Medical_and_Pharmacy_Reviews_for_2022-2024.pdf

Collier County Government

2022 Quarter 4 Review

CONSULTATIVE

ANALYTICS

Quarter 4 Review Financials - Current Period: Claims Paid 1/1/2022 – 12/31/2022

Prior Period: Claims Paid 1/1/2021 – 12/31/2021 Utilization - Current Period: Claims Incurred 1/1/2022 – 11/30/2022 Paid Through 12/31/2022

Prior Period: Claims Incurred 1/1/2021 – 11/30/2021 Paid Through 12/31/2021 Catastrophic Claim Threshold > $100,000 Cedar Gate Government Benchmark

Executive Overview

Experience Cost prior to Stop Loss reimbursements (p. 5) Medical PMPM decreased 11.9%.

Demographics (p. 4) Member to Subscriber Ratio is 2.11, compared to the Allegiance BOB Ratio of

1.95.

Causes Frequency & Severity of Large Claimants >$100K (p. 14) January-December 2022 had 54 cases totaling $12.8M January-December 2021 had 61 cases totaling $14.3M

Utilization Comparison to Government Industry Benchmark

(p. 5) Medical PMPM = +49.0% Inpatient PMPM = +44.8% Outpatient PMPM = -8.5% Office PMPM = +108.5% Emergency PMPM = +428.8%

(p. 6) ER Visits per 1000 = -25.0% Average Allowed per Outpatient ER Visit = +210.5% Urgent Care Visits per 1000 = -61.2% Average Allowed per Urgent Care Visit = +46.8%

(p. 7-8) Admits per 1000 = -28,5% Average LOS = +1.0% Average Allowed per Admit = +45.7%

(p. 9) Office Visits per 1000 = +13.8% CT Scans per 1000 = +56.5% MRI Scans per 1000 = +42.2% Chiropractic Visits per 1000 = +42.7%

Note: Differences from the benchmark are related to (1) utilization, especially the frequency and severity of high cost cases ; (2) unit price; (3) plan design differentials; and

(4) population risk characteristics.

Claimant Stratification – Medical claims

Notes:

• Data is run on a paid basis for each period. Pharmacy dollars are excluded.

Comments:

• 80.7% of claimants have less than $5K in paid claims and are accounting for 16.8% of paid claims in the current period.

• In the current year, 39 claimants (0.8% of claimants) cost the plan over $100K each and account for 31.5% of the total plan spend.

8.3%

11.5%

11.7%

5.6%

6.5%

12.5%

27.1%

16.8%

0.1%

0.2%

0.5%

0.4%

0.7%

2.1%

15.4%

80.7%

$500,000-$999,999

$250,000-$499,999

$100,000-$249,999

$75,000-$99,999

$50,000-$74,999

$25,000-$49,999

$4,999-$24,999

$0-$4,999

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

2022 Q4 % of Payment Bands

% Paid % Claimant

Claim Payment Band Paid Claimants

$500,000-$999,999 2,510,789$ 4

$250,000-$499,999 3,485,804$ 11

$100,000-$249,999 3,561,106$ 24

$75,000-$99,999 1,694,134$ 19

$50,000-$74,999 1,975,447$ 34

$25,000-$49,999 3,800,767$ 109

$4,999-$24,999 8,241,555$ 782

$0-$4,999 5,105,274$ 4,105

Summary 30,374,877$ 5,088

Claim Payment Band Paid Claimants

$500,000-$999,999 3,222,304$ 5

$250,000-$499,999 3,454,685$ 11

$100,000-$249,999 4,470,655$ 31

$75,000-$99,999 2,236,901$ 26

$50,000-$74,999 3,587,390$ 58

$25,000-$49,999 5,162,558$ 154

$4,999-$24,999 7,466,653$ 691

$0-$4,999 4,893,219$ 4,004

Summary 34,494,365$ 4,980

9.3%

10.0%

13.0%

6.5%

10.4%

15.0%

21.6%

14.2%

0.1%

0.2%

0.6%

0.5%

1.2%

3.1%

13.9%

80.4%

$500,000-$999,999

$250,000-$499,999

$100,000-$249,999

$75,000-$99,999

$50,000-$74,999

$25,000-$49,999

$4,999-$24,999

$0-$4,999

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

2021 Q4 % of Payment Bands

% Paid % Claimant

Current period reflects claims paid between Jan 2022 and Dec 2022

Prior period reflects claims paid between Jan 2021 and Dec 2021

Cedar Gate – Executive Summary

Definitions:

The Benchmark represents the Government industry.

Comments:

Current Employee Count has increased 2.9% from the prior period.

The Member to Subscriber Ratio for this group is 2.11; this compares to an Allegiance BOB ratio of 1.97.

Demographics Jan - Dec '21 Jan - Dec '22 Trend Benchmark

Comparison to

Benchmark

Current Employees 2,182 2,246 2.9% -

Current Members 4,655 4,736 1.7% -

Employee Months 26,411 26,349 -0.2% -

Member Months 56,426 55,269 -2.1% -

Average Age 39.3 38.7 -1.7% 41.8 -7.5%

% Male (Current) 50.9% 50.8% -0.3% 44.1% 15.2%

Member to Subscriber Ratio 2.13 2.11 -1.2%

Average Relative Risk Score 1.490 1.440 -3.4% 1.00 44.0%

Status Employee Count % Count

Medical Paid

(Includes

Dependents) % Paid

Current Employee 2,302 99.8% $29,776,804 98.0%

New Hire 5 0.2% $596,841 2.0%

Grand Total 2,307 100.0% $30,373,644 100.0%

Inpatient 30.0%

Office 27.6%

Outpatient 19.9%

Other 12.5%

Emergency 10.0%

% of Total Medical Spend

Cedar Gate – Executive Summary, cont.

Notes:

Catastrophic is defined as members with $100K+ in medical paid.

Comments:

The Medical Plan Paid PMPM for the current period has decreased 10.1%, but is 49.0% above the benchmark. The Catastrophic PMPM had a 13.6% decrease from the prior period.

The Inpatient PMPM has decreased in the current year but is well above the benchmark.

Inpatient is the top POS in Medical spend. In the current period there are 10 claimants with $200K+ in spend compared to 13 in the prior period.

The Outpatient PMPM has decreased 11.1% from prior year. There were 6 claimants with $100K+ in the current period compared to 11 in the prior period.

The Office Plan Paid PMPM has increased from the prior period and continues to be above the benchmark as it has in past reports.

The ER PMPM has decreased 7.9% from the prior period. The top diagnosis for the ER is Chest Pain (6.7% of total), followed by Abdominal Disorders (6.4% of total) and Viral Infections (6.1% of total).

Ambulatory Surgical Center makes up the majority of the Other PMPM at $30.22 PMPM, followed by Independent Laboratory at $12.84 PMPM.

Medical Inpatient Outpatient Office Emergency

Prior $611.32 $212.17 $123.07 $149.08 $59.62

Current $549.58 $164.93 $109.43 $151.82 $54.89

Benchmark $368.80 $113.87 $119.57 $72.82 $10.38

$0

$100

$200

$300

$400

$500

$600

$700 PMPM by Place of Service

Current period reflects claims paid between Jan 2022 and Dec 2022

Prior period reflects claims paid between Jan 2021 and Dec 2021

Plan Spend Jan - Dec '21 Jan - Dec '22 Trend Benchmark

Comparison to

Benchmark

Medical Plan Paid $34,494,365 $30,374,877 -11.9% -

Medical Plan Paid PMPM $611.32 $549.58 -10.1% $368.80 49.0%

Non Catastrophic Med PMPM $411.12 $376.65 -8.4%

Catastrophic Med PMPM $200.20 $172.93 -13.6%

Inpatient Hospital Plan Paid PMPM $212.17 $164.93 -22.3% $113.87 44.8%

Outpatient Hospital Plan Paid PMPM $123.07 $109.43 -11.1% $119.57 -8.5%

Office Plan Paid PMPM $149.08 $151.82 1.8% $72.82 108.5%

Emergency Room Plan Paid PMPM $59.62 $54.89 -7.9% $10.38 428.8%

Other $67.37 $68.51 1.7%

Cedar Gate – Utilization Metrics

Emergency Room Utilization

Comments:

ER utilization decreased 1.7% from the prior period and is currently 25.0% below the benchmark.

