ALC-Employee Benefits Division Oversight Subcommittee

So some of you will recall I was here last year we didn't have the meeting in december but we are here to recard what we learned in the previous did analysis with diabetes and then talk about some more of the commodity and then mental health and other pieces of that and to do that with me I have selling anderson who is in RN on my team at and she's are clinical consultant and our rental health specialist so I will get started. Instead of reached on. Can we get a little help on how to move the sides for i'm unable to move. And with us there might be mad matter you there. Yes i'm here this is matthew with who did a lot of data. Figuring on how to move the slides. The. Members the packet is in front of you so we congest if you have a package with you we can just fall along with them while it works on here okay great. I will get started with the year with what we are presenting here. Okay until he figures out how to do the slides. I am going to talk about the core more abilities with their is falling now okay okay so there is this very complex thing going on here with the co mobilities of diabetes and this is a complex chart on the left side what you can see is the blue bar is always the high yes in all categories hypertension or be city hyperlipped email which is high college. Mental health I relieve it as a rescue disease then you have corner that is a cad suddenly substance he was disorder churches and yesterday hard for you and then see your pds you know it's the long complication this is the current employment rate is is. So. Blue buyers always hit what that means is if somebody has diabetes. That means that they're likely hold off having this hypertension obviously they have reliable higher and this is actually from your data from the arkansas data so we can see that. The dark blue bar which is twenty eight percent compared that with eighty one percent so in normal population twenty eight percent of how hypertension or if somebody with diabetes they have eighty one percent hypertension so that's what we call commodities so all of these are associated with diabetes that are higher in your population as well as usually across the across the bill up and in the yellow bar is our benchmark which is our shape is our database at as the seagle health analysis of plan experience that's our database which is you can call that our book of business sort of and they are also slightly lower than your population. Making it a point again again here that you know diabetes has huge homework but it is on the right side is the adi area the provision in next so when when I talk about that back in maybe november october I don't know when but area area the provision indexes as the higher the number of that adi. The more deprived. The area is deprived of medical supplies medical personnel physicians food deserts and all kinds of where people have no access to a lot of healthy living so the higher the number the more deprived area. Across those areas we didn't find a whole lot of difference in the diabetical mobile distribution but it's slightly higher so as but this is going like directionally higher in most of the categories so that's what on the point we're making here this light is talking about really the cost and utilization by more and what that is is just pay attention to how the bar goes up again which is no commodity lowest cause and then it as you keep on adding any commodity to divide is your pm. For member or mine feed amount goes up and that's like a kind of pretty obvious picture of. Toripm impatient admission while one thousand and also emergency room visit one thousand. Those are contributing to the pm but the point here is you are utilizing more resources as you add co morbidities to the divided population. And then this is the commodity by age group nor not a whole lot of different picture here but just a different. Scenario of. By different age groups again the twenty pm pm goes up as the core more where it is add up the ambition admissions for one thousand go up as different core more but it is add up and then are sim with the emergency room visits for one thousand these are all ultimately will come down to how they could be looked at as avoidable expenses if we manage the diabetic population better. Yeah. And then what are these call mobile is we had I had the full slide of all the lists of different conditions and different areas where diverting accumulated these different illnesses but here is a special graph where we are actually adding diabetes with the day reduced with hypertension with this with behavior of help and hypertension and you just keep on adding one and as you can see the again to repm. Ambition admission and emergency room call up and open up and mental health contributes a lot to that in our experience we have seen that repeatedly over data over years of data analysis there. Any of the colonic in this one of the underlying commodity that's always present is usually behavioral help or mental health and i'm gonna have saturday more about the details of what we found when we dive down deeper into what areas of mental health are contributing to not just. By themselves but to somebody with dabies. Yes so I think sometimes we get a little complacent because we think oh of course people who have more diagnosed of course they'll have more hospital admissions of course they'll have higher expenses and but the value here in breaking out the same combination of conditions one of the bars like say we'll look at the purple the two purple bars though the later purple one on the left is that combination of conditions but without the mental health and so you can really isolate the mental health component there and so using that example when you're looking at the inpatient admissions per thousand in the lower left comparing the light purple with the dark purple so these are folks with diabetes hypertension at heart disease adding that mental health component on tark really makes those impatient admission skyrocket and isolating it is what so value and it helps us show that if we can isolate and understand what's going on identify the members who have these co morbidities with their diabetes that's really where we can have an impact because once we can identify who those folks are then we can target interventions for them. So we're going to take a look at mental health from a high level now and see how that mental health commodity impact spokes with diabetes and so this is like before your plan's data here and what we're looking at is what the diabetics type two diabetics are have in terms of these are mental health diagnosis co morbidities so the first row here is people without a mental health condition I and what you'll see if you look here is that of the diabetic population it's more common to have a mental health condition then the folks who are not diabetic as a higher prevalence of this commodity i've meant a health compared to the non diabetics and take a look at these first two columns here comparing the diabetics and the nine diabetics as you run your eyes down this chart on those first two columns what you'll see is that the prevalence of these mental conditions diagnoses are higher and every single say situation except for anxiety actually but what does this tell us this tells us that the people who have these diabetes diagnoses they also have a lot of going on with mental health more than the general population this tells us that meant to halt as an important area to focus on four diabetics now I have a number circled in the upper rate of this table at this nine hundred and twenty five dollars in that first road you'll see that that's the monthly cost PM PM monthly cost per member of no mental health conditions so this is a type to diabetic without the mental health conditions so compare that nine hundred and twenty five that we see with the rest of that column looking down the row everything is more expensive than the folks who do not have the mental health condition who are diabetes only and take a look some of these are all significantly more expensive you know out that bottom row opined use disorder that's more than double the monthly cost. So this really gives us some action points in some takeaways here not only do we know that diabetics have a higher rate a mental health conditions but it shows us which mental health conditions really can make a big impact sometimes we get a little distracted when we only look at cost cost is only one piece of this rate but cost is a proxy for telling us the acute the experience of what the participant is going through and so it's an important thing now in these coming sides will look a little more about a breakdown that shows us more than just cost but but it's still is a good good information for us in looking where we need to do again so that we can take action in and develop these programs that can really impact people's lives. So first we're going to take a look at deep dive into sleep disorders if you remember from that chart we just looked at sleep disorders or the number wine mental health commodity for at this diabetic type two population that we have now let's put that in perspective this arm is actually very unusual usually when we look at mental health conditions not as comorbidities but just in general sleep disorders doesn't really crack the top for you so this is something that we need to pay attention to why are sleep disorders so prevalent among this diabetic population usually we see it around seven or eight percent of a population has sleep weak disorders here twenty four percent of the diabetic so three times have sleep weight disorders so you might be wondering what is the sleep weight disorder so examples of this could be in some yet to to little sleep waking up frequently hypersomia where people might get enough sleep at night whether having trouble staying awake and feeling functional during the day so in as hence a sleep wake disorder is a a is a sleep disorder not caused by another condition like a substance. I so whiteways is relevant oh when you look at the costs here you start to see a picture of where we are really what why is worth pointing out so take a look at the three circles that I have on that table you'll see that wine is read orange and green I comparing the cost of people with sleep disorders who also have diabetes and this is where it starts to be an interesting story so that right hand column in the table is looking at diabetics who do not have the sleep disorders I and then we see two columns though the two columns on the left that had the circles in them are those both pertain to diabetics who do have the sleep disorders so why are there two columns it's because we actually have two different cohorts within those that within that that grouping I and this is something that we've done a little bit of digging on because as you can see from the charts the bar charts on the right you see big differences between these two cohort so it's worth dividing them out so d blue bars that we see in our charts and it's that first column those are folks who started with the mental health condition so in this case it's the sleep wake disorder later on they got this diagnosis of diabetes later on in time so the underlying condition is the sleep disorder for these people I now contrast that with call him to here which is the purple that we see in the charts those are the opposite these are the diabetics who later developed a sleep disorder so you might think old does that really matter it does when you look at the cost I so we see that a diabetic without any sleep disorders is nine hundred and ten dollars monthly for