CITY_OF_EDINBURG_000243483_AL_-_City_of_Edinburg_Utilization_Analysis_(Oct_'23_to_Sept_'24).pdf

Blue Insight℠ Utilization Analysis Report

Incurred_10/01/2023 to 09/30/2024 Paid 10/01/2023 to 11/30/2024

CITY OF EDINBURG 000243483: ALL

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association © Copyright 2026 Health Care Service Corporation. All rights reserved.

Data Parameters 3

Executive Summary 4

Executive Summary Dashboard 5

Enrollment Overview 6

Key Indicators 7-8

Top Diagnostic Categories 9

Musculoskeletal and Connective Tissue 10

Neoplasms 11

Circulatory 12

Adult Chronic Conditions Analysis 13

High Cost Claimants Overview 14

High Cost Claimants Trend 15

High Cost Claimants Additional Details 16

High Cost Claimants Diagnostic Categories 17

High Cost Claimants Listing 18

Inpatient Facility Overview 19

Inpatient Facility – Details by Service Type 20

PLAN PERFORMANCE

Inpatient Deliveries 21

Inpatient Provider Summary 22

Outpatient Facility Overview 23

Outpatient Facility – Details by Service Type 24

Emergency Room Overview 25

Emergency Room – Leading Diagnoses 26

Frequent Users of the Emergency Room 27

Outpatient Provider Summary 28

Professional Services Overview 29

Professional Services – Details by Service Type 30

Preventive Care 31

Pharmacy Overview 32

Pharmacy: Top Non-Specialty Therapeutic Drug Classes 33

Pharmacy: Specialty Drug Analysis 34

Appendix: Financial Summary 35

Appendix: Glossary 36

CITY OF EDINBURG 000243483: ALL

Table of Contents

Data Parameters 3

Executive Summary 4

Executive Summary Dashboard 5

Enrollment Overview 6

Key Indicators 2 7

Top Diagnostic Categories 8

Adult Chronic Conditions Analysis 9

High Cost Claimants Trend 10

High Cost Claimants Additional Details 11

Inpatient Facility Overview 12

PLAN PERFORMANCE

Outpatient Facility Overview 13

Emergency Room Overview 14

Emergency Room – Leading Diagnoses 15

Frequent Users of the Emergency Room 16

Professional Services Overview 17

Preventive Care 18

Appendix: Glossary 19

CITY OF EDINBURG 000243483: ALL

Table of Contents

Benchmark data is based on Texas group population. Select benchmark utilization and expense measures, such as PMPMs and rates per 1,000, have been adjusted to reflect the group's age and gender distribution.

High Cost Claimants are defined as members with paid expenses greater than $50,000_within the reporting period.

The report includes medical and pharmacy claims.

Reporting Segments: ALL Characteristics: ALL Group/Sections: ALL Member MSA: ALL Group: ALL Medicare Primary Indicator: ALL Funding Type: ALL Product Type: ALL Employee Status: ALL Database(s): CITY OF EDINBURG 000243483: ALL

Reporting Support Contact Information

For reporting support, please contact Client Reporting Service Center Email: client_reporting@bcbsil.com Hours of Operation: Monday - Friday: 8:00am - 5:00pm CT

Report prepared on 07/02/2026

Current Reporting Period: The current reporting period represents claims incurred from October 1, 2023 through September 30, 2024 and paid October 1, 2023 through November 30, 2024.

Prior Reporting Period: The prior reporting period represents claims incurred from October 1, 2022 through September 30, 2023 and paid October 1, 2022 through November 30, 2023.

CITY OF EDINBURG 000243483: ALL

Data Parameters

CITY OF EDINBURG 000243483: ALL’s overall enrollment increased by_0.1%_between the two reporting periods. The average age among CITY OF EDINBURG 000243483: ALL’s members increased from 32.9 to 33.2_years of age. The gender mix of the population was 37.4%_female and 62.6%_male.

The overall paid expense per member per month (PMPM) increased by_6.8%_between the two reporting periods. The service category that impacted the paid PMPM trend the most was_inpatient facility, which increased by_36.1%. Additionally, paid PMPM for CITY OF EDINBURG 000243483: ALL_was_26.0%_lower than_the benchmark.

Inpatient paid PMPM increased by_36.1%_between reporting periods. The top two admission types by paid PMPM were Surgical_and_Medical. Surgical_increased by_>100%. Medical_decreased by_11.4%.

Outpatient paid PMPM increased by_0.7%_between reporting periods. The top two outpatient facility visit types by paid PMPM were Surgical_and Emergency Room. Surgical_increased by_93.8%._Emergency Room_decreased by_15.3%.

Professional paid PMPM decreased by_4.6%_between reporting periods. The top two professional service types by paid PMPM were Evaluation & Management_and Pathology & Laboratory. Evaluation & Management_decreased by_7.6%. Pathology & Laboratory_increased by_25.9%.

CITY OF EDINBURG 000243483: ALL’s overall top four diagnostic categories by paid expense PMPM were_Neoplasms, Circulatory, Health Status, and Infectious/Parasitic.These four diagnostic categories accounted for 49.1% of the overall paid expenses in the current reporting period.

For high cost claimants the total paid expenses increased by_92.7%_between the two reporting periods. HCCs are defined as claimants whose total expense equaled or exceeded $50,000. The number of HCCs also increased by_71.4%_from 14_to_24_during the same time frame. The proportion of paid expenses due to high cost claimants increased from 33.9% to 35.7% between reporting periods.

Paid PMPM for Emergency Room (ER) visits decreased by_15.3%_between reporting periods.Total ER visits/1,000 decreased by_20.3%_in the current reporting period and was 16.5%_lower than_the benchmark.

In the current reporting period, primary care physicians (PCP) accounted for 43.9%_of professional office visits compared to 30.7%_for the benchmark. PCPs accounted for 35.2%_of professional office expenses.

Medical paid PMPM increased by_5.8%_between reporting periods and was_28.6%_lower than_the benchmark.

Pharmacy paid PMPM_increased by_9.1%_between reporting periods.

CITY OF EDINBURG 000243483: ALL

Executive Summary

Oct 2022 - Sep

Oct 2023 - Sep 2024 % Change Benchmark

Allowed $5,294,590 $9,748,746 84.1%

Paid $4,245,582 $7,775,466 83.1%

Paid PMPM $347.94 $371.45 6.8% $501.73

Medical Plan Performance

Plan Share 78.3% 79.9% 83.3%

In-Network Paid % 99.9% 99.9% 99.3%

Discount % 73.6% 75.5% 63.6%

Members 1,743 1,744 0.1%

Subscribers 1,092 1,099 0.7%

Dependents 651 645 -0.9%

Key Metrics

Paid

PMPM

6.8%

Claimant Distribution % of Total Paid % of Total Unique Members

Dollar Range Prior Current Benchmark Prior Current Benchmark Non-Utilizers 0.0% 0.0% 0.0% 23.5% 19.8% 20.0%

$0-$50K 66.1% 64.3% 52.4% 75.8% 79.0% 78.4%

$50K-$100K 10.9% 11.5% 14.6% 0.4% 0.7% 0.9%

$100K-$300K 15.6% 19.4% 19.5% 0.3% 0.4% 0.6%

$300K and + 7.5% 4.9% 13.4% 0.1% 0.0% 0.1%

HCC Subtotal 33.9% 35.7% 47.6% 0.7% 1.2% 1.6%

Utilization

Cost and Case Mix

High Cost Claimants

Benchmark

-5.9%

-0.5%

2.7%

CITY OF EDINBURG 000243483: ALL

Executive Summary Dashboard

Reporting Period Oct 2022 - Sep 2023

Oct 2023 - Sep 2024 % Change Benchmark

Benchmark Variance

Average Membership 1,743 1,744 0.1% Employee 1,092 1,099 0.7% Spouse 116 116 0.4% Dependent 536 529 -1.2% Average Contract Size 1.6 1.6 -0.6% 1.8 -13.8% Average Age 32.9 33.2 0.7% 35.0 -5.2% Employee 41.2 41.4 0.6% 44.5 -6.8% Spouse 44.1 44.0 -0.3% 47.2 -6.7% Dependent 13.7 13.6 -0.6% 13.0 5.0%

% Under 30 45.7% 45.2% 40.8% % 30 to 49 33.8% 33.9% 32.7% % 50 to 64 19.3% 19.7% 22.7% % 65+ 1.2% 1.3% 3.8% Gender % of Males 62.6% 62.6% 49.8% % of Females 37.4% 37.4% 50.2% % of Females Ages 20-44 17.4% 17.0% 20.6%

• Overall, membership increased by_0.1%_between reporting periods.