Urgent Care Visits increased 17.9% from the prior period but are well below the benchmark. Upper Respiratory Infection and Viral Infections are the top diagnosis in the current period by visit count. 40.7% of the visits occurred at Collier Urgent Care Centers.

11.0% of the group’s population had an ER visit in the current period. There are 12 individuals that had 4+ ER visits.

Jan - Nov '21 Jan - Nov '22

% Change from

Prior Year

ER Visits Per 1000 167.6 164.8 -1.7% 219.7 -25.0%

Allowed per Outpatient ER Visit Average Allowed $4,990 $4,513 -9.6% $1,454 210.5%

Urgent Care Visits Per 1000 102.9 121.3 17.9% 313.0 -61.2%

Allowed per Urgent Care Visit Average Paid $229 $238 3.9% $162 46.8%

Benchmark

Comparison to the BenchmarkMetrics Metric Type

ER Visits By Category

Visits per

Average

Total Cost per Visit

% of

Members with Visit

Visits per

Average

Total Cost per Visit

% of

Members with Visit

Visits per

Average

Total Cost per Visit

% of

Members with Visit

Limited / Minor Visits 0.0 $0 0.0% 0.0 $0 0.0% 1.6 $300 0.2%

Low to Moderate Severity 2.5 $761 0.2% 5.0 $1,160 0.4% 8.7 $436 0.8%

Moderate Severity 33.1 $1,158 2.8% 33.7 $1,092 2.6% 48.9 $669 4.3%

High Severity 54.0 $2,661 4.5% 55.3 $2,825 4.3% 79.1 $1,161 6.4%

Life Threatening 77.4 $8,389 5.8% 70.5 $7,721 5.1% 76.7 $2,376 6.1%

Other 0.5 $5,967 0.0% 0.2 $955 0.0% 4.8 $1,769 0.4%

Total 167.6 $4,990 11.6% 164.8 $4,513 11.0% 219.7 $1,454 15.1%

Current BenchmarkPrior

Current period reflects claims incurred between Jan - Aug and paid through Dec 2022

Prior period reflects claims incurred between Jan - Aug and paid through Dec 2021

Medical Surgical Maternity Mental Health

Substance Abuse

NICU

Jan - Nov '21 19.9 24.1 7.9 6.7 1.9 0.5

Jan - Nov '22 15.0 15.4 6.4 3.8 5.0 0.2

Benchmark 23.7 25.5 10.3 2.9 1.1 0.6

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Admissions per 1000

Cedar Gate – Utilization Metrics

Inpatient Utilization

Comments:

Inpatient Days, ALOS, and Total Admits have all decreased in the current period.

There was a large decrease in the number of admits in the current period. In the current period there were 195 admits compared to 263 in the prior period.

Substance Abuse Admissions was the only admit type with an increase from the prior period.

Surgical Admits decreased 36.0% in the current period. There were 67 admits in the current period compared to 104 in the prior period. In the prior period the top 3 diagnosis by # of Surgical Admits were Gastrointestinal Disorders (23 prior vs 11 current), Cardiac Disorders (15 prior vs 9 current) and Infections (14 prior vs 6 current).

Substance Abuse Admissions increased significantly from the prior year. There were 21 admits in the current period compared to 8 in the prior period. One dependent claimant accounts for 42.9% of the admits in the current period.

While 30 Day Readmissions are steady between the two periods, the readmits are high compared to the benchmark. There were 30 readmissions in the current period and 18 of them were related to Mental Health/Substance Disorder.

30-Day Readmissions A Readmission is defined as an admit with a start date within 30-days of the end date of another admission for the same member (regardless of diagnosis).

Metrics Metric Type Jan - Nov '21 Jan - Nov '22

% Change from

Prior Year Benchmark

Comparison to the Benchmark

Inpatient Days Per 1000 399.8 255.0 -36.2% 353.3 -27.8%

Average Length of Stay Average Days 6.6 5.6 -15.2% 5.5 1.0%

Total Admissions Per 1000 61.0 45.8 -24.8% 64.1 -28.5%

Medical Admissions Per 1000 19.9 15.0 -24.9% 23.7 -36.9%

Surgical Admissions Per 1000 24.1 15.4 -36.0% 25.5 -39.6%

Maternity Admissions Per 1000 7.9 6.4 -18.6% 10.3 -37.5%

Mental Health Admissions Per 1000 6.7 3.8 -43.5% 2.9 31.9%

Substance Abuse Admissions Per 1000 1.9 5.0 168.9% 1.1 353.3%

NICU Admissions Per 1000 0.5 0.2 -48.8% 0.6 -60.4%

30-Day Readmissions Per 1000 7.2 7.1 -0.9% 3.5 103.5%

Cedar Gate – Utilization Metrics

Inpatient Cost

Comments:

Total Average Allowed per Admit has decreased from the prior year. There were 10 admits in the current period with an avg allowed over $100K. All of these admits were Surgical Admits.

While Surgical Admits were the most costly in the current period, there was a decrease in cost from the prior year. There were 20 admits in the prior period with an avg allowed of $100K.

Allowed per Maternity admit increased 5.3% in the current period. There was one costly Maternity admit in the current period.

9 day stay, $49K avg allowed, Naples Community Hospital. Removing this admit drops the avg allowed for Maternity to $11,215.

The NICU Avg Allowed has decreased 96.5% in the current period. There was one NICU admit in the current period and 2 in the period.

Medical Surgical Maternity Mental Health

Substance Abuse

NICU

Jan - Nov '21 $25,876 $94,837 $11,986 $7,762 $13,688 $58,411

Jan - Nov '22 $22,115 $67,036 $12,622 $4,552 $11,322 $2,048

Benchmark $13,819 $33,072 $14,253 $11,619 $15,208 $150,791

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

$160,000

Allowed per Admit

Metrics Metric Type Jan - Nov '21 Jan - Nov '22

% Change from

Prior Year Benchmark

Comparison to the Benchmark

Total Admission Allowed per Admission Average Allowed $49,229 $33,181 -32.6% $22,774 45.7%

Medical Admission Allowed per Admit Average Allowed $25,876 $22,115 -14.5% $13,819 60.0%

Surgical Admission Allowed per Admit Average Allowed $94,837 $67,036 -29.3% $33,072 102.7%

Maternity Admission Allowed per Admit Average Allowed $11,986 $12,622 5.3% $14,253 -11.4%

Mental Health Admission Allowed per Admit Average Allowed $7,762 $4,552 -41.4% $11,619 -60.8%

Substance Abuse Admission Allowed per Admit Average Allowed $13,688 $11,322 -17.3% $15,208 -25.6%

NICU Admission Allowed Per Admit Average Allowed $58,411 $2,048 -96.5% $150,791 -98.6%

Routine Preventive Mental Health Substance Abuse

Jan - Nov '21 4,523.2 417.7 966.1 10.7

Jan - Nov '22 4,069.7 555.7 1,030.1 11.6

Benchmark 3,804.7 345.2 734.3 13.6

0.0

500.0

1,000.0

1,500.0

2,000.0

2,500.0

3,000.0

3,500.0

4,000.0

4,500.0

5,000.0

Office Visits per 1000

Cedar Gate – Utilization Metrics

Office Visit & Other Utilization

Comments:

Overall office visit utilization decreased from the prior year but is 13.8% above the benchmark. Routine Office Visits are the majority of the visits.

Preventive Visits have increased 33.0% from the prior period which can be viewed as a positive.

Mental Health Office Visits have increased in the current period by 6.6%.

There were 939 claimants with 4,338 MH visits in the current period compared to 876 claimants with 4,168 visits.

Substance Abuse Office Visits have increased in the current period. There were 4 claimants with 5+ Substance Abuse visits in the current period.