that participant but then look at how much higher that is for the purple bar are on the rate that second call him in the table almost seventeen hundred dollars a month a huge difference in even there are the the the yellow circle there is still notably higher per month. For those people who have the the sleep first diagnosis and then the diabetic diagnosis. So why do we have these two different coverage why do they experience these different things when we look into the ideology of the diseases that gives us a little bit of perspective here so that blue group that the columns that are blue in the charts and there that first call them in the table where they have the sleep as the first diagnosis they've been pushing their bodies hard they are tired their sleep deprived and what comes along with that it's a lot of stress hormones that google core codes that are giving them their body their mun system a lot of trouble is increasing their resistance to the insulin so the sugar in their blood vessels is not getting moved into the cells where it needs to be a new basically it's an increasing their risk of getting diabetes so sleep disorders is increasing that risk of getting diabetes I and I think in the medical community there is a lot of hesitant seeded say because in effect we like to talk about correlation because it can be hard to prove anything but in this case we've actually had studies that have been experimental data to prove if you're sleep deprived you're more likely to get to diabetes or increase your risk and so i'm glad I was not a participant in the sleep studies but what they did as they deprive people of sleep and even after only four or five days of little sleep there is seeing a huge decrease in that insulin um sensitivity so that huge decreases twenty five to thirty percent less sensitive which think about how huge that it's for four five days of little sleep so what are we doing to people who you know shift workers people who have irregular schedules i'm a nurse I used after come in for my next shift less than eight hours after I left from the previous of that's tough and that takes that hall on our body so when we think about what we can do to help folks on with diabetic management and keep folks from becoming die back in the first place we need to think about sleep we need to um the assessing what is happening with people sleeping what we can do to help get a better sleep pattern in place so that we don't have people becoming diabetic down the line. So that's the blue I call him and that the the folks who had the first diagnosis of mental health which is a sleep disorders in this case what's going on with the purple we see that huge cost that in the pmp chart of the purple people so those are the the folks who had the diabetic diagnosis first so a little bit of a different story behind them we had the people who were sleep to prived and stressing their body these are the folks on the other hand that they are diabetic and there more likely to be experiencing sleep problems as a result of their diabetes so what does that mean we see folks who have not having to go use the restroom a few times during the night that's disrupting their sleep you have not turned on hypothetime yet so their blood surgeries getting low at night and that's causing them to have sleep disruptions like they're waking up sweaty they're having headaches they're having nightmares all because of that blood sugar and then you have ignore pain than your opposite are restless legs that go along with diabetes as well so what what does this mean are takeaways here are that we have these two different cohorts depending on the order of diagnosies where diabetics with sleep disorders have very different experiences are very different at focus is different interventions that we can do umm to affect these different groups. I so that that's really our first take away here now we're going to look a little more into detail about what this experiences for the sleep disorders for the folks who have the type two diabetes but also have the sleep disorders. So if you recall I said that the purple bar on the previous chart was a lot higher that total expense for the folks who had diabetes first was high so I said that and that purple bar court corresponds to the second column in the chart but if you're looking at that chart you might be saying wait a minute II was talking about how expensive these people are how cute things are but I see a lot of green circles which are good signs on that second column for those people that are more expensive so what is going on here this gives this very important information about what to do to treat these folks because as we can see there actually doing pretty well in terms of their health measures so avoidable emergency visits we can estimate when emergency visits are avoidable and what we see is that these people this cohort that has the diabetes first before the sleep disorders they're not abusing emergency room visits like we see what the other group of the sleep disorder diagnoses first we see that they're getting there annual a one c test which is a blood test that you should get to make sure that your diabetes is on track so it's a it's it shows us if you're taking the test that you're trying to be compliant in that hearing with your care we see that that's actually pretty good for these folks too and we see that the medication had hearing set that that's the r x inherent so that's pretty good to so what does this tell us about the the purple group that it's more expensive but pretty compliant this tells us that interventions for the diabetes sleep disorder call more bittery for the folks who have diabetes first really need different interventions then then the rest because they're not needing education so much about when to go to the emergency room and please don't do that again for him to avoid a bullet visit that's not the focus the focus is more supporting the symptoms what can we do so you're not awake feeling your legs all night hurting what can we do so that you can get better sleep what can we do so that we can help you when you're disorders at your your conditions our lower cu. So that you don't need to become an impatient admission so that that's really where I want us to take away what we're looking at here today is that we want to try to prevent a and help sleep disorders among the general population so that we don't have more diabetics as a result of that i'm trauma to the body and then in people with the sleep to book disorders who develop diabetes so the blue people here we want to work on resolving the room because of of those sleep disorders educate on avoidable emergency visits give them the support in that regard but in the purple group once someone already has diabetes and then they developed a sleep disorders let's focus on how we can treat those symptoms a little more. So now we're looking at that seem a group of people but split up by each so why does this matter when when we have the mental health commerciality to diabetes what we see is that there are different experiences for different generations different age groups I and this is important because when we're thinking about interventions we want to make sure that what we're doing is resumed with the age group that it's affecting the most and so what you can do by looking at this as we see though the light value on the rate the kind of tear color is kind of our baseline those of the diabetics who do not have the asleep disorder and where are we seized bikes in the dark blue and the purple that are different from that that tells us we need to look at that and figure out what we can do to support those people so a few examples here are the one sea adherence we actually see a problem which is unexpected that the folks who don't have the sleep disorders are doing a west good job of getting that care or are you those annual blood tests I saw that tells it something that tells us that the people who are having these the disorders are probably already kind of engaged with their with their treatment plan maybe having more visits to their regular doctors and so that's that's good information for us you might be wondering about that huge spake on the impatient and missions I do see that on the under eighteen this is actually an interesting thing and I want to point it out because it tells us something else about what we can do to help this population this bike for impatient emissions for the under eighteen was only caused by one or two of our participants in this plan so we have a one or two people who are really driving up what's going on and what is our take away from that or take away is that yes it's great to divide and splace the data it's fine we could do that all day long but we can't lose sight of what's going on with individuals you know people are not a trend necessarily so we need to make sure that what our programs are doing is having some data analytics on the back and to identify. This person needs help with the specific thing because that's where really we can impact change. Alright so next we're going to take a look at a different commodity related to mental health and this one is exiting so this is just like what we did we looked at the tight two diabetics who are who had sleep disorders now we're going to look at the type two diabetics who have anxiety now you'll see a few similarities and a few differences and so it's important to give us a whole picture of the license being mental health is not a manner with where if you have mental health this is easy we know how to treat your rate the different conditions do it out give us a better sense of what specific recommendations that we would want to make. And and keep in mind that this day days coming from your claims data that means your population has used the services to see care for example anxiety the next one will be a I think you have depression and then we have these school mobile it is of prepared I present mental health but these are actual expenses that you are incurring that's what we are showing from the data so keep that in mind that this is real. Exactly and that's a good point to to bring up that this is claims data rate some the experience of people with anxiety we're looking at the people who have incident who are diabetic who have gotten treatment for the anxiety right there is a whole different section of people who were diabetic who have not had that doctor's visit and you can see that in when you look at the percent female there's a lot of different research out there with anxiety disorders and the gender split but as you can see from your data that we have a whole lot high percentage of women out who have that diagnoses that's a commorbity of diabetes and anxiety I earned that that really speaks to whose getting seen and treated that's although the main theory at this point is that women are more likely to seek careful anxiety I still keep that in mind that that's part of the nature of looking at data and understanding it is you have to remember the pieces that you're not seeing because this is claims data so what's the relationship between anxiety and diabetes so let's talk about the the blue group for so these are the folks who had the mental health condition diagnosed first just like before so this is an exiting diagnose and then later down the line they got that diagnosis of diabetes so we see some similar with what we saw with the sleep sleep disorders I stress hormones if you're anxious your body is pumping out a lot of groupo quarter quotes and that is influencing your ability to absorb the gluten coast you also see a little bit of an accumulation of the visceral fat in your body