• The average age was 33.2and increased by_0.7%_between reporting periods.

• Contract size decreased by_0.6%_between reporting periods.

• The percentage of females between ages 20 and 44 decreased from_17.4% to 17.0%_between reporting periods.

CITY OF EDINBURG 000243483: ALL

Enrollment Overview

The above chart shows the % change from prior period to current period in paid PMPM, the % change in the amount paid per service (cost), and the % change in the number of services per 1,000 (utilization) by service category.

$371.45 Current Paid

PMPM

6.8% Change Year

Over Year

26.0% Lower than Benchmark

Cost Utilization Cost Utilization Cost Utilization

39.4% -2.4% 13.9% -11.6% -4.1%-0.6%

Cost Utilization

3.7% 5.3%

Inpatient Facility

Outpatient Facility

Professional

6.8%

PMPM

36.1%

IP PMPM

0.7%

OP PMPM

-4.6%

PS PMPM

Pharmacy

9.1%

RX PMPM

CITY OF EDINBURG 000243483: ALL

Key Indicators

• Total medical paid PMPM increased_5.8%_in the current reporting period and was28.6%_below_the benchmark.

• Excluding high cost claimants, the total paid PMPM trend was 3.9%.

Service Category Reporting Period

Oct 2022 - Sep 2023

Oct 2023 - Sep 2024 % Change Benchmark

Benchmark Variance

Inpatient Facility

Paid PMPM $49.08 $66.78 36.1% $99.24 -32.7% Paid PEPM $78.36 $105.98 35.2% $186.15 -43.1% Allowed PMPM $57.81 $94.77 63.9% $112.84 -16.0% Admissions/1,000 45.2 44.1 -2.4% 45.0 -2.0% Days/1,000 152.4 206.9 35.8% 241.8 -14.4% Average Length of Stay 3.4 4.7 39.1% 5.4 -12.7% Paid/Admission $13,019 $18,154 39.4% $26,448 -31.4% Paid/Day $3,864 $3,872 0.2% $4,925 -21.4%

Outpatient Facility

Paid PMPM $113.26 $114.03 0.7% $137.03 -16.8% Paid PEPM $180.84 $180.98 0.1% $264.72 -31.6% Allowed PMPM $147.43 $144.04 -2.3% $183.74 -21.6% Visits/1,000 1,383.7 1,222.8 -11.6% 1,254.3 -2.5% Paid/Visit $982 $1,119 13.9% $1,311 -14.6%

Professional

Paid PMPM $86.85 $82.85 -4.6% $132.87 -37.7% Paid PEPM $138.67 $131.49 -5.2% $260.58 -49.5% Allowed PMPM $116.68 $111.41 -4.5% $173.37 -35.7% Services/1,000 21,394.9 20,526.1 -4.1% 20,178.5 1.7% Paid/Service $49 $48 -0.6% $79 -38.7%

Medical Summary

Paid PMPM $249.18 $263.65 5.8% $369.14 -28.6% Paid PEPM $397.87 $418.46 5.2% $711.44 -41.2% Allowed PMPM $321.92 $350.22 8.8% $469.94 -25.5% In-Network Paid % 99.9% 99.9% 99.3% In-Network Services % 99.0% 98.7% 98.1% Plan Share % 78.3% 79.9% 83.3%

Pharmacy

Rx Paid PMPM $98.76 $107.79 9.1% $132.59 -18.7% Rx Paid PEPM $157.69 $171.09 8.5% $250.85 -31.8% Rx Allowed PMPM $111.99 $115.49 3.1% $147.18 -21.5% Prescriptions/Member 10.8 11.4 5.3% 12.6 -9.5% Paid/Prescription $109 $113 3.7% $126 -10.2%

Overall Summary

Paid PMPM $347.94 $371.45 6.8% $501.73 -26.0% Paid PEPM $555.56 $589.54 6.1% $962.29 -38.7% Allowed PMPM $433.91 $465.71 7.3% $617.12 -24.5%

CITY OF EDINBURG 000243483: ALL

Key Indicators

Diagnostic Categories with Paid PMPM Oct 2022 - Sep 2023

Oct 2023 - Sep 2024

% Change Benchmark Benchmark Variance

Neoplasms $53.01 $39.63 -25.2% $45.28 -12.5%

Circulatory $14.88 $36.22 >100% $38.61 -6.2%

Health Status $26.71 $30.46 14.1% $32.56 -6.5%

Infectious/Parasitic $11.90 $23.22 95.1% $12.13 91.5%

Digestive $18.96 $21.75 14.7% $26.75 -18.7%

Symptoms/Ill-Defined $15.38 $17.32 12.6% $20.16 -14.1%

Genitourinary $15.12 $12.92 -14.6% $17.67 -26.9%

Respiratory $9.37 $12.07 28.8% $14.50 -16.8%

Endocrine $10.56 $11.64 10.2% $12.80 -9.1%

Mental Health $8.51 $10.77 26.6% $20.21 -46.7%

All Others $64.78 $47.66 -26.4% $128.47 -62.9%

Total $249.18 $263.65 5.8% $369.14 -28.6%

• Neoplasms_was the most costly diagnostic category and paid_PMPM _decreased_25.2%_ between reporting periods.

• The top 4 diagnostic categories accounted for _49.1%_ of total medical costs in the current period.

• The_Circulatory_category experienced the largest percentage increase in the current period.

CITY OF EDINBURG 000243483: ALL

Top Diagnostic Categories

Reporting Period Oct 2022 - Sep 2023 Oct 2023 - Sep 2024 % Change Benchmark Benchmark

Variance

Inpatient

Paid PMPM $0.70 0.0% $6.55 -89.3%

Admissions/1,000 0.6 0.0% 1.4 -58.2%

Paid/Day $0 $244 0.0% $14,050 -98.3%

Paid/Admission $0 $14,631 0.0% $57,234 -74.4%

Outpatient

Paid PMPM $6.51 $3.78 -41.9% $16.27 -76.8%

Visits/1,000 118.0 75.7 -35.9% 150.1 -49.6%

Paid/Visit $662 $600 -9.4% $1,300 -53.9%

Professional

Paid PMPM $3.02 $2.88 -4.6% $14.33 -79.9%

Services/1,000 1,183.1 1,099.5 -7.1% 2,573.9 -57.3%

Paid/Service $31 $31 2.6% $67 -53.0%

Total Medical

Paid PMPM $9.53 $7.36 -22.8% $37.15 -80.2%

Non High Cost $6.27 $6.91 10.2% $20.45 -66.2%

High Cost $3.26 $0.45 -86.1% $16.70 -97.3%

Paid/Claimant $444 $435 -1.9% $1,452 -70.0%

Claimants/1,000 150.3 202.9 35.0% 251.5 -19.3%

% of Total Medical Paid 3.8% 2.8% 10.7%

Musculoskeletal paid PMPM accounted for 2.8%_of the total medical paid PMPM

Pa id

P M

PM

$0 Spinal Surgery Knee Replacement

Hip Replacement

Prior $0.00 $0.00 $0.04

Current $0.07 $0.00 $0.00

Benchmark $5.77 $1.31 $0.90

M ed ic al

C la im an ts /1

,0

0 Spinal Surgery Knee Replacement

Hip Replacement

Prior 0.0 0.0 0.6

Current 0.6 0.0 0.0

Benchmark 1.8 1.3 0.8

Common Musculoskeletal Surgical Procedures Paid PMPM

Common Musculoskeletal Surgical Procedures Claimants/1,000

CITY OF EDINBURG 000243483: ALL.