All Imaging Utilization is higher than the benchmark.

The top provider for CT Scans was Naples Community Hospital.

The top provider for MRIs was Proscan NCH Imaging.

The top provider for PET Scans was Florida Cancer Specialists.

Jan - Nov '21 Jan - Nov '22

% Change from

Prior Year

Total Office Visits Per 1000 6,046.5 5,845.8 -3.3% 5,134.9 13.8%

Routine Office Visits Per 1000 4,523.2 4,069.7 -10.0% 3,804.7 7.0%

Preventive Office Visits Per 1000 417.7 555.7 33.0% 345.2 61.0%

Mental Health Office Visits Per 1000 966.1 1,030.1 6.6% 734.3 40.3%

Substance Abuse Office Visits Per 1000 10.7 11.6 9.1% 13.6 -14.7%

CT Scan Per 1000 166.0 190.9 15.0% 122.0 56.5%

MRI Scan Per 1000 119.1 114.2 -4.1% 80.3 42.2%

PET Per 1000 8.1 9.0 11.2% 7.0 29.1%

Chiropractic Visits Per 1000 958.2 956.0 -0.2% 669.86 42.7%

Physical Therapy Per 1000 692.4 603.6 -12.8% 820.90 -26.5%

Newborn Deliveries Per 1000 7.4 6.2 -16.8% 9.59 -35.6%

Office Visit Utilization

Imaging Utilization

Other Utilization

Metrics Metric Type Benchmark

Comparison to

Benchmark

Network Savings

Comments:

The CHP Network discount increased although utilization had a small decreased in the current year.

Out of Network utilization has increased 0.9 points. There were 4 claimants in the current period that each had $350K+ in eligible claims compared to 2 in the prior period.

Network Eligible Discount Discount % Network Eligible Discount Discount %

CHP 53,017,010$ 27,484,607$ 51.8% CHP 48,138,411$ 25,940,894$ 53.9%

Cigna 20,182,743$ 11,897,699$ 58.9% Cigna 17,738,582$ 10,467,955$ 59.0%

Other 1,395,300$ 345,899$ 24.8% Other 1,510,232$ 364,846$ 24.2%

Out of Network 3,867,815$ 1,370,802$ Out of Network 4,186,108$ 2,249,252$

Total In Network 74,595,054$ 39,728,206$ 53.3% Total In Network 67,387,225$ 36,773,694$ 54.6%

January 1, 2021 - December 31, 2021 January 1, 2022 - December 31, 2022

CHP

67.6%

Cigna

25.7%

Other

1.8%

Out of Network

4.9%

Distribution of Claims-2021 Q4 Period

CHP

67.3%

Cigna

24.8%

Other

2.1%

Out of Network

5.8%

Distribution of Claims-2022 Q4 Period

Catastrophic Summary (Members over $100K)

Overview Costs Conditions

54 individuals

Average Age 53.2

59.3% Male

26 Employees

20 Spouses

8 Dependents

$236K average cost per individual

5 members had over $500K in combined medical and pharmacy costs

20.1% of the total spend was for Pharmacy

98.1% have a chronic condition

Top Chronic Conditions were Blood Disorder, Hyperlipidemia, and Hypertension.

87.0% of individuals have 2+ conditions

Cancer was the highest diagnosis group by spend (9 individuals), followed by Infections (5 individuals).

Total Catastrophic Spend was

$12.8M

Cedar Gate - High Cost Detail Top 20 Members over $100K

Notes:

• Data is pulled from Cedar Gate and includes both medical and pharmacy claims.

Comments:

• 8 out of the 54 individuals had pharmacy claims over $100K.

• Claimant #1 had a medical diagnosis of Pulmonary Disorder and the top prescription drug was Ravicti.

• Claimant #14 had a medical diagnosis of Cancer and the top prescription drug was Stelara.

• Claimant #19 had a medical diagnosis of Cancer and the top prescription drug was Qinlock.

# Gender Age Relationship Status Classification Highest Paid Diagnosis Medical Paid Rx Paid Total Paid Highest Paid Provider