because of the stress hormones so what does that mean that means that your pain creates isn't working as well because you have a little more fat around your mid section internally and that is making it harder for your painter yes to do its job of making the slight so may basically your increasing your risk of getting a diabetes from this anxiety now let's compare that to the purple group the people who started with the diabetes diagnoses and developed. Anxiety I think we all have a guess we can imagine if that was ourselves how that could happen right you get this life altering diagnosis of than you're worrying about your blood sugar for the first time you're having to poke yourself and take care yourself and plan your social life differently different food that's a lot and so we see that stress and the anxiety come in that group in that way and then of course we know that diabetes we've seen this in the data in research that anxiety can make diabetes worse as well. So let's take a look at what we're seeing with the circles in the data. So let's look at that first road a medical pm pm which is the monthly cost for medical I have two circles there now the red one is self explanatory and is higher than the green one right so we can say okay the folks who had that anxiety diagnosed as first they're spending a lot on their medical spend monthly compared to the folks who just have diabetes without anxiety diagnosis I think that kind of makes sense to us rate from what we've seen from the charts we looked at a minute ago we see okay medical diagnosis sure more expensive but I have a circle under that for the rxp m PM and I want to point that out look at that compare that to the diabetics without anxiety we're looking at two hundred and fifty eight dollars monthly compared to four hundred and twenty five so why did I make a lower number of red isn't less spend good this is this is part of what we want to talk about here and we'll deal with into this a little more in the next slide. Lower spend is good in certain ways but not all the ways and if you are having trouble getting your medications filled in taking your medications that's not a cool or fine cost reduction that's a problem indicating that you are going to have further expenses down down the road so will drive into that a little more coming up here in the next slide specifically looking at that rx which is what these circles are on this side corresponding to so we can see for that group that had the anxiety first this is their number one struggle when their diabetic is a medication insurance so you can see it's quite half about green circle area that fifty seven point five for the diabetics without anxiety so this is almost low hanging fruit for us in only think about what program interventions that can help knowing someone has an anxiety diagnosis and a depression diagnosis knowing the order of that would q us to ask for their questions how are you doing with getting your medications are there barriers to getting your medications I owe you know what what is going on that is leading you to not get your medications and as you can imagine folks who are not getting their diabetic medications are not going to have a good time and and and it's very possible sometimes analysis paralysis happened so we could go deeper and deeper in data and we might lose you we probably have only lost if he heard so a better with us but we did not do this even by adi for that reason because you could do that by area to provision index and actually find what she's saying that as the adi goes up it's possible that those people it's very hard to opt in medications because there is simply no pharmacy out there or something like that it could be happening but we haven't really gone into that level. Absolutely yeah so this really helps develop our takeaways here so you have someone who has diabetes they have anxiety or takeaways are different interventions for the different conditions the order of conditions so the people who are are purple people there are they though diabetics first who then I get the anxiety diagnosis we're seeing more about the supporter navigation helping them proactively I get help before you know something gets to the point where they need to have those expensive impatient admissions are whereas the blue that people with the mental health which is anxiety in this case first a little more about it you know how how how how can we help you so you're not using the emergency department when you when you shouldn't be so that doesn't really the takeaways here now lastly on anxiety you won't split this by age now we see a lot of similarities here when we look at the different age cohorts remember I purpose of doing this is interventions what's going to resonate with different age groups and where are our pain points for the different age groups. And so really I want to point out emergency department visits because that is where our eyes go to on this side that bottom rate and where we see that we have a lot of struggle compared to the diabetic only population with regard to using the emergency room so this would be the focus looking at those age groups that eighteen to forty four and in the forty eight five to fifty four actually really are below retirement age we we really need to make sure that communications going out to these folks are showing people who look like their age that is something that resonates with them and that we can support them through that diagnosis. Alright this is our last co morbidity for a diabetes that we're looking at for mental health so you might have noticed some trends of what we've been talking about some of the things are common between anxiety and a sleep disorders where we're talking about things like avoidable emergency department visits and I education on proactive resources so we don't get folks who get very sick very fast there's actually a little bit of difference here with the pressure and some of those trends still hold up but the difference that I want to say is that when you have folks who have diabetes are ended up depression at the same time that linkage between those two conditions is a lot more studied and a lot more understood and a lot more direct. So why do we care because this relationship is so closely in or twin between these two conditions we need to be on the ball about this I think sometimes it can be easy to catch the low hanging fruit like I pointed out the emergency department visits for those with things I yes those are that's important but because this relationship is so much closer between these two conditions are we we need to be proactive about how we're outreaching the folks who have say depression diagnosis but no diabetes and on the other hand someone who just got a new diabetes diagnosis but doesn't have depression yet that those are really gold minds of opportunity for us. So what are these connections that i'm talking about that make these two diagnoses so in our least when you have meant to help first so that's our our blue chart here are blue columns in that first column in the table when you have that depression first it can be tough to take care of yourself to eat healthily to exercise to do the things you need to do like see your physician preventively to get the early diagnoses all those things are really tough to do but there's more than that folks who are on anti depressions have been an interesting area of study for researchers and this is an area that's not very well defined and there's some controversy to this but i'll give you a sense of what it is which is that it's thought that certain anti depressions actually can increase your risk of diabetes. I so there are either of their tighter presence that are thought to do the opposite and so it's a mixed bag but then you might be thinking okay well if that's a little dangerous that anti depressions if that could be causing our population to come down with ibs that is one component but think about the perspective what is the opposite of someone with untreated depression is certainly going to be a higher risk to develop day beat is there going to be struggling with just getting through the day I so where do we go with this information these people who are there depression first the blue. And that first call on they're the ones who need a lot of careful medication support we need to make sure that whatever medications they're on for depression or complementing their treatment for diabetes and that were not making something worse by accident as less where you need a lot of involvement like clinical experts who can help make those judgements now the the purple the second column here little bit of a different story but a similar idea about how in or lace these conditions are so these are the folks who got the diagnosis of depression and this is a huge life altering event there's something called reactive depression where you know there's a big event that can can cannot make some of those changes in your brain that makes it so that you have depression here you don't think about your testing your blood sugar you're changing your diet all those things so huge life change that makes it more likely that these fox you could see symptoms of depression but then also this is that that close in a releasing of these two diagnoses changes in the brain as a result of what's happening with your diabetes i'm disease progress and can actually cause your brain up to have that structural change where it is more likely to develop depression so i'm talking about nerve damage actually within your brain and blood vessel damage in your brain that's caused by the diabetes that can cause depression I so that's why i'm saying that these two diagnoses are very closely linked so what what do we do with this this is really where our recommendations become a little more suggestive of inperiod we really need to make sure that folks who have a co morbidity between depression and diabetes are getting very close monitoring and care and outreach what can we do to ease both symptoms of both conditions what can we do to marriage medications like we talked about to make sure that we are getting the best. Clinical outcomes and sometimes that means changing the diabetic treatment just a little bit to make remove barriers you know if people are having trouble because they're depressed and they're having you know it means difficulty focusing in difficulty making decisions why can we do the streamlined diabetic treatment so that they're more likely to be able to do the diabetic treatment at all so that's really worth considering and that's where you need the clinical experts who can help guide the participant get back to the root cause social determines of help why can we do to make this an easier journey up for these folks who have the depression. Alright. So we see a lot of similar similar things to what we just talked about and i'll use an example here as we're looking at at these sites diabetic foot exams or something that we need to have our participants do who are diabetic but if you are experiencing depression how well are you doing with getting you know an appointment scheduled getting that plan getting your shoes inspected to make sure they're not rubbing on your feet that's really where we had that impact is a small thing right a diabetic exam but if that can impact some of those in patient admissions you see how high some of those are the emergency visits are high as well that's really we can you know you can save money so easily we can save pain so easily by some of those little interventions and it's more than just educating saying hey you need this thing you need this diabetic exam but hoping make it happen facilitating