Musculoskeletal and Connective Tissue

Variance Inpatient

Paid PMPM $5.82 $1.92 -67.0% $8.74 -78.0%

Admissions/1,000 3.0 1.7 -41.7% 2.1 -17.8%

Paid/Day $4,736 $8,041 69.8% $8,581 -6.3%

Paid/Admission $23,681 $13,401 -43.4% $50,167 -73.3%

Outpatient

Paid PMPM $35.84 $29.94 -16.5% $24.40 22.7%

Visits/1,000 77.7 106.6 37.2% 72.3 47.4%

Paid/Visit $5,536 $3,369 -39.1% $4,048 -16.8%

Professional

Paid PMPM $11.35 $7.77 -31.5% $12.13 -36.0%

Services/1,000 623.5 499.9 -19.8% 592.5 -15.6%

Paid/Service $218 $187 -14.6% $246 -24.1%

Total Medical

Paid PMPM $53.01 $39.63 -25.2% $45.28 -12.5%

Non High Cost $2.84 $4.67 64.7% $7.66 -39.0%

High Cost $50.17 $34.96 -30.3% $37.62 -7.1%

Paid/Claimant $11,761 $10,369 -11.8% $6,071 70.8%

Claimants/1,000 31.6 45.9 45.3% 82.7 -44.5%

% of Total Medical Paid 21.3% 15.0% 13.4%

4.6%_of members had a Neoplasms diagnosis compared to 9.9%_of the book of business members

Breast Cervical Colorectal Endocrine Leukemia Lymphoma Melanoma Non-

Melanoma Prostate Respiratory Claimants 7.5% 0.0% 5.0% 2.5% 0.0% 3.8% 0.0% 0.0% 3.8% 0.0%

Paid 20.3% 0.0% 24.4% 8.8% 0.0% 25.4% 0.0% 0.0% 0.1% 0.0%

CITY OF EDINBURG 000243483: ALL

Neoplasms

Variance

Inpatient

Paid PMPM $5.99 $14.33 >100% $17.88 -19.8%

Admissions/1,000 4.9 10.3 >100% 5.5 87.7%

Paid/Day $3,179 $5,358 68.6% $7,592 -29.4%

Paid/Admission $14,622 $16,669 14.0% $39,039 -57.3%

Outpatient

Paid PMPM $4.28 $16.74 >100% $13.31 25.8%

Visits/1,000 91.5 79.1 -13.5% 79.3 -0.3%

Paid/Visit $562 $2,539 >100% $2,014 26.1%

Professional

Paid PMPM $4.61 $5.14 11.6% $7.42 -30.6%

Services/1,000 1,724.0 1,651.0 -4.2% 1,096.2 50.6%

Paid/Service $32 $37 16.5% $81 -54.0%

Total Medical

Paid PMPM $14.88 $36.22 >100% $38.61 -6.2%

Non High Cost $9.26 $13.70 48.0% $12.88 6.4%

High Cost $5.63 $22.52 >100% $25.73 -12.5%

Paid/Claimant $588 $1,919 >100% $2,145 -10.5%

Claimants/1,000 177.3 226.4 27.7% 189.3 19.6%

% of Total Medical Paid 6.0% 13.7% 10.2%

Circulatory paid PMPM accounted for 13.7%_of the total medical paid PMPM

Pa id

P M

PM

$0Coronary Heart Disease

High Blood Pressure

Heart Attack Stroke Arterial Plaque

Prior $0.00 $2.84 $0.00 $0.00 $0.00

Current $4.62 $3.92 $2.99 $1.85 $0.88

Benchmark $1.93 $3.01 $2.86 $2.94 $0.22

Inpatient Circulatory Top Five Diagnoses by Paid PMPM

CAD Diabetes CHF Hyperlipidemia Hypertension Current 21.8 83.1 4.0 134.1 169.7

Benchmark 17.1 37.5 5.9 74.6 117.1

Common Circulatory Comorbidity: Claimants/1,000

Claimants can be counted in more than one chronic condition category.

CITY OF EDINBURG 000243483: ALL

Circulatory

Oct 2023 - Sep 2024 Benchmark

Benchmark Variance

CHF 6.5 8.1 -20.0%

CAD 29.4 25.0 17.6%

Claimants/1,000 Diabetes 162.2 98.1 65.4%

Hyperlipidemia 310.8 193.8 60.4%

Hypertension 262.0 203.4 28.8%

No Chronic Conditions 583.6 738.3 -21.0%

CHF $46,547 $57,093 -18.5%

CAD $25,441 $24,713 2.9%

Paid/Claimant Diabetes $11,278 $10,535 7.1%

Hyperlipidemia $8,257 $6,706 23.1%

Hypertension $8,481 $9,464 -10.4%

No Chronic Conditions $2,370 $2,211 7.2%

CHF $25.06 $31.22 -19.7%

CAD $62.39 $54.46 14.6%

Paid PMPM Diabetes $152.46 $129.27 17.9%

Hyperlipidemia $213.86 $172.53 24.0%

Hypertension $185.16 $213.59 -13.3%

No Chronic Conditions $115.26 $157.13 -26.6%

• Hyperlipidemia_was the most prevalent chronic condition and was above the benchmark.

• CHF_was the most costly chronic condition on a Paid/Claimant basis and was below the benchmark.

* For a member to be included in one of these chronic condition categories, they must be 18 years or older and have had at least two claims for one of the chronic condition categories that were incurred within 180 days of each other and paid within the last 39 months. Paid per claimant and Paid PMPM rates are for those members in each chronic condition category for the most current reporting period. Costs include the total claimant cost and are not limited to the cost of the chronic condition. This report includes medical and pharmacy claims where applicable. Claimants and their claim spend can be counted in more than one chronic condition category in this report. CAD: Coronary Artery Disease; CHF: Chronic Heart Failure.

Per the American Heart Association, three of the seven key health factors that increase the risks for heart disease and stroke include: High Blood Pressure (Hypertension), High Cholesterol (Hyperlipidemia) and High Blood Glucose (Diabetes). The below chart and bar graphs show key metrics for CITY OF EDINBURG 000243483: ALL for five types of chronic conditions* along with comparative data for members who did not have any known type of chronic condition. All data reflects members aged 18 and above.

CITY OF EDINBURG 000243483: ALL

Adult Chronic Conditions Analysis

1.38% Of Membership

2.08%_Benchmark

35.7% of Total Paid

47.6%_Benchmark Accounted for

High Cost Claimants

14_prior

33.3% Repeat HCCs 21.9%_Benchmark

$2.8M Total Paid

$1.4_M_in prior period

75.0% Employees

60.9%_Benchmark

Average Age

47_Benchmark

29.2% Female

51.8%_Benchmark

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Overview

Oct 2022 - Sep 2023 Oct 2023 - Sep 2024 % Change Benchmark Benchmark Variance High Cost Claimants 14 24 71.4%

% of Total Members 0.80% 1.38% 2.08%

HCC Paid $1,440,140 $2,775,634 92.7%

% of Total Paid 33.9% 35.7% 47.6%

Total Paid PMPM $347.94 $371.45 6.8% $501.73 -26.0%

Non-High cost $229.92 $238.85 3.9% $266.30 -10.3%

High Cost $118.02 $132.60 12.3% $235.42 -43.7%

HCC Paid/Claimant $102,867 $115,651 12.4% $133,428 -13.3%

• 1.38%_of members were high cost claimants in the current period compared to 0.80%_in the prior period and 2.08%_for the benchmark.

• High cost claimants accounted for_35.7%_of total costs in the current period compared to 33.9%_in the prior period and 47.6%_for the benchmark.

• Paid PMPM for high cost claimants _increased by_12.3%_between the two reporting periods and was_43.7%_lower than_the benchmark.

• Paid PMPM excluding high cost claimants increased by_3.9%_between the two reporting periods and was 10.3%_lower than_the benchmark.

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Trend

• The_$100,000-$299,999_paid band experienced the largest percent increase_in paid dollars in the current reporting period.

• 24_claimants accounted for 35.7%_of the total paid amount in the current reporting period.