1 M 59 Employee Active Long Term Pulmonary Disorders $2,145 $778,763 $780,908 PHARMACY

2 M 60 Employee Active Long Term Infections $698,128 $37 $698,165 NAPLES COMMUNITY HOSPITAL

3 M 41 Employee Active Long Term Infections $688,859 $257 $689,116 TAMPA GENERAL HOSPITAL

4 M 65 Spouse Active Long Term Neurological Disorders $566,489 $510 $566,999 PHYSICIANS REGIONAL PINE RIDGE

5 M 10 Dependent Active Long Term Cancer $557,313 $4,862 $562,175 NICKLAUS CHILDRENS HOSPITAL

6 M 45 Employee Active Long Term Gastrointestinal Disorders $494,316 $946 $495,263 NAPLES COMMUNITY HOSPITAL

7 M 1 Dependent Active Long Term Pregnancy-related Disorders $413,247 $0 $413,247 NAPLES COMMUNITY HOSPITAL

8 M 65 Spouse Active Long Term Cancer $349,641 $34,915 $384,556 NAPLES COMMUNITY HOSPITAL

9 F 44 Spouse Active Long Term Gastrointestinal Disorders $277,243 $90,103 $367,345 LMHS REGIONAL CANCER CENTER

10 F 58 Spouse Active Long Term Gastrointestinal Disorders $182,296 $153,674 $335,971 TAMPA GENRAL

11 M 65 Spouse Active Long Term Spine-related Disorders $326,204 $556 $326,759 PHY REG MEDICAL CENTER NORTH

12 M 17 Dependent Active Long Term Mental Health $285,471 $171 $285,642 FAMILY FIRST ADOLESCENT SVCS

13 F 63 Spouse Active Long Term Infections $280,055 $1,412 $281,467 NAPLES COMMUNITY HOSPITAL

14 F 56 Spouse Active Long Term Cancer $3,594 $275,270 $278,864 PHARMACY

15 M 67 Employee Termed Termed Cardiac Disorders $261,659 $10,938 $272,597 NAPLES COMMUNITY HOSPITAL

16 M 43 Employee Active Long Term Non-malignant Neoplasm $269,587 $29 $269,616 BROWARD HEALTH MEDICAL CENTER

17 M 66 Employee Active Long Term Gastrointestinal Disorders $264,207 $333 $264,540 PHYSICIANS REGIONAL PINE RIDGE

18 F 63 Employee Active Long Term Cardiac Disorders $264,175 $0 $264,175 PHYSICIANS REGIONAL PINE RIDGE

19 M 35 Employee Active Long Term Cancer $40,522 $189,624 $230,146 H LEE MOFFITT CANCER CENTER

20 M 22 Dependent Active Long Term Hematological Disorders $225,478 $25 $225,503 HUENEME FAMILY PHARMACY

Top 20 Claimants $6,450,629 $1,542,426 $7,993,055

Cedar Gate - High Cost Detail Top 20 Members over $100K

# Gender Age Relationship Status Highest Paid Diagnosis Medical Paid Rx Paid Total Paid Highest Paid Provider

1 M 59 Employee Active Pulmonary Disorders $775 $713,800 $714,574 PHARMACY

2 M 52 Spouse Termed Infections $699,568 $545 $700,113 NAPLES COMMUNITY HOSPITAL

3 M 10 Dependent Active Cancer $663,755 $3,133 $666,888 NICKLAUS CHILDRENS HOSPITAL

4 M 57 Employee Active Cardiac Disorders $657,949 $241 $658,190 PHYSICIANS REGIONAL PINE RIDGE

5 M 58 Employee Termed Infections $608,952 $3,837 $612,789 PHYSICIANS REG COLLIER

6 F 61 Spouse Termed Cancer $592,080 $1,267 $593,347 MARINERS HOSPITAL

7 M 52 Employee Termed Infections $452,389 $5,151 $457,540 NAPLES COMMUNITY HOSPITAL

8 M 63 Employee Active Congenital/Chromosomal Anomalies $417,317 $272 $417,589 PHYSICIANS REGIONAL PINE RIDGE

9 F 44 Spouse Active Gastrointestinal Disorders $350,864 $1,974 $352,838 LMHS REGIONAL CANCER CENTER

10 F 56 Spouse Active Cancer $54,523 $283,769 $338,292 PHARMACY

11 M 67 Employee Termed Renal/Urologic Disorders $323,946 $5,341 $329,287 BONITA SPRINGS DIALYSIS

12 M 75 Employee Active Cardiac Disorders $315,250 $1,277 $316,527 PHYSICIANS REGIONAL PINE RIDGE

13 F 72 Employee Termed Cancer $281,383 $337 $281,720 JAY WANG MD

14 M 65 Spouse Active Cardiac Disorders $271,488 $4,554 $276,043 NAPLES COMMUNITY HOSPITAL

15 F 60 Spouse Active Renal/Urologic Disorders $273,742 $0 $273,742 NAPLES COMMUNITY HOSPITAL

16 M 64 Employee Active Cardiac Disorders $255,102 $18,273 $273,375 PHYSICIANS REGIONAL PINE RIDGE

17 M 41 Employee Active Infections $258,780 $234 $259,014 TAMPA GENERAL HOSPITAL

18 M 22 Dependent Active Hematological Disorders $254,424 $2,969 $257,393 HUENEME FAMILY PHARMACY

19 M 62 Employee Active Infections $234,476 $1,468 $235,944 NAPLES COMMUNITY HOSPITAL

20 F 45 Employee Active Trauma/Accidents $226,815 $416 $227,231 NAPLES COMMUNITY HOSPITAL

Top 20 Claimants $7,193,577 $1,048,858 $8,242,434

Cedar Gate - Large Claimant Summary over $100K by Highest Paid Diagnosis & Relationship Class

Claimants Paid Paid % Claimants Paid Paid %

Cancer 9 $2,666,903 18.6% 9 $2,196,471 17.2% 28.6% -11.4%

Infections 9 $2,920,048 20.4% 5 $1,979,152 15.5% 11.4% 4.1%

Gastrointestina l Disorders 5 $1,009,333 7.0% 6 $1,717,631 13.5% 5.7% 7.8%

Neurologica l Disorders 5 $658,298 4.6% 4 $947,007 7.4% 7.7% -0.2%

Pulmonary Disorders 1 $714,574 5.0% 2 $926,693 7.3% 2.2% 5.0%

Cardiac Disorders 11 $2,448,257 17.1% 4 $842,905 6.6% 9.8% -3.1%

Spine-related Disorders 2 $258,522 1.8% 3 $571,135 4.5% 3.6% 0.9%

Mental Health 0 $0 0.0% 3 $568,779 4.5% 1.6% 2.9%

Hematologica l Disorders 2 $419,135 2.9% 3 $535,869 4.2% 3.3% 0.9%

Musculoskeleta l Disorders 5 $674,763 4.7% 4 $472,915 3.7% 2.7% 1.0%

Pregnancy-related Disorders 0 $0 0.0% 1 $413,247 3.2% 3.6% -0.3%

Trauma/Accidents 3 $569,367 4.0% 2 $320,009 2.5% 3.1% -0.6%

Vascular Disorders 1 $217,997 1.5% 2 $282,687 2.2% 1.4% 0.8%

Non-mal ignant Neoplasm 0 $0 0.0% 1 $269,616 2.1% 1.0% 1.1%

Renal/Urologic Disorders 4 $933,923 6.5% 1 $203,912 1.6% 3.3% -1.7%

Eye/ENT Disorders 1 $141,471 1.0% 1 $166,581 1.3% 0.2% 1.1%

Congenita l/Chromosomal Anomal ies 2 $562,540 3.9% 1 $122,746 1.0% 2.5% -1.6%

Medica l/Surgica l Compl ications 1 $127,674 0.9% 1 $115,790 0.9% 3.4% -2.5%

Fever 0 $0 0.0% 1 $106,351 0.8% 0.0% 0.8%

Total 61 $14,322,805 54 $12,759,494

Claimants Paid Paid % Claimants Paid Paid %

Employee 30 $7,383,337 51.5% 26 $6,277,755 49.2% 59.3% -10.1%

Spouse 26 $5,443,005 38.0% 20 $4,455,129 34.9% 25.3% 9.6%

Dependent 5 $1,496,464 10.4% 8 $2,026,610 15.9% 15.1% 0.8%

Total 61 $14,322,805 54 $12,759,494

Above/Below

Relationship Category

Book of

Business Above/Below

Jan - Dec '21 Jan - Dec '22

Jan - Dec '21 Jan - Dec '22

Major Diagnostic Category

Book of

Business

$121.02

$197.56 $172.93

$0

$50

$100

$150

$200

$250

Jan-Dec '20 Jan-Dec '21 Jan-Dec '22

PMPM >$100K Claimants

$348.91

$413.76 $376.65

$0

$50

$100

$150

$200

$250

$300

$350

$400

$450

Jan-Dec '20 Jan-Dec '21 Jan-Dec '22

PMPM <$100K Claimants

Impact of Large Claimants

Notes:

Data is medical claims only, pharmacy is excluded. This impacts the number of large claimants from the prior slides.

Comments:

The number of claimants had decreased 17.0% from the prior period however the severity of those claimants has increased 5.7% in the current period and 40.1% on a 2 year basis.

PMPM paid for claimants over $100K has decreased 12.5% from the prior year, but increased 19.5% on a two year CAGR.

PMPM paid for claimants under $100K has decreased 9.0% from the prior year, but increased 3.9% on a two year CAGR.

*Expected number of claimants in excess of $100K is between 7.58 and 8.06 per 1000 members *Expected claim amounts in excess of $100K is between $114K and $116K

Jan-Dec '20 Jan-Dec '21 Jan-Dec '22

Jan-Dec '22 over

Jan-Dec '21 2 Year CAGR

Enrollee Months 26,743 26,411 26,349 -0.2% -0.7%

Member Months 57,495 56,426 55,269 -2.1% -2.0%

Dollars $27,018,595 $34,494,365 $30,374,877 -11.9% 6.0%

< $100,000 $20,060,481 $23,346,721 $20,817,177 -10.8% 1.9%

> = $100,000 $6,958,114 $11,147,644 $9,557,699 -14.3% 17.2%

PEPM $1,010.31 $1,306.06 $1,152.79 -11.7% 6.8%

< $100,000 $750.12 $883.98 $790.06 -10.6% 2.6%

> = $100,000 $260.18 $422.08 $362.73 -14.1% 18.1%

PMPM $469.93 $611.32 $549.58 -10.1% 8.1%

< $100,000 $348.91 $413.76 $376.65 -9.0% 3.9%

> = $100,000 $121.02 $197.56 $172.93 -12.5% 19.5%

Claimants 5,128 4,980 5,088 2.2% -0.4%

< $100,000 5,088 4,933 5,049 2.4% -0.4%

> = $100,000 40 47 39 -17.0% -1.3%

Claimants per 1000 1,070.3 1,059.1 1,104.7 4.3% 1.6%

<$100,000 1,061.9 1,049.1 1,096.2 4.5% 1.6%

>= $100,000 8.3 10.0 8.5 -15.3% 0.7%

Average Paid in Excess of $100,000 $73,952.86 $137,183.92 $145,069.22 5.7% 40.1%

Top 10 Providers

Notes:

Data is run on a paid basis and refers to dollars paid to each provider NPI.

Comments:

Spend at Naples Community

Hospital has decreased 20.7% from the prior period. There were 6 claimants in the current period with $100K+ in paid claims compared to 13 in the prior period.

There was a drastic increase in spend at Tampa General.

One claimant accounts for 78.9% of the spend at this provider (Infectious Disease-

COVID-19).

Spend at H Lee Moffitt Cancer Center has increased 51.8% in the current period.

There were 6 claimants in the current period with $25K+ in paid claims compared to 3 in the prior period.