it after these folks where this would be a barrier to them. Alright so we're lastly we're going to split this up by age like what we did before. So i'll point out just one or two things here so are a one c adhere it so that's that blood test you need to do annually to check on how well your diabetes has been controlled I we see a much better experience here for the diabetics than for the folks who had the anxiety I alot more adhering to the treatment plan going to the doctor to get these tests done. And we see a lot of acuity higher cutie with the depression folks who have the diabetes a lot of sick people you can see that in the age ranges as well but where we really see it ability to impact some of this is the emergency visits and it's similar to what we saw things I we see a lot of emergency visits that are not necessarily appropriate usage of the emergency room and that's where we have this opportunity based on these age groups that were seeing how can we hope educate them on best resources help provide them you know whether there's telehealth resources that can be more convenient to them whether there's communications that are about showing you someone like me and here's how I can get help that's not the emergency room some of those interventions really come to light here. So we've talked so far about the order of diagnosies in depression anxiety and sleep disorders when someone has added diabetes we talked about how the order of die no season packs what their treatment would be what I recommendations are how they should be managed and supported and we also talked about age bounds how different ages have different needs and different opportunities and that we need to make sure that we are appealing to the appropriate age groups on for some of these concerns that we see and then we're we also looked at how medal health diagnoses themselves whichever what it is disorders versus depression have some of the different clinical profiles where it tells us what the interventions are best focused are on based on that so now we're going to just look quickly at one final topic which is pre diabetes so these are the folks who have the elevated blood sugar more resistance are of getting the blood sugar from there are blood vessels into the sales and is before they actually retain level of becoming officially diabetic. And so you can see of course from this table that it makes sense your the least expensive if you don't have diabetes or pre diabetes but you are more expensive if you have the diabetes and then you're even more expensive if you get that diabetic diagnosis. So what we did on the right here is compared to your membership of the folks who were pre diabetic who did not have a mental health diagnosis with the pre diabetics who did have a mental health diagnosis I and so what we saw is there you're a little more likely to develop diabetes over time if you have that mental health diagnosis so think about what that means for the membership this means that the folks who have the day with the pre diabetes they need some sort of outrage for mental health too rate because otherwise were ignoring this progression of disease this increased likelihood of disease because of the mental health call morbidity and were ending up with more diabetics because of it I so that's that's really are taken away here is a think about the pre diabetics are when we think about best in class program planning I so now we're going to take a look at overall recommendations here for it for the common items so have we made the case enough for a important day but is is in your population and it's not it just doesn't enter diabetes because of all these other call but it is so that's basically the point here is mental health hypertension all of the commodity that are associated with somebody would do this as well as somebody with a pre directive borderline which is who is going to become a debited tomorrow so as we sign the series of these presentations I just want to bring it all together on what I spoke to you guys in october in november end today cd's of this for conditions the prevalence and cost of liability that it means very high in your plan and it does need to be addressed come over it is present a very high burden of in this on the people and how they do make to go about their lives I would say including rental health as a core more but it means it's serious condition by the way one thing I can tell you as a primary care physician. We take blame for letting mental health go out of hand we did as clinicians we will never thought to look at mental health as a standalone it was always an afterthought you treat somebody who comes to your office in their physical symptoms and you know when the reasons that we use to say well once that's handling it might be helpful be fine but it's no longer the case we actually have changed now that we read each motion I graduated thirty some years ago from excluded by today's students actually do look at mental health as the first line of in this and a voice line of treatment and then we kind of follow other diseases to so it's it's equally important and that's kind of work I want to reiterate that here as well. So would we do about it your help plan and your pbm has access to the members and they do limited things based on the claims that are submitted and provided. But there are legal limitations as to what they can do and how they can outreach those but there are many point solutions out there point solution is something that bridges the gap between benefits that's why they have all point solutions. Point solutions are usually no they are usually there you know at based cell phone based all they could be available online as a internet source or with the health courage on the phone and all of the about and sometimes there are physicians nurses dietitians health cautious involved in delivering that car and this point solutions do address some of the gaps in care that existed for your membership what anybody's membership for that matter including mental health and great reading that as a priority because you have health cares and physical psychologists that can talk to the patience either through their app or through the chat machine or through their preferred model communication. Are they doing regret your claims into kind of depository where they can reach out two members how to control the glp and cost our next men what we are going to talk at length about that and the point solutions can help with that too mainly about getting the shell be ones in the hands of those who really need it and preventing them from getting into the hands of those who don't need it simple as that and then perform is getting because we can hold them accountably for some performance guarantees and we have expertise in doing all of the about like we can compare them a funded fees credits allowances how that works for your population compliance there are many laws that go when these relationships that the monthly headphoney the some of the other iran wellness rules and what not so we can work with the compliance so that the vendors are compliant with these laws and then how to roll out. The product communicate with members and then obviously actually driven auto I which is what we are experts said and actually is like patrick engage heavily in that so that was sort of our next steps and recommendation and we will come back to the committee without written recommendations as well but this is what I just wanted to highlight and bring all these three presentations together. So that's the end of this far. We should probably accurate is now and then we can get into the cost and analysis that was asked specifically on your ones that patrick and I and my ad had worked on mad a care of because he's the voice up there great thank you for their presentation members like she mentioned we've got the cost analysis report neck so if your questions may be retained to that you may just want to wait until we go over that as well but if not we'll start with senator boyd your recognized. Thank you mister chair two two quick questions number one I just this might be for staff and when I find out if these slides are going to be available on the internet at some point there's some good information here they will be ok thank you in the gone back early in the presentation and it just this really stood out to me and i'm touched on something later but I still don't think it answered this question. Onco more abidities age groups eighteen to forty four. There's a big jump in the impatient admissions per one thousand in the eighteen to forty four group and is that one of those situations were one or two people drove that or is that like there's something going on in that population and maybe that's not for the discussion today but I thought it was interesting. The. Which out commodity was that sir was as all comes the beginning cost cost and universation back a more bit it is and then you've got you know this so it was before you ever got into the individual common okay yeah it's it's very possible that it was driven by a few but we have a dive deeper into that level yet but good observation I see it too yeah thank you. This is people in in arkansas that that was a known thing we did it over and over again if you're used to it you developed a relationship with the doctor probably more likely to go every year and now we have a whole bunch of younger people that entered our work force in it our plans that never had the incinemator may never be going to see their primary care physician honor in your basis until they're sick or till they make it to the emergency whatever it may be i'm just concerned and really want to see at some point how does this all mesh together in why did we do that and is it really accomplishing what we want it to accomplish. Big picture I think we had a short term cost. Cut in and I think we're gonna have a long term impact. So it was there a presentation that I missed on that. Or is that something like that I could go back and get. Yeah like two years ago. Yeah. And people were kind of doing the. R y but I don't. You know there are some financial challenges at the time. I probably have to come. Is an in your correct it was at the time of the financial but it was also this would you all know and we're probably a large part of is that the members themselves do not like that now whether or not this reason enough you know for the long term and you know whether it would be more costly that maybe something to disgroup has to do but it was also based not only on the financial part of it but just the pure fact that the members of the plan literally do not want to do that I mean it was just seems like a very large percentage that are always grapping about him to do it sorry hope that the helps are. Yeah may I completely agree but also had something caught that previous the huge cost of state of arkansas and that and probably not the only one in and so I get it I just at some point II do want to I know what we're doing and it were we were taking a look at the data and you know kind of getting down to when it's recommendations that we make but I don't want to lose side of the fact that almost every one of these talks about being preventative yeah I mean if we're preventative then the cost goes down and we've taken away one of the biggest as in as we add to be preventative or encourage people to go or actively see you can found out something was wrong I just do want to circle back to it at some point we'll have some data about your people even going to getting a longest exam at this point that they have to pay for out of pocket because they that's how this works at this point without