• By service category, Outpatient Facility_accounted for the largest percent of high cost claimant paid dollars in the current reporting period.

• Employee_accounted for the largest percent of high cost claimant paid dollars in the current reporting period.

Claimant Distribution by Paid Band

Oct 2022 - Sep 2023 Oct 2023 - Sep 2024 % Change Dollar Range Claimants Paid Paid % Claimants Paid Paid % Claimants Paid No Claims 444 $0 0.0% 400 $0 0.0% -9.9% 0.0%

$0-$49,999 1,432 $2,805,442 66.1% 1,599 $4,999,832 64.3% 11.7% 78.2%

$50,000-$99,999 8 $460,789 10.9% 14 $892,574 11.5% 75.0% 93.7%

$100,000-$299,999 5 $661,393 15.6% 9 $1,504,784 19.4% 80.0% 127.5%

$300,000+ 1 $317,958 7.5% 1 $378,276 4.9% 0.0% 19.0%

HCC Subtotal 14 $1,440,140 33.9% 24 $2,775,634 35.7% 71.4% 92.7%

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Additional Details

Oct 2022 - Sep 2023 Oct 2023 - Sep 2024 Top 5 HCC Diagnostic Categories by Paid Claimants Paid Paid/Claimant Paid % Claimants Paid Paid/Claimant Paid % Neoplasms 5 $680,258 $136,052 47.2% 6 $847,065 $141,177 30.5%

Circulatory 1 $108,879 $108,879 7.6% 8 $748,878 $93,610 27.0%

Infectious/Parasitic 1 $108,007 $108,007 7.5% 2 $439,421 $219,711 15.8%

Health Status 0 $0 $0 0.0% 4 $428,128 $107,032 15.4%

Digestive 1 $62,807 $62,807 4.4% 1 $115,647 $115,647 4.2%

All others 6 $480,188 $80,031 33.3% 3 $196,495 $65,498 7.1%

Summary 14 $1,440,140 $102,867 100.0% 24 $2,775,634 $115,651 100.0%

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Diagnostic Categories

Rank Relationship Age/Gender

Band Leading Diagnostic Category Leading Diagnosis Inpatient Paid Outpatient

Paid Professional

Paid Pharmacy Paid Total Paid Prior HCC Prior Period

Paid

1 Subscriber Male 50-59 Infectious/Parasitic Septicemia $280,728 $15,398 $78,911 $3,239 $378,276 NO $1,188

2 Subscriber Female 50-59 Health Status Organ transplant status $0 $3,210 $1,130 $225,522 $229,862 YES $104,439

3 Subscriber Female 50-59 Circulatory Myocarditis and cardiomyopathy $0 $112,386 $4,720 $104,226 $221,332 YES $54,205

4 Subscriber Male 20-29 Neoplasms Hodgkin lymphoma $0 $210,940 $1,580 $34 $212,554 YES $317,958

5 Subscriber Male 40-49 Neoplasms Gastrointestinal cancers - colorectal $31,023 $139,000 $23,461 $15,435 $208,919 NO $8,761

6 Subscriber Male 65+ Circulatory Myocarditis and cardiomyopathy $58,091 $73,917 $9,458 $9,792 $151,258 YES $108,879

7 Spouse Female 40-49 Neoplasms Breast cancer - all other types $0 $117,095 $24,370 $201 $141,666 YES $57,497

8 Subscriber Male 50-59 Neoplasms Endocrine system cancers - pancreas $19,730 $31,099 $47,873 $22,717 $121,419 YES $145,231

9 Spouse Male 50-59 Digestive Gastrointestinal and biliary perforation $103,214 $770 $11,563 $100 $115,647 NO $147

10 Subscriber Male 40-49 Neoplasms Gastrointestinal cancers - colorectal $0 $94,473 $6,459 $1,192 $102,124 YES $55,133

11 Subscriber Male 60-64 Circulatory Hypertension with complications and secondary hypertension $59,589 $7,325 $10,134 $825 $77,873 NO $26,914

12 Subscriber Male 60-64 Circulatory Coronary atherosclerosis and other heart disease $59,193 $0 $13,222 $4,409 $76,824 NO $2,798

13 Dependent Male <1-19 Mental Health Neurodevelopmental disorders $0 $635 $73,010 $128 $73,773 YES $50,508

14 Subscriber Female 40-49 Health Status Neoplasm-related encounters $0 $400 $1,147 $71,638 $73,185 NO $12,137

15 Subscriber Male 60-64 Nervous Polyneuropathies $55,619 $12,171 $4,118 $459 $72,367 NO NA

16 Dependent Male <1-19 Health Status Exposure, encounters, screening or contact with infectious disease $0 $0 $712 $63,258 $63,970 NO $15,396

17 Subscriber Female 50-59 Infectious/Parasitic Septicemia $36,661 $5,722 $8,933 $9,830 $61,146 NO $24,216

18 Dependent Male <1-19 Health Status Other aftercare encounter $0 $45,885 $3,729 $11,496 $61,110 NO $24,637

19 Subscriber Female 60-64 Neoplasms Breast cancer - all other types $0 $32,721 $12,317 $15,343 $60,381 NO $6,731

20 Subscriber Female 50-59 Circulatory Cerebral infarction $8,239 $29,445 $12,564 $7,422 $57,670 NO $12,410

* NA : member was not enrolled in prior period

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Listing

Variance

Medical Pharmacy Paid

PMPM $50.03 $28.64 -42.8% $52.79 -45.8%

Non High Cost $9.26 $10.12 9.3% $14.10 -28.2%

High Cost $40.77 $18.51 -54.6% $38.70 -52.2%

Paid/Claimant $1,071 $778 -27.4% $1,385 -43.8%

Claimants/1,000 327.0 442.0 35.2% 432.9 2.1%

Special Medical Pharmacy Paid PMPM $34.95 $14.95 -57.2% $30.22 -50.5%

Gene and Cell Therapy Paid

PMPM 0.0% $0.76 -100.0%

Med Rx as % of Total Paid 20.1% 10.9% 13.5%

• Total paid PMPM for Medical Pharmacy decreased by 42.8% in the current reporting period and was 45.8%below the benchmark.

• Neoplasms was the most costly diagnostic category for Medical Pharmacy and paid PMPM decreased by 54.8% between reporting periods.

• J9042 - ADCETRIS was the most costly drug for Medical Pharmacy and paid PMPM decreased by 23.6% between reporting periods.

Medical Pharmacy Paid PMPM by Top-3 Diagnostic Categories

Medical Pharmacy Paid — PMPM Top-5 Drugs*

Neoplasms accounted for 48.3% of the total Medical Pharmacy Paid PMPM in the current period.

*Leading diagnostic category for each drug is listed under drug name.

Pa id

P M

PM

$0.00 J9042 - ADCETRIS

Neoplasms

J9299 - OPDIVO

Neoplasms

Q5108 - FULPHILA

Neoplasms

J2350 - OCREVUS

Nervous

J9206 - CAMPTOSAR

Neoplasms

Prior $3.81 $9.29 $6.92 $6.03 $3.59

Current $4.71 $2.77 $1.89 $1.81 $1.23

Benchmark $0.54 $1.34 $0.42 $1.47 $0.10

Pa id

P M

PM

$0.00 Neoplasms Nervous Health Status

Prior $30.61 $6.31 $3.47

Current $13.83 $2.85 $2.69

Benchmark $18.36 $5.42 $5.01

Report Description: Medical Pharmacy applies only to drugs paid under the Medical Plan.

CITY OF EDINBURG 000243483: ALL.

Medical Pharmacy

• Inpatient paid PMPM increased by _36.1%_between the two reporting periods and was 32.7%_lower than_the benchmark.

• High Cost Claimants accounted for 58.0%_of total inpatient spend compared to 49.3%_from the previous reporting period.

• Admissions/1,000 decreased by _2.4%_between reporting periods and was 2.0%_lower than_the benchmark.

• Infectious/Parasitic_was the most costly diagnostic category for inpatient services in the current reporting period. It increased_>100%_and was >100%_higher than_ the benchmark.