$312,978

$423,087

$471,953

$567,833

$640,587

$822,981

$872,672

$939,149

$2,845,174

$7,102,867

$206,222

$517,165

$469,174

$653,011

$612,714

$113,240

$1,754,451

$1,610,031

$3,468,164

$8,962,279

H Lee Moffitt Cancer Center

Quest Diagnostics Atlanta

Alejandro Perez Trepichioe

Gulf Coast Medical Center

Nicklaus Childrens Hospital

Tampa General

Physicians Reg Collier

Childrens Rehab Center

Physicians Regional Pine Ridge

Naples Community Hospital

Jan - Dec '21 Jan - Dec '22

Definition:

A member is identified as having a chronic condition if any one of the following three conditions is met within a 24-month period:

1. Two outpatient claims for the Dx on separate days of service

2. One ER Visit with the Dx as the primary

3. One Admission with the Dx as the admitting *For Diabetes only, one or more pharmacy claims can be used to identify the condition.

Comments:

Diabetes, Hyperlipidemia and Hypertension are the most prevalent chronic diseases for this group.

Cedar Gate – Top 10 Chronic Conditions

36.5

41.7

50.4

56.9

67.1

71.2

92.3

99.9

179.8

255.6

37.0

39.6

53.2

55.5

64.7

64.9

88.7

85.3

176.7

227.3

0.0 50.0 100.0 150.0 200.0 250.0 300.0

Asthma

Morbid Obesity

Osteoarthritis

Cancer

Metabolic Disorders

Depression

Blood Disorders

Diabetes

Hypertension

Hyperlipidemia

Members per 1,000

Prevalence of Top 10 Chronic Diseases

Prior Current

Cervical Colon Breast

% Compliant 90.1% 59.3% 78.3%

Benchmark 63.9% 34.5% 57.0%

0%

20%

40%

60%

80%

100% Cancer Screenings

Definition:

Well Visits are those that are considered preventive.

PCP visits are defined as office/preventive office visit codes with a primary care provider or specialist.

Completion Rates are calculated by dividing the number of visits by the average member count in each dependent category.

Cancer Screening data is pulled from Cedar Gate Care Quality Measures and compared to the Cedar Gate benchmark database.

Comments:

The overall Total PCP Visit Completion rates have increased in the current period.

For the total population Well Visit Completion rates have decreased from the prior period with Employees having the largest increase and the largest decrease coming from Spouses.

All Cancer Screening rates are above the benchmark population.

Preventive Care

Employee Spouse Child Total

Jan - Dec '21 75.4% 70.6% 65.4% 71.2%

Jan - Dec '22 84.9% 73.8% 65.7% 76.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PCP Visit Rates

Employee Spouse Child Total

Jan - Dec '21 81.7% 86.2% 67.9% 78.3%

Jan - Dec '22 86.9% 70.8% 58.2% 74.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Well Visit Rates

Call System Reporting

49.9%

38.4%

4.3%

3.1% 2.5%

1.6%

0.1% Member Calls

Question about payment / Claim Status / EOB requests

Benefits / Prior Authorization / Network Status

Eligibility / Enrollment question

Website / SSO / LIN login assistance

Request for ID card / change of address / etc.

Pharmacy

Appeals

73.9%

23.6%

1.8% 0.5%

0.1% 0.0% Provider Calls

Question about payment / Claim Status / EOB requests

Benefits / Prior Authorization / Network Status

Eligibility / Enrollment question

Appeal / Provider Review Request

Claim Mailing Address / EDI Payer

ID

Website / SSO / LIN login assistance

Description

Number of

Calls % of Total

Question about payment / Claim Status / EOB requests 1,359 49.9%

Benefits / Prior Authorization / Network Status 1,044 38.4%

Eligibility / Enrollment question 117 4.3%

Website / SSO / LIN login assistance 85 3.1%

Request for ID card / change of address / etc. 69 2.5%

Pharmacy 44 1.6%

Appeals 3 0.1%

Total 2,721

Description

Number of

Calls % of Total

Question about payment / Claim Status / EOB requests 7,598 73.9%

Benefits / Prior Authorization / Network Status 2,428 23.6%

Eligibility / Enrollment question 182 1.8%

Appeal / Provider Review Request 56 0.5%

Claim Mailing Address / EDI Payer ID 7 0.1%

Website / SSO / LIN login assistance 4 0.0%

Total 10,275

Performance Guarantees

I. Medical Time to Process Goal Q1 Q2 Q3 Q4 YTD

Medical Time to Process 90% in 14 days 98.9% 97.4% 99.4% 95.7% 97.9%

II. Medical Call Services Goal Q1 Q2 Q3 Q4 YTD

Average Speed of Answer 75% in 30 seconds 73.9% 72.9% 73.5% 77.6% 74.5%

Abandonment Rate <3% 2.8% 4.6% 5.3% 5.2% 4.5%

First Cal l Resolution 85.6% 89.9% 86.7% 94.7% 89.2%

III. Medical Claim Quality Goal Q1 Q2 Q3 Q4 YTD

Financia l Accuracy 99% 99.6% 99.5% 98.6% 98.9% 99.2%

Process ing Accuracy 95% 98.5% 97.7% 97.5% 99.0% 98.2%

Questions?

Data sources and reconciliations:

Three separate sources have been used to develop the reports in this presentation: (1) SQL databases populated by LuminX, (2) iBiz, (3) Cedar Gate. In addition, although the reports have been run for the same timeframes, timing differences on receipt and processing of data may not coincide fully. As a result, the numbers presented may not tie to one another completely. For example, Cedar Gate generally excludes terminated groups whereas they are included in the SQL and iBiz databases and member counts in iBiz also include administrative enrollments for purposes of billing PPO and other fees.

Further, several of the reports provide information on claims experience prior to any stop loss reimbursements.

Plan Review

CONSULTATIVE

ANALYTICS

Year End Review

Financials - Current Period: Claims Paid 1/1/2023 – 12/31/2023

Prior Period: Claims Paid 1/1/2022 – 12/31/2022

Utilization – Current Period: Claims Incurred: 1/1/2023 – 11/30/2023, paid through 12/31/2023

Prior Period: Claims Incurred: 1/1/2022 – 11/30/2022, paid through 12/31/2022

Catastrophic Claim Threshold > $100,000

Benchmark data represents the Cedar Gate Government Industry

Diagnosis Group Base Current Trend

Cont to

Trend Base Current Trend

Cardiac Disorders $40.29 $57.96 43.8% 3.2% 219.9 231.6 5.3%

Gastrointestinal Disorders $61.69 $57.69 -6.5% -0.7% 246.0 244.2 -0.7%

Cancer $39.67 $55.96 41.1% 3.0% 54.5 53.5 -1.8%

Health Status/Encounters $47.61 $43.16 -9.3% -0.8% 875.5 800.5 -8.6%

Musculoskeletal Disorders $30.64 $38.43 25.4% 1.4% 256.2 266.4 4.0%

Trauma/Accidents $21.71 $34.87 60.6% 2.4% 227.5 248.4 9.2%

Spine-related Disorders $30.15 $34.11 13.1% 0.7% 213.6 213.4 -0.1%

Neurological Disorders $36.17 $32.05 -11.4% -0.8% 143.5 147.0 2.4%

Pregnancy-related Disorders $18.65 $31.57 69.3% 2.4% 32.1 31.7 -1.3%

Medical/Surgical Complications $7.58 $31.50 315.5% 4.4% 75.3 111.1 47.5%

All Other $215.36 $198.78 -7.7% -3.0%

Total $549.52 $616.09 12.1% 1,112.0 1,050.4 -5.5%

PMPM Members per 1k

Executive Summary

Current Period reflects claims paid between Jan and Dec 2023

Prior Period reflects claims paid between Jan and Dec 2022

Observations

• Catastrophic is defined as members with over $100K in medical paid.

• The number of active EEs on the plan increased 2.8% from the prior year; active members increased 2.9%.