the incident I would just be curious to know because if i'm hearing everything over and over in every meeting. We cannot did away with the first step which was prevented or encouraging people to be engaged out anyway thank you maybe there's some additional information out there something may just be a decision made because we felt like we need to so it will be interesting in the data i'm not sure if. Because we have historical data probably before and after that change happened and i'm not sure if the people are tagged you are saying okay yeah wellness credit you didn't swap to see but I think we could definitely look at the period before an afternoon cea. How things changed and then every could get another layer in and isolating the people that had the credit and see how their behavior's change and be interesting so what will see what we can bring back and it'll let me tell you something about the human behavior to as long as nothing hurts nobody goes to the doctor so one of these free divides conditions is you forget is high but there is no symptom as such a then are going to seek medical care unless they actually want into your regular preventive visit and then it came out all you should get is really high so for that reason the awareness and education is so much more important than just in sending somebody to go because they're not going to go unless our i'm fine I don't feel anything so. If you're back hurts they go to the document more often than any kind of other so that's what our obsoletion it's but it's it's it's a it's a journey it's a slow step in the right direction good question. Thank you. Sir it's double field recognize. Thank you miss german i've just a couple of observations I would like to make first of all I know there's a lot of people who are walking around with sleep at night that don't even realize they have sweep avenue every year thousands of thousands of more diagnosed with it is that. Accounted in all this. Information. But what you will see is that we have that associate. There were some common commercialities. This. Is this better yes ok at what I was seeing is it's not encounter is that included in the sleep wake disorder bucket but we see that association be city is a common risk factor for both diabetes and for sleep avenue are but then also just think about the cause is early at the effect of it is about the same if you're having trouble sleeping you're waking up many many times throughout the night which is what happens with obstructive at sleep avenue you're you're going to be seeing some of the same symptoms that we see with this group that that subset with the sleep disorders. At plus. Many people was like that what breathing for. Longer pretty to ten I have always been curious as to why certain countries on this planet. Have populations that will be of. Past hundred so I had an amount of study it took me a long time because i've always been choosed about this and I found out that these countries were people live hundred years old in older. And then they have a lot in their eighties and nineties and they're still mobile that the differences that what they were doing and what we are doing here in this country was they are much more mobile. They're die is much different they very little refined sugar. They eat more faith. They have much less stress in their lives is for the relationships and their jobs are concerned all of these countries have this income when you come here we are actually killing ourselves with refined sugar. And other things we do is forwards our diet. We are we have a couple we've come become a very set and I know this is tough for a lot of people here but we have become a very settlementary as society. Would we sit in our cars we drive to work we get in the chair we sit there all day we go back we sit on the couch or reclaim we don't move these people in these countries that are appear. They were moving to nine o'clock at night they were walking there when a swimming pool they were working and they were. They would considered impoverished compared to most americans and yet they were living to a hundred a hundred and ten. It's really is it really less simple. The. Yup and some of the hopefully the if we get the right program to work with us they can work with the people to teach them about the healthy lifestone you know whether or not people will adopt or not it's like a million dollars billion dollar question so what can at least teach them how to live heavy we just we just are not either educating our society are there wealthily refusing to to accept that education and apply to their life yup no absolutely too and I can include in that depression and all the things you listed because we haven't want to have a percentage of. Percentage you have depression of any country in the world. And so the sat might have that. Thank you. Use it thank you senator representative you're recognized thank you miss chairman quick question about the diabetes and and these popular drugs that we're seeing prescribed up and had quite a few considerance to contact me that are diabetic there a one sea level is high so they go to the doctor that the doctor prescribes one of these drugs major old or whatever it is. In some of them work well and if they don't work well they go to the next company's drug of the same type eventually they once he gets to an a normal range you know after six months or a year. They go back to the doctor have a blood test to try to follow up and the answer is in the normal range now i'll send the insurance company won't cover the medication that help them get this a once a level under control. So I mean I don't know this is right group and to that but it's a vicious cycle for a lot of these folks. You're diabeting your answers high that you go through this process and it's not a short price as as you understand I said you know the the number gets down into the normal range over time now also you considered not diabetic so they won't cover this drug anymore and so these folks are happy to pay eight hundred to a thousand dollars out of pocket is that something you're seeing happening. It being all over the depth only in arkansas with whether it's an insurance company or a pbn problem or what. We didn't see that in your data so when we actually doled deeper into the glp one calculation in my november presentation we don't see any kind of a break in coverage like that about our next memory will talk about some of the assumptions we had to make about how many people will go on the dragon come off the drug for whatever reason and then get back on the drug to also look forward to here now thank you then thank you representing far sinner urban I believe you're next thank you mister terror thank you one of the follow up with senator does may on the wellness but could you also look at the way the incentive was structured because sometimes it's all about the execution so you may have an instant you may it may be that that it was an executed properly with the membership and I say that to say you know not everybody can just call up the doctor and go see the doctor tomorrow or next week so if we send out a notice saying that you need to have your own cheque before this day. And we send it out a month before that date. You're not going to go get your wellness check because you can't get in to see your doctor in most places so I actually think a lot of people didn't like it because it was frustrating because they had this hard deadline and there was no education about it to be honest with you and you look at how it's executed on behalf of the plan and I think i'll that had a lot to do with it because if you can't get in then you're frustrated why gotta get the swells must check in but this date or you know my my premium goes up or I pay more money versus an incentive the other way so I really think if we can look at that and look at the way it's structured and give as much flexibility as possible to let people schedule it within their life. Well you know their life schedules instead of it being that's very hard. You know box did approach I really think that that also contributed to you the fact that people didn't like that so II personally think it was the execution part of the incentive not necessarily incentive itself caused we have busy schedules my schedules very different than everybody else were not a one size fits all people you know and down and it may be different with men or women women may want be able to go and see or may be more appable to going first man I don't know but I really think we need to be more continuous about the way we structure some other things if we're really trying to move in move the need on change behavior so I just wanted to add if we could also look at it from that perspective if we're going to look at it. Yes at that I think that's a good idea now I do I do believe that that's back to the physical stamp one because we were scheduling those I think it certain times of course to be able to get a large discount would be massumption on that so I think that if we're going to do that that we need need a factor that in also because that would be part of the financial piece they weather not you're just going to your doctor or whether or not we had it structured at some hotel for january time their clinic may be so so yes in urban you have a follow up. How long we tried to turn you back and then I just had a quick question on page tune you are talking about the one individual I think under eighteen and the impatient emissions was that you said that was one person. You have to turn off your mike sorry okay so one or two one or two yes but we but if we know that but legally we can't necessarily contact that one or two patient to see what's going on with them well you you can depending on how the program is set up so and cannot carry it again okay that so the the plan could the carrier could notify the physician that's on records and say what's you know how can we okay yeah they should be triggering are in some sort of case management report or you know some sort of at some sort of alert to that though the folks know who are managing the care in in you know as part of the vendor to to say this person needs outrage because of this reason and do we know if our plan is robust enough to be able to do that with case management so currently I believe it's the top five to ten percent of risk. Oh that's being contacted okay oh so you know when you have a a lot of people when you're not you know making a laser focus on diabetes say when you're looking at the top percentage of risk you're going to miss a lot of what we talked about to pay just because it won't be in that very top risk okay thank you. Thank you senator representative ladyman table europe. Thank you mister chairman yes i'm over here I got a few questions mate maybe outside of the what we're talking about here if it is just tell me that but. First off sent a boy that I agree with what he said earlier is a lot of good data i'd like to study there and see that you're that the age groups very well done in its interesting data I think it'll be helpful but. Talking about the annual physicals that's been brought up and discussed but not if if I go to an annual physical is scheduled by someone else I may be fine if i've got that badies or happen glasses that may be a good day for me in that position I mean it may be worthless for him to check me for that if i'm checking my blood sugar and it's great I know exhibit any of these other things I don't know that an annual review when you're not sick does any good I mean is that it is out of valid view of that so go ahead okay that's where that annual a one seat has that I mentioned is actually