Reporting Period Oct 2022 - Sep 2023

Oct 2023 - Sep 2024 % Change Benchmark

Benchmark Variance

Allowed $705,406 $1,983,877 >100% Allowed PMPM $57.81 $94.77 63.9% $112.84 -16.0% Paid $598,864 $1,397,826 >100% Paid PEPM $78.36 $105.98 35.2% $186.15 -43.1% Paid PMPM $49.08 $66.78 36.1% $99.24 -32.7% Non-High Cost $24.87 $28.04 12.8% $24.14 16.2% High Cost $24.21 $38.73 60.0% $75.10 -48.4%

Admissions 46 77 67.4% Admissions/1,000 45.2 44.1 -2.4% 45.0 -2.0% Days/1,000 152.4 206.9 35.8% 241.8 -14.4% Average Length of Stay 3.4 4.7 39.1% 5.4 -12.7% Paid/Admission $13,019 $18,154 39.4% $26,448 -31.4% In-Network Paid % 100.0% 100.0% 99.3% In-Network Admissions % 100.0% 100.0% 98.7%

CITY OF EDINBURG 000243483: ALL

Inpatient Facility Overview

Inpatient Paid PMPM by Service Type Inpatient Admissions/1,000 by Service Type

Inpatient Paid/Admission by Service Type Inpatient Average Length of Stay (ALOS) by Service Type2023

Ad m iss io ns /1

,0

0 Medical Surgical Maternity Mental Health Complex Newborns

Prior 17.7 7.9 11.8 2.0 4.9

Current 16.1 13.8 8.0 4.6 1.1

Benchmark 15.6 9.2 9.6 5.2 4.2

Pa id

P M

PM

$0 Surgical Medical Maternity Mental Health Complex Newborns

Prior $13.95 $21.45 $7.28 $0.38 $0.94

Current $38.92 $19.00 $5.67 $1.63 $0.86

Benchmark $46.00 $28.90 $7.74 $4.27 $7.83

AL

O

S

0 Post-Acute Care Surgical Complex Newborns

Mental Health Medical

Prior 12.0 3.6 2.0 3.0 4.0

Current 60.0 5.2 5.0 4.4 3.6

Benchmark 18.4 5.2 5.4 11.2 4.2

Pa id

/ A dm iss io n

$0 Surgical Post-Acute Care Medical Complex Newborns

Maternity

Prior $21,279 $61,859 $14,543 $2,302 $7,403

Current $33,949 $14,631 $14,204 $9,008 $8,475

Benchmark $59,870 $40,775 $22,271 $22,390 $9,725

CITY OF EDINBURG 000243483: ALL

Inpatient Facility - Details by Top 5 Service Types

Normal Delivery and C-Section Overview:

Paid PMPM Admissions/1,000 Paid/Admission

Reporting Period Oct 2022 - Sep 2023

Oct 2023 - Sep 2024 % Change Benchmark

Benchmark Variance

Paid $75,051 $87,821 17.0%

Paid PMPM $6.15 $4.20 -31.8% $6.71 -37.5%

Admissions 12 13 8.3%

C-Section Delivery 3 5 66.7%

Normal Delivery 9 8 -11.1%

Admissions/1,000 11.8 7.5 -36.9% 8.9 -16.1%

Days/1,000 25.6 14.3 -44.0% 22.9 -37.5%

Average Length of Stay 2.2 1.9 -11.2% 2.6 -25.5%

C-Section Delivery 2.7 2.2 -17.5% 3.3 -32.8%

Normal Delivery 2.0 1.8 -12.5% 2.2 -20.9%

Paid/Admission $6,254 $6,755 8.0% $9,072 -25.5%

Average Mother Age 26.9 28.9 7.4% 30.6 -5.6%

The C-Section rate was 38%_which is above_the benchmark (36%) .

$0 Normal Delivery C-Section Delivery

Prior $5,452 $8,660

Current $5,570 $8,652

Benchmark $7,444 $12,125

0 Normal Delivery C-Section Delivery

Prior 8.9 3.0

Current 4.6 2.9

Benchmark 5.8 3.1

$0.00 Normal Delivery C-Section Delivery

Prior $4.02 $2.13

Current $2.13 $2.07

Benchmark $3.59 $3.12

CITY OF EDINBURG 000243483: ALL

Inpatient Deliveries

Oct 2023 - Sep 2024

Top Inpatient Providers by Admissions

Provider State

Admissions Paid % of Total Paid

Paid/ Admission

MCALLEN HOSPITALS L P TX 32 $489,737 35.0% $15,304.28

DOCTORS HOSPITAL AT RENAISSANCE, LTD TX 24 $292,629 20.9% $12,192.88

COLUMBIA RIO GRANDE HEALTHCARE, L.P. TX 10 $404,869 29.0% $40,486.92

UNIVERSITY OF TEXAS M. D. ANDERSON CANCER CENTER TX 3 $41,828 3.0% $13,942.55

OCHSNER CLINIC FOUNDATION LA 2 $103,214 7.4% $51,607.05

VHS HARLINGEN HOSPITAL COMPANY, LLC TX 2 $28,418 2.0% $14,209.18

MISSION HOSPITAL, INC. TX 1 $17,327 1.2% $17,326.75

VAL VERDE COUNTY HOSPITAL DISTRICT TX 1 $14,631 1.1% $14,631.37

MIDLAND COUNTY HOSPITAL DISTRICT TX 1 $3,732 0.3% $3,731.63

KNAPP MEDICAL CENTER TX 1 $1,441 0.1% $1,441.21

All Other 0.0% $0.00

Summary 77 $1,397,826 100.0% $18,153.59

• MCALLEN HOSPITALS L P_was the most frequently utilized inpatient facility.

• The top inpatient facility by paid amount was_MCALLEN HOSPITALS L P, which accounted for 35.0% of the total inpatient paid amount in the current reporting period.

• The top 10 inpatient providers accounted for 100.0%_of the total inpatient spend in the current reporting period._

CITY OF EDINBURG 000243483: ALL

Inpatient Provider Summary

Sep 2023

Oct 2023 - Sep 2024 % Change Benchmark

Benchmark Variance

Allowed $1,798,955 $3,015,196 67.6% Allowed PMPM $147.43 $144.04 -2.3% $183.74 -21.6% Paid $1,381,946 $2,386,977 72.7% Paid PEPM $180.84 $180.98 0.1% $264.72 -31.6% Paid PMPM $113.26 $114.03 0.7% $137.03 -16.8% Non-High Cost $71.12 $66.22 -6.9% $78.45 -15.6% High Cost $42.14 $47.81 13.5% $58.58 -18.4%

Visits 1,407 2,133 51.6% Visits/1,000 1,383.7 1,222.8 -11.6% 1,254.3 -2.5% Paid/Visit $982 $1,119 13.9% $1,311 -14.6% In-Network Paid % 100.0% 100.0% 99.5% In-Network Visits % 99.8% 100.0% 98.2%

• Outpatient paid PMPM increased by _0.7%_between the two reporting periods and was 16.8%_ lower than_the benchmark.

• High Cost Claimants accounted for 41.9%_of total outpatient spendcompared to 37.2%_from the previous reporting period.

• Neoplasms_was the most costly diagnostic category for outpatient services in the current reporting period. It decreased_16.5%_and was 22.7%_ higher than_the benchmark.

CITY OF EDINBURG 000243483: ALL

Outpatient Facility Overview

Outpatient Paid PMPM by Service Type

Outpatient Visits/1,000 by Service Type Outpatient Paid/Visit by Service Type

• Surgical_was the service type with the highest paid PMPM for outpatient services in the current reporting period. Paid PMPM increased_93.8%_and was 34.9%_lower than_the benchmark.

• Pathology & Laboratory_had the highest rate of visits/1,000 in the current reporting period.