• Medical Trend increased 12.1% in the current period. While there was an increase in the

PMPM for both Non-Catastrophic and Catastrophic, Non-Catastrophic contributed more to the trend at 8.2%. There was a 42.9% increase in the number of claimants with spend between

$25K-$100K.

• For the claimants that fell into the $25K-$100K payment band, Cardiac Disorder was the top diagnosis by spend and member count. 16.1% of the 230 claimants had this diagnosis.

• Looking at Cardiac Disorder, 3.1% of the claimants has $25K+ in spend and they accounted for 67.8% of the dollars ($39.33 PMPM).

• Medical/Surgical Complications was the diagnosis with the greatest impact to trend. One claimant accounts for 47.5% of the spend under this diagnosis. This is claimant #2 on slide 8.

The majority of this large claimants spend was IP at Shands UF.

Non-Catastrophic Medical Trend

Catastrophic Medical Trend

Total Medical Trend +11.9%

+12.5%

$421.61 PMPM

$376.61 (Base)

$194.48 PMPM

$172.91 (Base)

Top Medical Diagnosis Groups

2,309 employees, +2.8%

4,871 members, +2.9%

Average Family Size 2.11

(Benchmark 1.94)

50.7% M, 49.3% F

(Benchmark: 43.7% M, 56.3% F)

Average EE Age 47.7

Average Spouse Age: 50.2

Average Child Age: 15.2

Average Concurrent Risk: 1.52

(Benchmark: 1.00)

+12.1%

$616.09 PMPM

$549.52 (Base)

0.0%

18.4%

13.1%

24.8%

43.8%

2.8%

11.1%

17.6%

29.4%

39.0%

$1,000,000+

$250,000-$999,999

$100,000-$249,999

$25,000-$99,999

$0-$24,999

Base Current

Med Payment Bands

Claim Payment Band Base Current

$1,000,000+ 0 1

$250,000-$999,999 14 9

$100,000-$249,999 26 43

$25,000-$99,999 161 230

$0-$24,999 4,897 4,781

Total 5,098 5,064

Claimant Counts

Hospital

Office Outpatient Hospital

Emergency Room - Hospital

Ambulatory Surgical Center

Other

Cont to Trend 5.4% 2.4% 2.3% 1.0% 0.0% 1.0%

Prior $164.91 $151.80 $109.42 $54.89 $30.21 $38.29

Current $194.54 $165.08 $122.33 $60.27 $30.19 $43.69

-1.0%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

$0.00

$50.00

$100.00

$150.00

$200.00

$250.00

Medical Spend

Plan Spend by Place of Service

Observations

• On a PMPM basis, Inpatient spend increased 18.0%. Inpatient spend is the most significant contributor to the overall medical trend in the current year (+5.4%). Under IP spend there was an increase in the cost and number of Catastrophic claimants. In the current period there were 31 claimants with spend over $100K with a PMPM of $117.85. This compares to 23 claimants with a

PMPM of $103.20 in the prior period.

• The highest paid diagnosis group for IP was Pregnancy-related Disorders with a PMPM of $26.53 in the current period ($14.95 in the prior period). One claimant accounts for 54.8% of the spend under this diagnosis. This is claimant #3 on slide 8. This child accounted for $14.43 PMPM.

• Closing following Pregnancy-related Disorder is Medical/Surgical Complication at $26.04 PMPM ($3.93 PMPM in the prior). As mentioned on slide 2, one claimant accounts for the majority of the spend under this diagnosis ($14.97 PMPM).

• The Office PMPM has increased 8.7% in the current period and contributes 2.4% to trend. Health Status/Encounters has the highest PMPM at $22.74 ($24.10 PMPM prior) but Mental Health is the highest contributor to the trend increase at 1.7%. The Mental Health PMPM increased 23.4% ($13.56 PMPM current). There were 4 claimants with over $25K in Mental Health OV spend. Each of these claimants had an Autistic Disorder diagnosis.

32% of Outpatient Spend was for Cancer

60.6% OF INPATIENT SPEND WAS

FOR CATASTROPHIC MEMBERS

(PRIOR YEAR – 62.6%)

Current Period reflects claims paid between Jan and Dec 2023

Prior Period reflects claims paid between Jan and Dec 2022

Pregnancy-related Disorders, 46

Mental Health, 32

Cardiac Disorders, 23

Gastrointestinal Disorders, 23

Neurological Disorders, Cancer, 14

Infections, 13

Hematological Disorders, 9

Pulmonary Disorders, 8

Trauma/Accidents , 8

Utilization Dashboard

Observations

• IP Admits have increased 12.8% in the current period, but the average cost decreased. There were 239 admits in the current period vs 202 in the prior period. Medical and Maternity admits both had double digit trend increases.

• 38.1% of the admits were Medical Admits. The top diagnosis for the Medical admits was Cardiac Disorder (16 of 91). The highest cost and longest admit fell under the Medical category. It was the Medical/Surgical Complication with an avg allowed of $1M for a 36 day.

• Maternity Admits per 1000 increased 55.4% (Actual - 44 current vs 27 prior).

While there was an increase in the number of admits the cost and LOS decreased.

• OV per 1000 have increased 6.9% in the current period. Routine Office visits account for the majority of the visits and increased 7.2%. These visits contribute 5.0% to the 6.9% increase. Mental Health visits are the next highest contributor to trend.

Admissions by Top 10 Diagnosis Group

Average Allowed per Admits

57.3% OF ADMITS IN THE CURRENT YEAR

OCCURRED AT NCH WHICH IS UP FROM

THE PRIOR PERIOD (137 ADMITS CURRENT

VS 83 PRIOR).

Metric Jan - Nov '22 Jan - Nov '23 Trend Benchmark

Inpatient Admits per 1k 48.0 54.1 12.8% 59.7

Inpatient Cost per Admit $39,098 $32,514 -16.8% $21,175

Inpatient Bed Days per 1k 299.4 257.4 -14.0% 308.0

Average Length of Stay 6.2 4.8 -23.8% 5.2

ER visits per 1k 170.5 162.6 -4.6% 230.6

Urgent Care Visits per 1k 123.5 122.9 -0.4% 299.6

Total Office Visits per 1k 5,823.8 6,226.1 6.9% 5,078.9

Outpatient / Ambulatory Surgeries per 1k 194.2 189.9 -2.2% 240.3

23 23

15 14 13 9 8 8

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

Pregnancy-related Disorders

Mental Health Cardiac Disorders Gastro intestinal Disorders

Neurological Disorders

Cancer Infections Hematological Disorders

Pulmonary Disorders

Trauma/Accidents

Admits

Current Period reflects claims incurred between Jan and Nov 2023, paid through Dec 2023

Prior Period reflects claims incurred between Jan and Nov 2022, paid through Dec 2022

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0

All Other

Dermatological Disorders

Spine-related Disorders

Pregnancy-related Disorders

Infections

Renal/Urologic Disorders

Cardiac Disorders

Neurological Disorders

Eye/ENT Disorders

Gastrointestinal Disorders

Trauma/Accidents

Avoidable Total Visits

Observations

• ER Utilization decreased in the current period. The top diagnosis for ER visits was

Trauma/Accidents at 15.0% of total, followed by Gastrointestinal Disorder at 14.9% of total.

• Eye/ENT Disorder visits increased in the ER by 16.0%. This was the top diagnosis for avoidable ER visits.

• 68.0% of ER visits occurred at NCH.