very valuable so it's not looking at your moment in time that you're out the doctors office it's actually able to look at how your blood super has been over around three months and so you can't really cheat on it it thought it gives you that long term view that that helps your provider no it is this treatment working is this person able to manage their diabetes while this time thank you. I have a couple of it's all right yes anxiety you know you have charged that show with anxiety maybe other people know this but I don't how do you verify anxiety that you ask the person I was or tests for that how do you verify that yes and so of course these are the folks who admit to it but they have some some assessment scales there's a common one called the gad seven that's used to diagnose or or it's a good indicator of when someone has a diagnosis for so you would have that as part of your primary visit or if you have a mental health specific visit are in assessment like that would be incorporated couples that weren't on a chartered did you look at or is there any studies that look sad the treatment for diabetes are their side effects could some of these other things be caused by the treatment is there any studies about that. But exactly and sleep in that sort of thing. Not a good question not that i'm aware of that diabetes is caused by any of the drugs no I am especially in the mental health arena I mean there are so many side effects of so many drugs but. Rebuildings is usually started usually to get start. Started with basically the incident in the resistance and that's not typically drug related it's just your own body is getting used to the insulin so the treatment for diabetes does not cause any of these other cold morbidities there is not known no not that it's documented that we know okay or more yes sir and i'll be in her what about the effect i'd like to see a chart that shows if you have a steady group and they exercise the effect of exercise. On treating the ideas is it you'll end look at that or is that something that might be done in the future there are many studies that will exercise and getting the wait reduction to a certain eleven and and been tending that healthy rate which in three's then bodies in soolin response absolutely gets her that's called less called basically the non medical treatment of david the lifestate management. It's the nutrition lifestyle exercise all of that you can manage day beat is very well thank you thank you thank you sir and also members just from just as a reminder we do have one more item on the agenda right now I have senator hammer and then after that it would be representative wing. Thank you miss share. On the question of the wellness check if the chair would allow one thing maybe is to look at the effectiveness of it as far as do we have everything in there that really needs to be in a wellness checker would we do well maybe to add something that's not on the list that's included in wellness check and i'm curious what other states do in comparison to what we did to see if maybe if we added one or two things it might cost more but in the long run at my savers if it detected something like cancer or what every case may be at a because of find out about how we compared the second thing is. We over the years have invested money in like life coaches especially you talk about a key population your life coaches one time conversation but navigators that would go in and you know work with individuals. In the cost that you're sharing with us today did you factor in any of that money or did you look at any of the programs that we currently offer or even services that doctors you know may provide within seeing the patient that would have any contributing factor to the cost. So the cost analysis that we have it comes through the medical claims there are submitted by the doctor's office and the hospitals into the system so all of the documents services are part of that. Not sure about the other programs that you talked about so to your actually using the hardcost or whatever possibly the others could be subjective or whatever in yet i'm just thinking of the other programs where we have invest money to like a sign people to maybe help people with you know diabetes get it under control maybe even upside the doctor's officer do you know in other states do do they do things like that that may be out be outside the normal doctor's visit where they are signed somebody in in the cost that you have any report is that taking in consideration would that be an additional cost on top of these numbers. So anything that's not part of the claims costs will not be part of this analysis so if somebody is you said the willness coordinators are whoever that is hired outside the flame system will not be reflected here. So there's not part of that okay so how would we know that in the effectiveness of somebody like a life coach. You know anything outside of what's being built how would we know whether or not those programs are being effective that will be a separate analysis will have to conduct if those programs are working or not we'll have to set people into different cohorts. And one cohort group of people who is beneficial of the life coaches and those who are not and will have to kind of. Uhm look at the costs of one against the other to see the effectiveness of that yeah i'm not sure in the data if we if we can separate the populations by you know somebody who is working with the life coach or not so I think that we need an a different source of data. Okay well that would help you know whether or not what we're doing in those areas are actually contributing benefit we're just spend money and not get any of the results especially if our costs are higher otherwise that that's a whole lot of conversation may be curious about that thank you thank you center hammer in I mean I think nothing what you said I think the disbody is gonna whenever we got do this I mean there was a lot of discussion that had taken place as far as the willness been a fed back whenever we did all that so you know i'm not disagreeing with anything that i've heard today especially with what center dismaying that maybe over the long term it is it's going to help us they will cost. But that was not the direction that this body wanted to do at that particular appointment I think that maybe we need to take just a little bit of time and see if we want to you know if we do want to put that back in and maybe get our or you know potentially put it back in I understand we're going to get some more data but I mean we've been over there but if if we're able to if if that's what this body wants to do that I think that what things such as sender hammer is just said were you know maybe we incorporate other items within there if that's possible to look at the other states I know that's a little different what he was saying but you will look at the other states and see you know if they've got some other tap tears they put in there to help so. I don't want to get the court before the horse because I know that was a big thing before and I don't want to do just a whole bunch of stuff and then all of a said we say we're not going to in no way shape or fashion put the wildness back in because quite frankly are constituents or are members a little bit of both in this in this plan of course the weather not you know if they don't want to do it in I don't want to go to a whole lot of trouble so if we can take a month or so and think i'll get through and have some discussions I think i'd be health sender hammer you have a file. I think I got just wanted if I may address here because my mom remember to all that conversation seemed like we had report down in the bottom line was we're looking for call savings and when we measured the effectiveness of those wellness visits and the utilization of them and what they were producing did not equate to what we thought was going to be the savings and seemed like we had report done I don't know if it was by single credit assessor to them whatever so maybe we could get out I think that's a good idea in a staff doesn't mind this list of bag I mean that's been. That's been quite some time solicitable back and get our previous information you know that we did on this how we can come to this why don't we look at that and kind of make sure that everybody wants to continue with forward with you know this conversation with her to date if that's okay with you and I think ebd had the previous director had some way and on that conversation back when all that can I blew up so maybe they could help out thanks it will look into seeing everything that we've got to try to dig back through there and then we'll we'll have that discussion you know based upon that information whether we want to go forward you know with. Putting that back in so representative wing I think at said you're up next. The. Thank you mr chair thank you for your presentation very good data a lot of things to absorb here as I was looking at the numbers and see some of the high costs of a various treatments in various things do we have a way this is going to be a broadbased question but do you do we have a way of incentivising. Good healthy choices in a way to that would come back obviously good health is going to be its own reward for the individual but do we have a way financially because we've broken down all of these costs into financial with we got real numbers real data is there a way for the the participants here to see a benefit financially as well as health wise for making good choices which brings down the cost for everybody it's a wind wind is there anything that we have or anything that you see that other states are doing in that regard. The. So we can share what others are doing in that regard and we do conduct this on what's called the state survey that we do it's probably where in the middle of the next one now so once we have good results i'll be happy to share that and that's that we make it publicly available as well there are many reasons that. Willness programs in center ways members to engage some work for some constitutions from some don't some some actually compelled people to enroll in certain programs so that they do certain things and some employers are willing to do that and someone not so we have to sort of work with the constituents and what is the appetite for. I called that november noise so that we have to sort of slowly and see what what what a member noise will tolerate but incentives are always welcome by members of what they have to do to get that we have to design very carefully there is somebody else on my team who is all willingness expert station was on a state also she was on a call one of these presentations in her job was to be a health coach. On this seat or these years and she has some fantastic ideas that we can bring to your table to discuss for there that'd be greater you know when you look at this obviously some of this is not preventable some of this is is is inherent it's genetic whatever but a lot of this is preventable and can be adjusted by the choices that we all make and if we can come up with the double incentive that better health and financial we might be able to be on the path that helps us all that the gentleman here talk about the mediterranean direct that's what keeps people living longer and him there but if only we could get our people to adopt that if somebody solves that question you get my wood sounds good thank you very much nick mister chair. Singer irving you're recognized yet does not but II really do think that maybe we could even if it if it is an issue we need to look at the funny and so back to the wildness check i'm talking