therapy in Type 2 diabetes: general recommendations. Moving from the top to the bottom

of the figure, potential sequences of antihyperglycemic therapy. In most patients, begin with lifestyle changes;

metformin monotherapy is added at, or soon after, diagnosis (unless there are explicit contraindications). If the

HbA1c target is not achieved after approximately 3 months, consider one of the five treatment options combined

with metformin: a sulfonylurea, TZD, DPP-4 inhibitor, GLP-1 receptor agonist, or basal insulin. (The order in

the chart is determined by historical introduction and route of administration and is not meant to denote any

specific preference.) Choice is based on patient and drug characteristics, with the overriding goal of improving

glycemic control while minimizing side effects. Shared decision making with the patient may help in the selection

of therapeutic options. The figure displays drugs commonly used both in the U.S. and/or Europe. Rapid-acting

secretagogues (meglitinides) may be used in place of sulfonylureas. Other drugs not shown (a-glucosidase

inhibitors, colesevelam, dopamine agonists, pramlintide) may be used where available in selected patients but

have modest efficacy and/or limiting side effects. In patients intolerant of, or with contraindications for, metformin,

select initial drug from other classes depicted and proceed accordingly. In this circumstance, while published trials

are generally lacking, it is reasonable to consider three-drug combinations other than metformin. Insulin is likely

to be more effective than most other agents as a third-line therapy, especially when HbA1c is very high (e.g.,

≥9.0%). The therapeutic regimen should include some basal insulin before moving to more complex insulin

strategies. Dashed arrow line on the left-hand side of the figure denotes the option of a more rapid progression

from a two-drug combination directly to multiple daily insulin doses, in those patients with severe hyperglycemia

(e.g., HbA1c ≥10.0–12.0%). a Consider beginning at this stage in patients with very high HbA1c (e.g., ≥9.0%). b Consider rapid-acting, non-sulfonylurea secretagogues (meglitinides) in patients with irregular meal schedules

or who develop late postprandial hypoglycemia on sulfonylureas. c See Table 1 of the Position Statement for additional potential adverse effects and risks. d Usually a basal insulin in combination with non-insulin agents. e Certain non-insulin agents may be continued with insulin. Consider beginning at this stage if patient presents

with severe hyperglycemia (≥16.7–19.4 mmol/L [≥300–350 mg/dL]; HbA1c ≥10.0–12.0%) with or without catabolic features (weight loss, ketosis, etc.).

Key: DPP-4=DPP-4 inhibitor; Fxs=bone fractures; GI=gastrointestinal; GLP-1-RA=GLP-1 receptor agonist; HF=heart failure; TZD=thiazolidinedione.

Adapted from the 2012 ADA/EASD Position Statement

Inzucchi, S. E., et al. (2012). Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach: Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. Retrieved from http://care.diabetesjournals.org/content/early/2012/04/17/dc12-0413.full.pdf+html

MethodologyGENERAL DATA

IMS Health gathered national-, state- and local-level data included in this Summary from a variety of sources between February 2011 and June 2014, by contacting each state’s department of insurance, mailing a survey to each plan and following up, when necessary, with a telephone or email survey.

Most data in this Summary are from a census of health plans. When data were not available from all plans, a smaller sample was used.

In addition, IMS Health compares its data with those published in other sources, including trade associations in the managed care industry, state regulatory agencies, and periodicals and journals. Doing so provides an additional check on the accuracy of its database of operating health plans. Hospital data for this report are based on information from the IMS Health Hospital Procedure/Diagnosis (HPD) database.

IMS Health generated Type 2 diabetes data for this Summary out of health care professional and institutional insurance claims, representing more than 7.7 million unique Type 2 diabetes patients nationally in 2013 with a diagnosis in the 250.00–250.92 range. Data from physicians of all specialties and from all hospital types are included.

IMS Health also gathers data on prescription activity from the National Council for Prescription Drug Programs (NCPDP). These data represent some 2 billion prescription claims annually, or more than 50% of the prescription universe. These data represent the sampling of prescription activity from a variety of sources, including retail chains, mass merchandisers and pharmacy benefit managers. Cash, mail-order, Medicaid and third-party transactions are tracked.

MARKET DEFINITIONS

IMS Health gathered information on the service areas of every health plan—commercial, Medicare and Medicaid—during the survey process, then aggregated it to the appropriate metropolitan statistical area (MSA) and state level. Finally, to ensure the integrity of the data, MSA data are reported only for those areas served by five or more health plans. All health plan demographic and utilization data in this Summary include members in point-of-service (POS) plans.

Unless otherwise noted, data provided in this Summary are based on total health plan enrollment, including Medicare beneficiaries and Medicaid recipients. Utilization data provided on Medicare beneficiaries and Medicaid recipients enrolled in health plans were gathered only from those plans in each state that have such members.

ANAGED CARE DIGEST SERIES SI N C E 1 9 8 7 HOSPITALS ...€¦ · Kelvin Yamashita...

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