• Surgical_had the highest amount paid per visitin the current reporting period.Pa id

P M

PM

$0 Surgical ER Radiology Pathology & Laboratory

Pharmacy & IV Therapy

Prior $18.10 $30.18 $17.26 $17.85 $24.28

Current $35.07 $25.57 $17.15 $14.52 $14.46

Benchmark $53.89 $30.90 $15.54 $4.81 $14.37

Vi sit s/ 1, 0 Pathology & Laboratory

Radiology ER Other Outpatient

Services

Surgical

Prior 584.2 175.1 238.0 100.3 84.6

Current 456.9 218.4 189.7 78.0 76.2

Benchmark 213.8 186.7 227.1 97.9 114.5

Pa id

/ V isi t

$0 Surgical Pharmacy & IV Therapy

Observation ER Radiology

Prior $2,567 $4,114 $729 $1,522 $1,183

Current $5,520 $3,254 $1,739 $1,617 $942

Benchmark $5,650 $3,919 $1,481 $1,633 $999

CITY OF EDINBURG 000243483: ALL

Outpatient Facility - Details by Top 5 Service Types

• ER paid PMPM_decreased by _15.3%_between the two reporting periods and was 17.3%_ lower than_the benchmark.

• ER visits/1,000 decreased _20.3%_between reporting periods and was 16.5%_ lower than_the benchmark.

• Spouses_had the highest ER visits/1,000 rate in the current period.

ER Visits/1,000 by Relationship

Oct 2022 - Sep 2023

Oct 2023 - Sep 2024 % Change Benchmark

Benchmark Variance

ER Allowed $592,438 $882,600 49.0% ER Paid $368,301 $535,270 45.3% ER Allowed PMPM $48.55 $42.16 -13.2% $47.01 -10.3% ER Paid PMPM $30.18 $25.57 -15.3% $30.91 -17.3% ER Visits 242 331 36.8% ER Visits/1,000 238.0 189.7 -20.3% 227.2 -16.5% ER Allowed/Visit $2,448 $2,666 8.9% $2,484 7.4% ER Paid/Visit $1,522 $1,617 6.3% $1,633 -1.0% % of ER Claimants with 3+ Visits 5.4% 6.0% 9.5%

Total ER Allowed/Visit* $2,824 $3,103 9.9% $2,890 7.3% Total ER Paid/Visit* $1,687 $1,768 4.8% $1,900 -6.9%

*Includes physician charges

Oct 2022 - Sep 2023

Oct 2023 - Sep 2024 % Change Benchmark

Benchmark Variance

Employee 243.4 175.6 -27.9% 240.5 -27.0%

Spouse 296.7 310.1 4.5% 255.9 21.2%

Dependent 214.3 192.7 -10.1% 222.5 -13.4%

CITY OF EDINBURG 000243483: ALL

Emergency Room Overview

Top ER Diagnoses for Oct 2023 - Sep 2024

ER Diagnosis Paid Claimants Visits %Visits Potentially

Non-Emergent * Injury/Poisoning $91,302 63 67 1.5%

Symptoms/Ill-Defined $77,963 42 45 35.6%

Respiratory $48,438 28 33 84.8%

Circulatory $59,398 26 31 16.1%

Genitourinary $55,328 25 29 41.4%

Digestive $45,780 26 27 40.7%

Infectious/Parasitic $42,814 27 27 25.9%

Musculoskeletal $26,434 18 18 33.3%

Nervous $28,407 14 15 26.7%

Ear $8,352 8 8 75.0%

All Others $51,055 30 33 9.1%

Summary $535,270 248 331 29.9%

• 29.9%_of ER visits were potentially non-emergent in the current reporting period compared to 31.0%_in the prior reporting period and 29.3%_for the benchmark.

• The conditions with the highest volume of ER visits in the current reporting period were_Injury/Poisoning_, _Symptoms/Ill-Defined_, and _Respiratory.

* Not reflective of benefit design

CITY OF EDINBURG 000243483: ALL

Emergency Room Leading Diagnoses

• 6%_of ER claimants visited the ER three or more times in the current reporting period compared to 5%_in the prior reporting period and 10%_for the benchmark.

• Claimants with 3 or more ER visits accounted for 16%_of the ER paid expenses in the current reporting period compared to_13%_in the prior reporting period and 30%_for the benchmark.

ER Visits Claimants Claimants % of Total ER Visits ER Paid 1 192 77.4% 192 $317,417

2 41 16.5% 82 $132,224

3 10 4.0% 30 $37,002

4 2 0.8% 8 $16,096

6 2 0.8% 12 $17,656

7 1 0.4% 7 $14,874

10+

Summary 248 100% 331 $535,270

ER Utilization and Costs by Number of Visits for Oct 2023 - Sep 2024

Diagnosis ER Paid ER Visits Claimants Circulatory $17,726 9 5

Respiratory $15,082 11 6

Symptoms/Ill-Defined $13,030 9 7

Genitourinary $12,208 7 4

Infectious/Parasitic $5,067 4 4

Top Diagnoses of Claimants with 3+ ER Visits for Oct 2023 - Sep 2024

CITY OF EDINBURG 000243483: ALL

Frequent Users Of The Emergency Room

Oct 2023 - Sep 2024

Top Outpatient Providers by Visits

Provider State

Visits Paid % of Total Paid

Paid/ Visit

DOCTORS HOSPITAL AT RENAISSANCE, LTD TX 1,116 $942,598 39.5% $844.62

MCALLEN HOSPITALS L P TX 306 $632,987 26.5% $2,068.59

HARLINGEN VAMC TX 205 $66,308 2.8% $323.45

COLUMBIA RIO GRANDE HEALTHCARE, L.P. TX 122 $148,529 6.2% $1,217.45

UNIVERSITY OF TEXAS M. D. ANDERSON CANCER CENTER TX 120 $402,818 16.9% $3,356.82

HEALTHQWEST LLC GA 57 $1,165 0.1% $20.43

FANNIN COUNTY HOSPITAL AUTHORITY TX 36 $13,538 0.6% $376.05

DRISCOLL CHILDRENS HOSPITAL TX 31 $98,090 4.1% $3,164.19

HEALTH CARE UNLIMITED, INC TX 26 $2,797 0.1% $107.56

VHS HARLINGEN HOSPITAL COMPANY LLC TX 16 $13,801 0.6% $862.59

All Other 98 $64,348 2.7% $656.61

Summary 2,133 $2,386,977 100.0% $1,119.07

• DOCTORS HOSPITAL AT RENAISSANCE, LTD_was the most frequently utilized outpatient facility.

• The top outpatient facility by paid amount was DOCTORS HOSPITAL AT RENAISSANCE, LTD, which accounted for 39.5%_of the total outpatient paid amount in the current reporting period.

• The top 10 outpatient providers accounted for 97.3%_of the total outpatient spend in the current reporting period.

CITY OF EDINBURG 000243483: ALL

Outpatient Provider Summary

Sep 2023

Oct 2023 - Sep 2024 % Change Benchmark

Benchmark Variance

Allowed $1,423,729 $2,332,113 63.8%

Allowed PMPM $116.68 $111.41 -4.5% $173.37 -35.7%

Paid $1,059,710 $1,734,211 63.6%

Paid PEPM $138.67 $131.49 -5.2% $260.58 -49.5%

Paid PMPM $86.85 $82.85 -4.6% $132.87 -37.7%

Non-High Cost $61.68 $65.19 5.7% $91.10 -28.4%

High Cost $25.17 $17.65 -29.9% $41.77 -57.7%

Visits/1,000 8,276.7 8,160.9 -1.4% 9,143.5 -10.7%

Services/1,000 21,394.9 20,526.1 -4.1% 20,178.5 1.7%

Paid/Visit $126 $122 -3.3% $174 -30.1%

Paid/Service $49 $48 -0.6% $79 -38.7%

In-Network Paid % 99.8% 99.8% 99.0%

In-Network Visits % 98.9% 98.6% 98.1%

• Professional paid PMPM decreased by_4.6%_between the two reporting periods and was 37.7%_ lower than_the benchmark.

• High Cost Claimants accounted for 21.3%_of total professional spend compared to 29.0%_from the previous reporting period.

• Health Status_was the most costly diagnostic category for professional services in the current reporting period.

It increased_25.9%_and was 12.7%_lower than_the benchmark.

• Primary Care Physicians accounted for_43.9%_of the total professional visitsin the current reporting period.