about it i'm just telling you as personally a member on this plan I was incredibly frustrated cause she boxed me in and I don't want to be boxed in. I usually schedule on annual visit or annual tech up near my birthday cause I can remember it's but do not book you know some clinic or whatever and say you need to go here for your wellness check you might think that it's convenient for me no I am not comfortable with somebody I don't know I want to get a month doctor and I want to do it when I need to go do it so i'm just speaking for me as one person but you could probably survey pretty easily our membership and figure out what was going on here but I can just tell you from my perspective that's why it didn't work cause it was frustrating and it made me mad you know that I had only one month to get something scheduled and it wasn't. Working with them mass schedule so I think I don't under that that was not part of our steady and what was presented to us because I was part of that discussion so if we're going to go down that path let's go down that path and let's make sure that we understand the execution behind it and they'll be good to know your birthday so we can if we do ever window we make sure it's. Well that's my birthday developed representative. Thank you senator see no further questions that's moved to item see the president costs analysis for weight loss medication patrick take it away. Yeah register one of started by seeing this is something that was a follow up from the november meeting there and the slides is just on my mother and we were us to come up with the costs and cost benefit analysis of the glp one drugs keep in mind these are brand new drugs so there is no longer data available other than what the pharmaceutical company that produces them have produced and then where a little data that's already been in the public domain but we have studied over a six some different papers to give you an idea about who gets this drug and how many of them electurally stay on the drug how many of them will come off the drug because of the side effects how many will actually come off the drug who successfully actually achieve their goal and then not go back on the drug and then the cost effect in this comes over time so it's a very complex match that our activities are here have done so mad is on the line here and patrick so they really take credit they should be they did a lot of research and then I cannot just provide some input from from a high level. Please ask questions as as patrick is explaining the numbers yeah thanks yeah so there is there a lot of assumptions before we get into the numbers I also want to say that this is the third one of these analysis that i've done for in our state clients so this is a hot topic on weather plans should be covering these drugs there's also plans that have covered the drugs from the get go they've seen their costs skyrocket and they're trying to figure out how to stop covering the drug so you know depending on what side of the fence you're on people are looking at what they should be doing. So we did we did have plenty of resources as you'll see throughout the my mother's lot of foot nodes we also had your own plan specific data that we were over the poor the obese population for we got pricing from navidators and then we used some of our own client history. So there's three main pieces that we have to How long and then what the savings are after they take the drug so the first part will go into the cost the most straightforward assumption that we have in this whole thing is the actual cost of the drug itself because navities knows what the net prices prescript they were able to share that so the two major players are wagovie and a new drug that was launched in november called set bounds that bounds a little bit cheaper it's made by you I live. So in our inner analysis we're assuming like a fifty fifty market share starting in twenty twenty five through twenty thirty so the actual cost after rebate for a wagovia is eight hundred and sixty seven dollars per script. And then their boundaries six hundred and fifty two dollars so again we use the fifty fifty waiting and then we trend at that cost by five percent annually to get at the cost though through twenty twenty three third twenty thirty say. So any questions about the cost piece first. No. All right so when a member receives a drug they have an obligation at the member car share we assumed that the that would put this drug on the preferred brand here so therefore the member would have a forty dollar copay so that could subtracted from the the cost that I mentioned before so the net cost to the plan and are being seven hundred and twenty dollars prescript. So the more difficult assumption is how many people are going to use the drug we don't have any prior history with in ebd here covering the struggle so there there aren't a lot of robust studies out there saying what percentage will start taking the drug were really relying on information for the plans that they do cover the dragon. We know that utilization just skyrocketed and over the last couple of years there's this is become covered. Household name these drugs so the marketing social media you're seeing him everywhere so our assumption is the there'll be a thirty percent take rate in the first year and that will increase by five percent. The other kind of conflicting assumption is that we don't see another drug classes as how many people stay on the drug so it's a very low persistence rate there's been a study that said twenty seven percent of the people will start taking the truck will complete it for a full year of more recent study said forty percent so that's the assumption we're targeting but again that's sixty percent of people they are trying the drug and then stop taking it before years up. So when you put those to assumptions together you have this growing take great but then you have a lot of people there taking the drug and starting so the eligible pool of obese people start to decline so he put those together and you can have a steady number of utilisers throughout the the projection period as you'll see. So yet so given all those assumptions on the cost. So this is just purely cost of you look at this table we're projecting out the number of scripts the net claims after rebate. The member car share so that's at forty dollar cope and finally this is the the plan cost total so in the first year were projecting costs of forty four million dollars and that increases up to eighty five million dollars and twenty thirtieth. The. So before anything in a savings are factored in. And i'm actually going to turn over to math to talk a little bit about some of the studies that we utilize to come up with the medical the cost savings better so just myself my name is matthew when I was signal my back was actually as a part of system of variety areas from a patient hospital to even managing very clear collects for the department of defense overseas at expensive experience and data alex before hospital finances were for including for the dod so that's your colleague background we look at a variety of studies too many of them there's three kind of kirable at once in regards to a car savings you know really only look at the impact or I guess correlation of increase index and medical expenditures these are last thirties that you know wait last year it's more proceedings they really just want that the cost increase is as being increased using a large time trying to call record of east. So that we said it was pretty clear that you know I was being my increase as that legal one point my increase was about twenty fifty dollars extra cost per year for members who were always so between thirty eight that's about two thousand per year over a little seriously obvious that increased per rose to that thirty one hundred dollars not these numbers but children also just because these medications party acting improve approved for younger twelve so that has to be taken account when you take about possible plan coverage you send see similar trains as well for a better children where bc with alternative hundred and fifteen dollars of additional costs for children about ten dollars allowed for a year for several city. Now the most relevant topic study at home is actually one I was done by the american humm account management pharmacy and it's actually looked at the pack of nine thirty four week last financial cost so you know excluding periodic surgery or which includes by pass of things like along those lines and this after that the change cost is fine the amount of weight lost so they could these members into and wait a week change the three percent more by those where that were essentially deemed to the weekend so classified a few percent for the original way three or five percent we lost five to ten percent we lost it over ten percent we lost her they start to get ready whether these individuals was maintained or lost which was considered to be less than people again have a remerger so the measure is in the doors every year at for one twenty four months and thirty six months. Where comes down essentially that you know again the more we lost that was seeing that greater savings so about a quarter of a little bit in the federalities high great game just over fifty five percent of these individuals that you know change about eight percent had a three to five percent with loss which was often in about a fifty seven dollar savings per month and in terms of medical parents he's found seven point seven percent harry back to ten percent with last which actually was was off associated with a hundred dollars a week lost our procedures per month and then two point eight percent had a tablet center greater we lost resulting nearly twenty dollars in my spencer so and the number seen there are we we are utilization numbers back and it was out to the current the current dollar now now one thing there's a very large limitation on the study that will say is that it did not catch for halloween week was actually last in terms of where salarifications dietary changes exercise wall gives it locations was low so that last ten point five percent members by in the study actually worked out to have cost medication the other thing is that this study was the twenty twelve twenty eighteen before the fine when we go and I was about have been around we know that these medications are much greater in terms of how much we can be lost then the order generation and medications. No it here is a big issue with a long term recently drugs you know the study that patrick is earlier where it was a thirteen twenty twenty seven percent months continued again was actually starting to let the overall collateral occasions which included some to have it around since twenty fourteen versus generation that really began twenty eighteen and really point one so those medications is pattern that will say a higher you know continuational rate covers a forty percent after one year so much approved I had a way though you know we're seeing that this is not really what you want to be charlie for most patterns of medications for example for diabete diabetics taking their medication you want that right to be closed eighty percent heading restricts. The last thing I want to talk about is the pass before for reading we gave me after there is discontinued federally when we look at the medications. The comment theme was that members would be all these bads for about eighty twelve months if you reach that therefore for their profile percent we lost at that point in time you continue additionally there's additionally for forgetting with us generally we thought about these medications