Utilization Dashboard Emergency Room Deep-Dive

ER Visits by Diagnosis Group

ER Frequent Flyers ER Visits by Severity Category

Frequency

-4.6%

-0.4%

162.6 per 1k

170.5 (Base)

$4,691

$4,710 (Base)

Average Cost

18.2% OF ER VISITS WERE

POTENTIALLY AVOIDABLE

Benchmark: 15.9%

ER Utilization Tier

Member

Count

Visit

Count

Members per 1k

Member

Count

Visit

Count

Members per 1k

Potentially

Avoidable

Two ER Visits 91 182 21.6 81 162 18.3 16.7%

Three ER Visits 17 51 4.0 19 57 4.3 17.5%

Four ER Visits 7 28 1.7 6 24 1.4 20.8%

Five ER Visits 3 15 0.7 5 25 1.1 36.0%

Six or More ER Visits 4 35 0.9 4 33 0.9 33.3%

Jan - Nov '22 Jan - Nov '23 ER Visits By Category

Visits per

1k

Average

Allowed

Visits per

1k

Average

Allowed

Limited / Minor Visits 0.0 $0 0.9 $1,031

Low to Moderate Severity 3.3 $905 4.3 $3,470

Moderate Severity 34.2 $1,067 22.2 $1,260

High Severity 57.7 $2,861 72.0 $2,636

Life Threatening 75.0 $7,907 62.7 $8,384

Other 0.2 $21,697 0.5 $7,036

Total 170.5 $4,710 162.6 $4,691

Jan - Nov '23Jan - Nov '22

Current Period reflects claims incurred between Jan and Nov 2023, paid through Dec 2023

Prior Period reflects claims incurred between Jan and Nov 2022, paid through Dec 2022

Network Savings

Observations

• The overall In Network discount increased to 55.2% in the current period.

• While there were 4 claimants that incurred claims at provider #4 Shands Teaching Hospital & Clinic, 97.7% of the spend was for the #2 claimant on slide 8.

• Out of Network utilization based on eligible dollars has decreased in the current period but there are still some substantial claims falling out of network for single claimants.

No. TIN Provider Name Claim

Count

Member

Count Eligible

1 590714812 LEE MEMORIAL HEALTH SYSTEM 2779 508 $7,046,401

2 593238634 H LEE MOFFITT CANCER CENTER 126 18 $1,635,856

3 812930469 USRC UPTOWN NAPLES LLC 30 1 $1,129,861

4 591943502 SHANDS TEACHING HOSPITAL & CLI 4 4 $1,089,975

5 592616017 UNIVERSITY OF MIAMI 34 18 $1,053,406

6 592013191 PEDIATRIX MEDICAL GROUP OF FLO 157 16 $612,814

7 650666516 CAPE CORAL HOSPITAL 103 52 $424,345

8 650252846 FAWCETT MEMORIAL HOSP 13 7 $375,209

9 593458145 FLORIDA HEALTH SCIENCES CENTER 5 3 $374,590

10 590724459 ADVENTIST HEALTH SYSTEM-SUNBEL 16 10 $337,620

All Other $11,105,130

Total $25,185,207

No. TIN Provider Name Claim

Count

Member

Count Eligible

1 261440485 DRG PHARMACY LLC 13 1 $400,471

2 271450252 BEACHWAY THERAPY CENTER 48 2 $228,800

3 582670224 DEERFIELD FLORIDA HOUSE INC 14 2 $197,485

4 475040973 INTEGRATED EMERGENCY MEDICINE 176 118 $183,247

5 850908631 CAPITAL ANESTHESIA SOLUTIONS 126 73 $137,331

6 822411538 PURE LIFE RENAL OF NAPLES LLC 24 1 $135,162

7 822534591 ABL MEDICAL CARE 34 17 $92,793

8 596000558 COLLIER COUNTY EMS 128 84 $88,595

9 450439149 MED-TRANS CORPORATION 1 1 $88,416

10 870533822 ROCKY MOUNTAIN HOLDINGS 2 1 $86,999

All Other $1,496,766

Total $3,136,066

Cigna Utilization Out of Network Utilization

Current Period Detail

Current Period reflects claims paid between Jan and Dec 2023

Prior Period reflects claims paid between Jan and Dec 2022

Network Eligible Discount Discount % % Eliglble Network Eligible Discount Discount % % Eligible

CHP $48,139,800 $25,941,855 53.9% 67.3% CHP $54,826,728 $30,043,195 54.8% 64.5%

Cigna $17,740,582 $10,469,430 59.0% 24.8% Cigna $25,185,207 $14,600,766 58.0% 29.6%

Other $1,510,232 $364,846 24.2% 2.1% Other $1,808,918 $483,814 26.7% 2.1%

Out of Network $4,189,252 $1,724,175 5.9% Out of Network $3,136,066 $1,288,902 3.7%

Total In Network $67,390,614 $36,776,131 54.6% Total In Network $81,820,852 $45,127,775 55.2%

Jan - Dec 2022 Jan - Dec 2023

Jan - Dec '21 Jan - Dec '22 Jan - Dec '23 Trend

2 Year

CAGR

Med PMPM -- $611.31 $549.52 $616.09 12.1% 0.4%

Non-Cat PMPM $411.11 $376.61 $421.61 11.9% 1.3%

Cat PMPM $200.19 $172.91 $194.48 12.5% -1.4%

Cat Claimants 46 40 53 32.5% 7.3%

Cat Claimants per 1k 9.8 8.7 11.0 26.5% 6.0%

Avg Paid per Cat Claimant $245,574 $238,942 $212,370 -11.1% -7.0%

Overview Costs

Top 10 Conditions

75 individuals

(prior 55)

$227K average cost per individual

(prior $232K)

37.3% have a behavioral health diagnosis

Total Catastrophic Spend

$17M (prior $13M)

Catastrophic Summary Combined Medical & Pharmacy

Impact

Catastrophic members accounted for 1.5% of members, and 34.8% of paid dollars

Average Age 55.5

53.3% Male

37 Employees

33 Spouses

5 Children

*Expected number of claimants in excess of $100,000 is between 7.58 and 8.06 per 1000 *Expected claim amount in excess of $100,000 is between $114K and $116K

Current Period reflects claims paid between Jan and Dec 2023

Cancer, 14

Gastrointestinal Disorders, 12

Cardiac Disorders, 10

Musculoskeletal Disorders, 6

Trauma/Acciden ts, 5

Infections, 5

Neurological Disorders, 5

Medical/Surgical Complications, 4

Spine-related Disorders, 3 Hematological

Disorders, 3

Catastrophic Detail-Top 20 Claimants

Current Period reflects claims paid between Jan and Dec 2023

# Gender Age Relationship

Current

Status Highest Paid Diagnosis Medical Paid Rx Paid Total Paid Highest Paid Procedure

Over $100K

Prior

1 F 58 Spouse Active Hematological Disorders $1,277 $1,420,765 $1,422,042 Berinert

2 M 71 Spouse Termed Medical/Surgical Complications $1,012,126 $70 $1,012,196 Operating Room

3 M 1 Dependent Active Pregnancy-related Disorders $926,821 $0 $926,821 Inpatient Hospital Care

4 M 60 Employee Active Pulmonary Disorders $1,790 $785,486 $787,276 Ravicti X

5 M 68 Employee Active Infections $581,233 $5,351 $586,585 Operating Room X

6 F 30 Employee Active Cancer $575,942 $10,505 $586,447 Drugs

7 M 39 Employee Termed Infections $487,149 $21 $487,171 Drugs

8 M 67 Spouse Active Trauma/Accidents $303,070 $112,767 $415,837 Inpatient Days X

9 F 59 Spouse Active Gastrointestinal Disorders $65,026 $317,203 $382,230 Stelara X

10 M 66 Spouse Termed Infections $238,162 $134,432 $372,594 Laboratory X

11 M 36 Employee Active Cancer $38,872 $304,051 $342,923 Qinlock X

12 M 23 Dependent Active Hematological Disorders $315,588 $3 $315,591 Drugs X

13 M 54 Employee Active Spine-related Disorders $250,917 $22,394 $273,312 Durable Medical Equipment

14 M 62 Employee Active Cancer $268,372 $728 $269,100 Durable Medical Equipment X

15 M 69 Employee Active Cardiac Disorders $254,083 $6,724 $260,807 Operating Room

16 F 74 Employee Active Cancer $223,080 $8,891 $231,971 Durable Medical Equipment

17 M 63 Employee Active Cancer $216,895 $2,855 $219,750 Cardiology

18 F 46 Spouse Termed Cancer $212,238 $0 $212,238 Laboratory

19 M 47 Employee Active Dermatological Disorders $171,602 $38,850 $210,451 Inpatient Days

20 F 55 Spouse Active Cancer $205,364 $0 $205,364 Drugs X

Top 20 Claimants $6,349,607 $3,171,099 $9,520,706

94.5

62.4

91.9

228.8

182.4

89.6

96.6

138.5

182.9

281.2

94.0

105.1

143.9

197.8

298.1

0.0 50.0 100.0 150.0 200.0 250.0 300.0 350.0

Diabetes

Blood Disorders

Lower Back Pain

Hypertension

Hyperlipidemia

Members per 1,000

Prevalence of Top 5 Chronic Diseases

Prior Current Benchmark

Chronic Conditions

Lower Back Pain Deep Dive

27.8% OF MEMBERS IDENTIFIED

WITH HYPERLIPIDEMIA;