CITY OF EDINBURG 000243483: ALL

Professional Services Overview

Professional Paid PMPM by Service Type

Professional Services/1,000 by Service Type Professional Paid/Service by Service Type

• Evaluation & Management_was the service type with the highest paid PMPM for professional services in the current reporting period. Paid PMPM decreased_7.6%_and was 21.6%_lower than_the benchmark.

• Evaluation & Management_had the highest rate of services/1,000 in the current reporting period.

• Anesthesia_had the highest amount paid per service in the current reporting period.

Pa id

P M

PM

$0 Evaluation & Management

Pathology & Laboratory

Medical Medical Services & Supplies

(HCPCS II)

Surgical

Prior $46.03 $9.86 $7.13 $10.12 $5.01

Current $42.55 $12.41 $8.58 $5.61 $5.20

Benchmark $54.26 $6.94 $15.53 $25.66 $15.25

Se rv ic e/

1, 0 Evaluation & Management

Pathology & Laboratory

Medical PT/OT/ST Radiology

Prior 11,349.9 6,303.9 1,379.8 591.1 708.1

Current 11,450.8 5,467.2 1,400.5 679.9 662.7

Benchmark 9,190.9 4,111.5 2,333.6 1,628.3 727.5

Pa id

/ S er vi ce

$0 Anesthesia Surgical Medical Services & Supplies

(HCPCS II)

Medical Radiology

Prior $336 $138 $234 $62 $43

Current $360 $177 $157 $73 $64

Benchmark $636 $193 $272 $80 $90

CITY OF EDINBURG 000243483: ALL

Professional - Details by Top 5 Service Types

Cancer Screenings:

Oct 2022 - Sep 2023 Oct 2023 - Sep 2024 Benchmark Cervical Cancer Screening 20.4% 30.0% 26.7%

Colorectal Cancer Screening 7.4% 11.6% 13.6%

Mammogram Screening 23.0% 41.9% 45.7%

PCP Care:

Oct 2022 - Sep 2023 Oct 2023 - Sep 2024 Benchmark Annual Physical 20.3% 27.7% 40.1%

Childhood Immunizations 52.5% 57.8% 66.8%

Well Infant Care 65.5% 78.6% 80.3%

Well Young Child Care 60.9% 61.7% 68.1%

Well School-Age Child Care 44.9% 50.5% 50.0%

Percentages represent utilization of preventive services by those members for which the service is deemed appropriate.

Compliance rates for well infant care, well young child care,well school-age child care, and childhood immunizations are based on utilization for claimants (not members) for whom the service is deemed appropriate, in order to account for newborn children who have little to no enrollment data.

CITY OF EDINBURG 000243483: ALL

Preventive Care

Metric Oct 2022 - Sep 2023 Oct 2023 - Sep 2024 % Change Benchmark

Variance

Paid $1,205,062 $2,256,451 87.2%

Paid PMPM $98.76 $107.79 9.1% $132.59 -18.7%

Member Cost Share % 12.1% 6.9% 10.1%

Paid/Claimant $1,061.73 $1,628.03 53.3% $1,709.87 -4.8%

Paid/Day $4.44 $4.61 3.9% $5.60 -17.6%

Prescriptions 11,018 19,898 80.6%

Prescriptions/1000 10,835.6 11,406.7 5.3% 12,602.6 -9.5%

Claimants 1,135 1,386 22.1%

Claimants/1000 651.1 794.5 22.0% 851.8 -6.7%

Scripts/Claimant 9.7 14.4 47.9% 13.3 8.2%

Generic Dispensing Rate 83.9% 85.3% 87.4%

Rx Retail as % of Prescriptions 99.6% 99.8% 97.3%

Rx Mail Order as % of Prescriptions 0.4% 0.2% 2.7%

Specialty % of Total Prescriptions 0.5% 0.4% 0.7%

Specialty % of Pharmacy Cost 30.7% 25.5% 46.5%

• Pharmacy Paid PMPM_increased _9.1%_and was 18.7%_ below_the benchmark in the current period.

• Prescriptions/1000 increased _5.3%_and was 9.5%_ below_the benchmark.

• The Generic Dispensing Rateincreased _1.4%_to 85.3%_and was 2.1%_ lower than_the benchmark.

• Specialty Drugs accounted for 25.5% of the pharmacy spend in the current period compared to 30.7%_in the prior period and 46.5%_in the benchmark.

Generic Dispensing Rate (GDR) vs. Benchmark

CITY OF EDINBURG 000243483: ALL

Pharmacy Overview

Top 10 Non-Specialty Drugs by Ingredient Cost: Current Period

Current/ Prior Rank Drug Product Name Plan Therapeutic Class Prescriptions

Utilizing Members Ingredient Cost

Avg. Ingredient Cost/

Prescription (Current)

Avg. Ingredient Cost/

Prescription (Prior)

Generic Indicator

Rank by Volume

1 1 OZEMPIC Incretin Mimetic Agents 530 73 $444,682 $839.02 $802.60 NO 7

2 2 MOUNJARO Incretin Mimetic Agents 317 41 $312,635 $986.23 $949.07 NO 13

3 PAXLOVID Antiviral Combinations 125 135 $133,128 $1,065.03 $0 NO 33

4 4 JARDIANCE Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors 234 33 $120,630 $515.51 $504.80 NO 20

5 6 FARXIGA Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors 131 20 $68,058 $519.53 $511.59 NO 31

6 10 SYNJARDY XR Antidiabetic Combinations 133 17 $55,603 $418.06 $373.38 NO 30

7 5 RYBELSUS Incretin Mimetic Agents 57 9 $49,837 $874.34 $840.05 NO 76

8 3 TRULICITY Incretin Mimetic Agents 57 9 $48,079 $843.49 $831.58 NO 77

9 8 XIGDUO XR Antidiabetic Combinations 85 11 $39,131 $460.36 $478.23 NO 57

10 9 SYNJARDY Antidiabetic Combinations 73 7 $36,199 $495.88 $464.47 NO 64

All Other 18,072 1,377 $531,189 $29.39 $40.55

Summary 19,814 1,386 $1,839,170 $92.82 $86.51

Top 10 Non-Specialty Drug Classes by Ingredient Cost: Current Period

Current/ Prior Rank Plan Therapeutic Class Prescriptions Utilizing Members Ingredient Cost

Avg. Ingredient Cost/ Prescription

(Current)

Avg. Ingredient Cost/ Prescription

(Prior) % Generic Rank by Volume

1 1 Incretin Mimetic Agents 962 122 $856,273 $890.10 $847.26 2

2 3 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors 365 52 $188,688 $516.95 $508.40 15

3 2 Antidiabetic Combinations 381 47 $163,613 $429.43 $425.68 7.6% 14

4 194 Antiviral Combinations 125 135 $133,128 $1,065.03 $0 38

5 4 Insulin 157 24 $47,182 $300.52 $337.83 33

6 5 Sympathomimetics 321 164 $37,146 $115.72 $132.46 73.2% 21

7 11 Viral Vaccines 330 192 $30,593 $92.71 $52.99 19

8 8 Digestive Enzymes 13 1 $22,967 $1,766.67 $1,731.46 126

9 7 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors 43 5 $21,976 $511.06 $503.78 77

10 9 Direct Factor Xa Inhibitors 39 6 $19,917 $510.69 $494.63 82

All Other 17,078 1,346 $317,688 $18.60 $26.07 96.8%

Summary 19,814 1,386 $1,839,170 $92.82 $86.51 84.8%

CITY OF EDINBURG 000243483: ALL

Pharmacy: Top Non-Specialty Therapeutic Drug Classes

Report Description: Specialty drugs generally have unique uses, require special dosing or administration, are typically prescribed by a specialist provider and are significantly more expensive than alternative drugs or therapies. This report provides a specialty drug analysis overview.