for my time limited perspective. When we looked at those studies we see that is highly effective there is a lot of rebound after the medication is happened discussing has sufficient lifestyle because you can have part of the replus program so for example for one medication group medication to advertise we thought about twenty one percent I had received last after thirty six weeks which is profound but for a member state continued to medication taking a certain amount a week back to the point where after another year we had five point five percent of weight loss this holiday as well for the magazine where at sixty weeks we saw about a seventeen percent have a fake last number that stopped sixty weeks later taking it about eleven point six percent of the week back for a neck of just five point six percent wait so these man actors now think that I think longer current studies at require potentially getting it like long statement for example with me recently there was a five year study that was for the special profile affects my kind of asked for our comes but members again the party's location for five years. And the other thing I don't want to mention is that the care about news it's also around in support these medications but there needs to be some part on to who was actually seeing these benefits for the legally study for example that was any population of forty five above he'll have the city or whatever we need to commercially who had a history of a car doctor disease so they have history of a heart attack a stroke performance with this for their so you're higher risk population and what we're seeing with a lot of plans that are covering these medications outside they don't have those higher criteria place where anyone can use these medications so we're seeing a shift in historically drugs they were there older what can really do is to a younger population can they certainly help you so this point when they consider could you decide to cover these medications. The. Things yes I think you know one of the big takeaways is in a none of these studies are perfect we're doing the best we can with what we have the savings that we used we did take it from one study but we compared it against other studies and we got pretty similar numbers so the way we're approaching savings were breaking in the people up and the three cohorts we've got a group that is continuously using an AM so they'll be savings associated with them discontinue taking and regain wait so there's no savings after they regain that way and they stop taking the drug. Discontinued taking after they achieved their weight loss so that's kind of the perfect savings that's the goal we want are from for any program that if we decide to go ahead with it that's the goal we want is take the drug achieved the goal and then maintain that healthy lifestyle by what you learned why being on the drop. And so we've assumed a hundred dollars savings roughly hundred dollar savings in your one so that can correlate so that 3-5 percent wait loss as a start to take the dragon and start to lose the weight and then after they have. Take out for a full year and your two three and a year further were round just over three hundred and three hundred dollars in monthly savings based on ten percent plus week last. So going back to the cost of the drug you know this is kind of the disconnect why just the numbers don't work out where you're even if you're saving three hundred dollars per month the cost of the drug is still seven hundred and twenty dollars. Okay so so the state was come a breakdown of the savings we've got the number of people that start on the drug you know that the number declines as people are continually taking the drug or took it and stopped using an you know the eom isn't for them so then we have that four year user and that. Slowly increases over time but in a settles in around ten thousand. And then here are the buckets where they're discontinuing. And the regaining the weight so that's the majority of people and then we do have a smaller bucket that discontinued but maintain that way then that's that's where you're getting that three hundred and thirty dollars savings but you also have no cost of the drug and they're there isn't a lot of it isn't been around long enough to know if if that's even a possible outcome because you know a lot of people stop and regaining the way itself but we hope that that that's that's possible. It's a dollar wise. We got six million dollars you know seven million dollars roughly and and twenty twenty five and savings and then that trends are the sixty five million dollars in the last year so there's a little bit of a lag because you got people in the first year that are stopping they're not taking it and get to that three hundred dollars savings until out years. And we don't trend all the savings numbers that we reported by seven percent. So we throw it all together and determine what the net cost is so we've got. That year wine we've got classed of roughly forty four million six seven million and savings so that's a thirty seven million dollar lives. Then that lost decreases over time so I guess in theory if we covered the and we covered at the right way maybe that would turn but if you look at the cumulative laws were almost up the two hundred million dollars at that point so. Um. Yeah I just and and again it's kind of a wild card on how many people are going to take the drug so the magnitude of these numbers could be lasted if there's less you know or ebd if they do want to cover it they can't target it at hire beaumi so there's all different ways to maybe reduce the utilization and decrease the magnitude of the numbers but directionally I think we're we're pretty comfortable saying that that at this point with what we know that there is going to be a you know nat wise. This. So i'm in the that's kind of the best we can do in terms of. Projecting costs like yesterday I was telling etc about my highway traffic analysis it's really predicting how many cars are going to be there at a certain point in time on the highway how many people stay on some people come in the exit some stay for a long time some cars break down and that increases the costs so number of cars so it's it's a it's a lot of projections that are kind of unknown at this point because these drugs are so new if you ask me about how many people are on aspirin in my population you can tell you like this because it's such a old drug and we know if we can stay on aspirin because there are no side effects and you can stay on there a few side effects but they are on manageable these are like two new for us to actually put our hands on but that's why we conclude by seeing that determining how to manage and whether to cover them at all is a unique decision based on your constitution or your constituents. But lifestyle changes and managing doors with that to some of the point solution programs that I talked about earlier we can help further decide about these drugs held those who really take it well and then that second bullet that we talk about that's the goal we want to achieve this continue after achieving weight lost goals and maintain a heliate through healthy habits and if we can find a program or a point solution that can actually help our people get the drug. Get them to lose with come off the drug if they are having so defects the health coaches work with that as well and then kind of achieve the goal of weight loss and then stay held the and I call that graduation from the program you graduate from the program i'm healthy basic the real outcome that we want to achieve and we can decide what level of control works best for your population and your health plan goods in dumbs of then the last three bitters which is managing the utilisation in the formula management as well as the personalist treatment clinical support that that I keep talking. And the other thing I forgot to mention is that. There's more and more farmer companies that are looking at entering the space so you know we had were covie had a price prescript it's been around for a little while zepound just entered the market and it was six hundred and fifty two vs eight sixty seven so already seen a decrease and so who's to say if there's more competition more farmer format comes into the space that we could get to numbers that are low enough to to maybe make make it work but so it's all we had and happy to take questions. Yeah. Thank you center point you recognize for a question and let me remind everyone that we are running really lay on time and there's an efficiency meeting that needs to happen so please keep these as brief please keep your response as free as possible thank you said or boy you're right now thank you mister chair so I won't go into all the questions I have I have a lot of on this is important presentation I just want to say that I have some concerns about what happens with these medications long term and could that also add additional costs that maybe we don't know you know I would like to see some that on like what happens if we just. You you had a white watch you know we just paid for their weight watchers app so that they could learn to do that or more intensive provider interventions at the the point that we know work and don't have the same net you know I just said like this. Do we quit paying to help people quit smoking cause they fell equipped one time you know so like you can change your eating habits and your exercise habits and you can do that and then maybe you fall off the wagon maybe it's not the right way to say but you get back on again at some later date so I just think there are other alternatives that i'd like to see us have discussion on before we get a you know it is we talk about what group really could benefit from the stap of medications because I do think there is a group thank you. Senator hammer you recognize. I've got several friends have actually used this for weight loss and the entire morning was pretty much been on the effects of metal health and dibedish weight loss and connecting of the two of the ones I have taken medication have experienced a better outlook on life will call it so do in all this discussion on this particular these drugs do you factor in any of the cost savings associated with the mental health as a result of them taking this medication losing weight and having a better outlook in life and maybe their mental health outcomes being better. Well yeah I think the where we got the information from and they were looking at their total claims in a cost so II think that would include yeah mental health if there is you know an impact there so yeah again we're we've we totally agreed that these drugs work in the they do have an impact I think you know what we're trying to get across here's as purely from a a financial standpoint we're not saying you should or shouldn't cover it but there's just kind of a disconnect between what it cost in what the the study say it saves and we remember our studies for projections of the next five years the the benefits of this could go on in two year thirty it's virtually impossible to get your arms around somebody's lifetime savings over this unless the drug is fifty years old and then I can actually measure somebody's lifetime savings so you see because it's so new and we have to go with projections we don't have the data there over somebody's lifetime. So that as definitely then okay but it could be a possible cost savings when you add in metal health passenger schedule is just so new we don't know yes thank you. R eight see no further questions thank you for coming today I appreciate the participation of the committee and we are thank you.