The Latest Leading Cost Drivers in the Blue System

In Thought Leadership by BHI

Using our massive data repository and powerful analytic tools, BHI regularly examines high-level cost and utilization trends.  In the most recent dive into our big data, comprised of more than 19 billion claims from over 190 million members, three trends stood out.

PMPM Costs Continue to Climb

At a macro level, total commercial health plan PMPM costs rose 6.5% — from $413 in 2016 to $440 in 2018.

Sepsis is Growing by Double Digits

BHI’s analysis of notable trends revealed that sepsis remains on a worrisome trajectory. Specifically, admissions related to septicemia or severe sepsis with major complications (DRG 0871) is the third largest PMPM national increase. The PMPM is up 11.2% primarily due to an 8% increase in utilization compared to 2017.

Specialty Rx Continues to Drive HiCCs

Other notable findings from BHI’s surveillance of national healthcare trends and opportunities reveals that:

  • Specialty drug nivolumab (OPDIVO®), approved last year for first-line treatment of intermediate- and poor-risk advanced renal cell carcinoma, hit the top 10 most expensive drug list. The PMPM is up 44.8% from the prior year, with the average cost per service driving that increase.
  • High-cost claimants (those with over $100,000 in annual total healthcare costs) are up 12% from the prior year. The use of specialty drugs is the major contributor to their overall costs.
  • Treatment episodes related to multiple sclerosis are up 41.8% from 2017 and have become the seventh fastest-growing episodic cost contributor.

Health Plans are Applying BHI’s Benchmarks

To turn recent trend insights into actionable opportunities, our clients regularly leverage regional and medical economic benchmarks. One health plan began by looking at relevant regional norms to see how its costs differed. With this comparison as their starting point, the plan narrowed in on a dozen cost-improvement opportunities. In one year, thanks to the work of several cross-functional teams, the plan realized a 2.4% reduction in total medical costs.