Top 10 Specialty Drugs by Ingredient Cost for the Year to Date

Brand Name Specialty Class Ingredient

Cost Prescriptions

Avg. Ingredient Cost/

Prescription Specialty Claimants

REVLIMID CAP 10MG CANCER $208,617 12 $17,384.74 1

ENBREL SRCLK INJ 50MG/ML AUTOIMMUNE $97,857 14 $6,989.79 1

GENOTROPIN INJ 12MG GROWTH HORMONES $63,530 8 $7,941.30 1

COSENTYX PEN INJ 300DOSE AUTOIMMUNE $56,279 8 $7,034.81 1

SKYRIZI PEN INJ 150MG/ML AUTOIMMUNE $40,641 4 $10,160.21 1

DUPIXENT INJ 300/2ML AUTOIMMUNE $39,530 11 $3,593.63 1

ACTEMRA INJ ACTPEN AUTOIMMUNE $28,005 12 $2,333.76 1

REVLIMID CAP 25MG CANCER $16,850 1 $16,850.32 1

COSENTYX UNO INJ 300/2ML AUTOIMMUNE $14,444 2 $7,221.96 1

OTEZLA TAB 30MG AUTOIMMUNE $9,355 2 $4,677.43 2

All Other $950 10 $95.00 3 Summary $576,058 84 $6,857.83 11

Oct 2022 - Sep 2023 Oct 2023 - Sep 2024 % Change Benchmark Benchmark

Variance

Unique Pharmacy Members 1,890 2,023 7.0%

Claimants 14 11 -21.4%

Percent of Utilizing Members 0.7% 0.5% 1.2%

Prescriptions 50 84 68.0%

Specialty Percent of Total Paid 30.7% 25.5% 46.5%

Percent of Total Prescriptions Paid 0.5% 0.4% 0.7%

Paid $369,612 $574,273 55.4%

Paid PMPM $30.29 $27.43 -9.4% $61.31 -55.3%

Average Ingredient Cost/Prescription $8,320 $6,858 -17.6% $9,274 -26.0%

Prior period is reflected only as it pertains to the Top 5 Specialty Classes of current period.

CITY OF EDINBURG 000243483: ALL

Pharmacy: Specialty Drug Analysis

Demographics

Members Current Period

Prior Period

Number of

Procedur es/1000

Prior Year Number of Procedure s/1000

% change Benchmar k Variance

Employee 1,072 2,227 #Error 2,810 -20.8%

Spouse 189 3,059 #Error 3,172 -3.5%

Dependent 538 3,368 #Error 4,184 -19.5%

Totals 1,799 2,656

• Membership increased by_#Error_from the previous reporting period, while the number of procedures increased by_#Error_ for the same time period._

• 36% of Total Members utilized their benefit during the current reporting period.

• DIAGNOSTICprocedures accounted for 62% of the total procedures for the account. Compared to 0%from the previous reporting period.

CITY OF EDINBURG 000243483: ALL

Dental Utilization Overview

• The_total paid amount increased by_90.8%_between reporting periods.

• Total in-network discounts(excluding Medicare) were $22,624,923_(76.4%)_for the current reporting period.

• The in-network paid percentage (excluding Medicare) was 99.6%_for the current reporting period.

Network Overview Oct 2023 - Sep 2024

Financial Order of Reduction (including Pharmacy)

Oct 2022 - Sep 2023 Oct 2023 - Sep 2024 % Change Billed $18,254,599 $40,488,149 >100%

Not Covered $1,512,916 $5,787,788 >100%

Covered $16,741,683 $34,700,361 >100%

Discount $11,634,399 $24,871,865 >100%

Allowed $5,107,284 $9,828,495 92.4%

Out of Pocket $965,894 $1,591,632 64.8%

COB $66,537 $11,817 -82.2%

COB Medicare $899 $417,973 >100%

Other Reductions $1,820 $2,370 30.2%

Other Adjustments ($18,507) ($481) 97.4%

Paid - Provider $4,090,640 $7,805,186 90.8%

Other Payments $3,458 $7,196 >100%

Total Paid $4,094,098 $7,812,382 90.8%

Allowed PMPM $418.56 $469.52 12.2%

Paid PMPM $335.53 $373.21 11.2%

Plan Share 80.9% 83.1% 2.7%

Medicare Primary Indicator Network Indicator Covered Discount Discount % Paid % of Paid

No In-Network $29,612,208 $22,624,923 76.4% $5,590,603 99.6%

Out of Network $139,438 $98,046 70.3% $5,053 0.1%

Yes In-Network $444,081 $1,262 $17,997 0.3%

Out of Network $948 $0 $123 0.0%

Summary $30,196,674 $22,724,230 76.4%* $5,613,776 100.0%

Claims on paid basis

*Calculated discount percent excludes Medicare Primary.

CITY OF EDINBURG 000243483: ALL

Appendix: Financial Summary

Admin Fees: The charge to an account for HCSC's operational cost of doing business.

Administrative Services Only (ASO): A contract between HCSC and a self-funded plan where HCSC performs administrative services only and does not assume any financial risk.

Services usually include claims processing but may include other services such as actuarial analysis and utilization review.

Aggregate: Constituting or amounting to a whole. For example, an aggregate account report includes data for the entire account.

Aggregate Stop Loss: A form of reinsurance that provides protection for medical expenses above a certain limit, generally on a year-by-year basis. Aggregate stop loss provides protection against the accumulation of total claims for a group as a whole exceeding a stated level.

Allowed: Amount considered eligible for payment by the plan ASO Adjustments: An amount added or deducted from ASO (Administrative Services Only) fees. This includes Stop Loss Reimbursements.

Average Age: The difference between the claimant's year of enrollment and year of birth. Calculated using the measure Average Age divided by the members represented in the report.

Average Contract Size: The average number of members per subscriber. It is calculated as: Medical Members / Medical Subscribers Average Dependents: Calculated using the measure Member Months (filtered on the Relationship = Dependents) divided by the number of months in the report.

Average Ingredient Cost: Represents the cost of the medication and is determined from the lowest submission of the pharmacy network rate, Usual & Customary amount, or Maximum Allowable Cost (MAC) Average Members: Calculated using the measure Member Months divided by the number of months included in the report.

Average Subscribers: Calculated using the measure Subscriber Months divided by the number of months included in the report.

Billed: Amount submitted for payment by the provider Billing and Accounts Receivable System (BARS): An HCSC financial system where all Administrative Services Only (ASO) customer bills are generated.

Blue Card Access Fee: Interplan Teleprocessing Services fee charged on out-of-state claims for accessing the local plan's provider network Brand Formulary: Brand name medications that are listed on the formulary Brand Non-Formulary: Brand name medications that are not listed on the formulary Claimants: Number of individual members submitting a claim Claim Lag: The amount of time between the date a claim is incurred and the date the claim payment is made.

CITY OF EDINBURG 000243483: ALL

Appendix: Glossary

COB: Portion of amount considered eligible for payment that has been paid by another insurance company (Coordination of Benefits)

COB Medicare: Portion of amount considered eligible for payment that has been paid by Medicare COBRA Members: Consolidated Omnibus Budget Reconciliation Act - A federal law which requires most employers sponsoring group health plans to offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) when coverage under the plan would otherwise end.

Coinsurance: Portion of covered amount member is responsible to pay for the claim Co-payment: Flat rate that the member is responsible to pay for the claim Coverage Tier: Eligibility tiers which stratify enrollment data based on the employee and others enrolled under the employee's coverage. Varying benefits can be assigned to tiers.

Covered Amount: Amount eligible for payment based on the terms of the medical/dental benefits agreement.

DAW/1: Indicates that the physician has specified 'do not substitute' on the prescription.

DAW2:Indicates that the Physician has allowed a substitution, but the patient requested brand to be dispensed Deductible: Portion of annual deductible amount member is responsible to pay applied to the claim.

Dental Loss Ratio: Calculated as the Dental Paid Claims Amount divided by the Billed Dental Premium Amount Dental Paid Claims: An amount paid to cover the Health Plan's liability for dental services provided to members for claims that have been processed and approved for payment Discount: Amount of reduction from billed amount that has been negotiated with the provider Discount %: For medical claims, the discount percent is calculated as Discount / Covered Dispensing Rate: The proportion of total drugs claims a certain drug or drug type is being dispensed Drug Type: An indicator on each Rx claim that tells whether a prescription is single source brand, multi-source brand or generic item.

Effective Discount %: The effective discount percentage is calculated as:…