PREVALENCE DECREASED IN THE

CURRENT PERIOD

Prevalence per 1k

Current Period reflects claims paid between Jan and Dec 2023

Prior Period reflects claims paid between Jan and Dec 2022

Preventive Care

Preventive Screening Rates*

Observations

• *Quality Metrics presented are designed by Cedar Gate clinicians in consultation with industry standard sources of such metrics

Current Period reflects claims paid between Jan and Dec 2023

Prior Period reflects claims paid between Jan and Dec 2022

Employee Spouse Child Total

Jan - Dec '21 81.7% 86.4% 67.0% 78.0%

Jan - Dec '22 87.4% 71.8% 59.5% 75.3%

Jan - Dec '23 68.7% 87.8% 54.9% 68.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% Well Visit Rates

Employee Spouse Child Total

Jan - Dec '21 75.3% 70.3% 64.4% 70.7%

Jan - Dec '22 84.9% 73.5% 64.3% 76.0%

Jan - Dec '23 76.8% 80.4% 65.8% 74.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% PCP Visit Rates

Cervical Cancer Breast Cancer Colon Cancer Prostate Cancer Well Child Exam Age 19-39 Prev

Visit Age 40-64 Prev

Visit Age 65+ Prev

Visit

Base 92.1% 81.9% 54.0% 91.6% 54.0% 71.0% 93.7% 78.8%

Current 91.0% 87.7% 61.1% 85.7% 55.7% 69.6% 93.6% 75.5%

Benchmark 63.3% 61.3% 36.0% 44.3% 45.3% 40.4% 58.3% 40.2%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Performance Guarantees

I. Medical Time to Process Goal Q1 Q2 Q3 Q4 YTD

Medical Time to Process 90% in 14 days 97.7% 97.0% 97.1% 92.9% 96.2%

II. Medical Call Services Goal Q1 Q2 Q3 Q4 YTD

Average Speed of Answer 75% in 30 seconds 75.5% 76.4% 71.6% 72.8% 74.1%

Abandonment Rate <3% 3.5% 2.3% 3.0% 2.6% 2.9%

First Call Resolution 93.6% 91.3% 95.3% 95.7% 94.0%

III. Medical Claim Quality Goal Q1 Q2 Q3 Q4 YTD

Financial Accuracy 99% 99.9% 99.8% 99.9% 99.9% 99.9%

Processing Accuracy 95% 99.1% 98.4% 99.6% 98.3% 98.9%

Glossary

Definition

Risk

Relative Risk Score: Measures population health risk or illness burden. Assesses the degree of cost variation explained by illness burden. Compares disease prevalence to the benchmark. The benchmark score for comparison is 1.0. Risk reported represents the concurrent relative risk score. The Concurrent score uses data from the prior 12 month period to calculate a risk score covering the same period.

Benchmark Benchmark data represents Government Industry

Catastrophic Catastrophic is defined as members with over $100K in medical paid (pg 2)

Catastrophic is defined as members with over $100K in medical and pharmacy paid (pg 7 & 8)

Chronic Conditions

Chronic Conditions: A member is identified as having a chronic condition if any of the following conditions is met within a 24 month period:

-2 OP claims for the Dx on separate days of service

-1 ER visit with the Dx as the primary

-1 Admission with the Dx as the admitting

-for Diabetes only, one or more pharmacy claims can be used to identify the condition

Cancer Screenings

Breast Cancer screening: women age 50-75 with screening mammogram in the last 24 months

Colon Cancer screening: Age 45 to 75 years with colorectal cancer screening

Prostate Cancer screening: Males age greater than 49 with PSA test in last 24 months

Well Visits

Well Child Exam: Annual well-child exam (all ages)

Age 19-39 Prev Visit: Members aged 19 years to 39 with preventive visit in last 24 months

Age 40-64 Prev Visit: Members aged 40 years to 64 years with preventive visit in last 24 months

Age 65+ Prev Visit: Members aged 65 years and older with an annual preventive visit

Collier County Government V.A.L.U.E. Review Partnership for Moving Medicine Forward | 1/1/2023-12/31/2023

I. Executive Summary

Overview

Plan Paid $8.5M

Trend: 32.1%

Plan Paid PMPM $146.40 Trend: 26.3%

Benchmark: $107.85 Trend: 9.3%

Specialty % of Plan Paid

58.6% Trend: 16.4%

Benchmark: 55.3% Trend: 0.3%

Generic Dispensing Rate (GDR)

84.3% Trend: 0.6%

Benchmark: 84.6% Trend: 3.7%

Previous Period: 1/1/2022-12/31/2022 ; Current Period: 1/1/2023-12/31/2023 Rebates are factored into all plan paid calculations and are estimated for claims submitted after 10/1/2023.

Key Performance Metrics

Trend is measured by the Current Period % change over the Previous Period *Drug Spend is net of discounts, rebates and amount paid by other payors including manufacturer Assistance

Rebates are factored into all plan paid calculations and are estimated for claims submitted after 10/1/2023.

TREND DRIVERS

Plan Paid PMPM Trend

Plan Paid PMPM increased by $30.46, a change of 26.3% Specialty Plan Paid PMPM increased by 47.0% Price Inflation & Drug Mix increased spend by 37.2% Rebates decreased spend by

12.7%

Previous Period: 1/1/2022-12/31/2022 ; Current Period: 1/1/2023-12/31/2023 Rebates are factored into all plan paid calculations and are estimated for claims submitted after 10/1/2023.

Previous* Current* Change Trend Benchmark Trend

$115.94 $146.40 $30.46 26.3% 9.3%

Copay Assistance Savings Total $744,496 Savings % Of Overall Drug Spend (Plan + Member Paid)

8.3%

II. Summary of Plan Statistics

The impact of Utilization factors on overall PMPM Trend was 2.8%

Utilizing members increased by 1.5%

% Utilizing Members was 78.7%, which was a decrease of 3.0%

Public Sector Benchmark % Utilizing Members was 77.0%

Utilization increased by 2.8%

Public Sector Benchmark Utilization increased by 1.3%

Previous Period: 1/1/2022-12/31/2022 ; Current Period: 1/1/2023-12/31/2023 Rebates are factored into all plan paid calculations and are estimated for claims submitted after 10/1/2023.

Utilization

Trend Driver Overall PMPM Trend Utilization Impact Non-Specialty Specialty

$30.46 26.3% $3.27 2.8% 2.8% 7.8%

Previous Current Trend BoB

Utilizing Members 3,732 3,787 1.5%

Avg. Invoiced Membership per Month 4,597 4,811 4.7%

% Utilizing 81.2% 78.7% -3.0% 77.0%

Script Count PMPM 0.9 0.9 -0.5% 0.9

Days Supply PMPM 40.5 41.7 2.8% 38.9

The impact of Price Inflation & Drug Mix factors on overall PMPM Trend was $43.08

Specialty drugs make up 58.6% of Plan Paid, which was an increase of 16.4%

AWP Price Inflation for Brand drugs was 5.1%

AWP Price Inflation

Previous Period: 1/1/2022-12/31/2022 ; Current Period: 1/1/2023-12/31/2023 Rebates are factored into all plan paid calculations and are estimated for claims submitted after…