2 Diabetes Report 2016

Transcription

1 SINCE 1987 Type MANAGED CARE DIGEST SERIES 2 Diabetes Report 2016 With a Special Focus on With Cardiovascular Disease in Partnership with

2 TENNESSEE TYPE 2 DIABETES REPORT 2016 Contents Introduction... 2 and Nation MSA Comparisons : Persistency...7 Diabetes and CV Disease CV Disease Discharges East: Chattanooga Knoxville Tri-Cities West: Jackson Memphis Nashville Position Statement and Methodology...24 Gaye Fortner Contacts gfortner@hc21.org Chief Executive Officer HealthCare 21 Business Coalition Christie Travis ctravis@memphisbusinessgroup.org Chief Executive Officer Memphis Business Group on Health Introduction Sanofi U.S. (Sanofi), together with HealthCare 21 Business Coalition (HC21) and the Memphis Business Group on Health, are pleased to present the inaugural edition of the Type 2 Diabetes Report, an overview of demographic, financial, utilization, and pharmacotherapy measures for Type 2 diabetes patients in key local markets across the state of. The report also examines cardiovascular (CV) disease as it relates to Type 2 diabetes, and provides discharge data for CV conditions commonly associated with diabetes. The report, intended to help providers and employers better identify opportunities to serve the needs of their patients, organizes Type 2 diabetes benchmarks into six local markets and as a whole. All data are drawn from the Managed Care Digest Series. Sanofi, as sponsor of this report, maintains an arm s-length relationship with the organizations that prepare this report and carry out the research. The desire of Sanofi is that the information in this report be completely independent and objective. The Type 2 Diabetes Report helps these organizations fulfill their mission of helping employers play an active and enthusiastic role in collaboration with health plans, providers, and purchasers; and of being a catalyst in promoting cost- effective delivery of quality health care to the benefit of the community. This report features examples of the kinds of patient-level, disease-specific data on Type 2 diabetes that can be provided by these organizations using the Managed Care Digest Series as a resource. Its focus on locales allows for heightened scrutiny of community progress with Type 2 diabetes patient populations. Type 2 diabetes is a chronic condition that affects the way the body metabolizes glucose, making diabetes patients resistant to the effects of the hormone insulin or unable to produce enough insulin to maintain a normal glucose level. The data (covering 2012 through 2014) were gathered by IMS Health, Parsippany, NJ, a leading provider of innovative health care data products and analytic services. The data provide employers with independent, third-party information against which they can benchmark their own data. Please see the back page for information on the data methodology. Greg Sampson Greg.Sampson@Sanofi.com Account Executive Sanofi U.S. US Market Access 12% PERCENTAGE OF POPULATION WITH DIABETES, % 11.1% 10.3% Nation SINCE 1987 MANAGED CARE DIGEST SERIES Provided by Sanofi U.S. Bridgewater, NJ Developed and produced by Forte Information Resources LLC Denver, CO Data provided by IMS Health Parsippany, NJ Percentage of Population 9% 6% 3% Knoxville photo credit: Kevin Ernsberger Data sources: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, TENNESSEE TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

3 TENNESSEE AND NATION AGE AND GENDER, Distribution of Type 2 Diabetes Nation AGE GROUP % 0.4% 0.4% 0.4% 0.4% 0.5% GENDER Male 44.5% 44.9% 45.1% 46.6% 46.7% 46.8% Female COMORBIDITIES AND COMPLICATIONS, ,3 Percentage of Type 2 Diabetes Nation ACTUAL COMORBIDITIES Depression 9.7% 10.4% % Hyperlipidemia Hypertension Obesity ACTUAL COMPLICATIONS Cardiovascular Disease 57.8% 57.5% 57.4% 56.2% Hypoglycemia Nephropathy Neuropathy AVERAGE LENGTH OF STAY PER INPATIENT DIABETES MELLITUS CASE, Average Length of Stay (Days) $3,600 $2,700 $1,800 $900 $ CHARGES PER INPATIENT DIABETES MELLITUS CASE, ,5 PROFESSIONAL CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, COMMERCIAL INSURANCE PAYERS, ,7 $3,502 $3,433 Inpatient Nation $1,217 $1,299 Outpatient $3,336 Ambulatory Surgery Center Emergency Room Office/ Clinic 1 On pages 3 9, the percentages are representative of the universe of Type 2 diabetes patients on whom claims data have been collected in a given year. 2 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, congestive heart failure, dysmetabolic syndrome, hyperlipidemia, hypertension, and obesity. 3 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, and retinopathy. 4 Average length of stay (ALOS) and hospital inpatient charge data come from IMS Health s Procedure/Diagnosis (HPD) database and are current as of end-of-year. 5 Charge data are per-case averages for inpatients with a particular diagnosis of interest. Charges may be for treatment related to other diagnoses. Data reflect the total charges billed by the hospital for the entire episode of care, and may include accommodation, pharmacy, laboratory, radiology, and other charges not billed by the physician. Data do not necessarily indicate final amounts paid. 6 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 7 Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. $45,000 $40,000 $35,000 $30,000 $25,000 $3,143 $30,023 $1,402 $32,416 $1, $38,554 $2,459 Nation $41,107 Nation $2,203 WORKING-AGE SHARE OF TN TYPE 2 DIABETES PATIENTS IS HIGH VERSUS NATION S In 2014, 49.8 Type 2 diabetes patients in were of working age (18 64), nearly two percentage points higher than the corresponding national share (48.). That year, Type 2 diabetes patients were more apt than their counterparts across the country to also have depression, hyperlipidemia, hypertension, cardiovascular disease, nephropathy, or neuropathy. CHARGES TOP NATION FOR TN TYPE 2 DIABETES PTS. WITH COMMERCIAL INSURANCE In four of the five settings profiled (hospital outpatient excluded), annual professional charges per Type 2 diabetes patient with commercial insurance coverage were higher in than they were nationally in For example, inpatient provider charges for such patients in were $3,502, versus $3,433 across the U.S. MANAGED CARE DIGEST SERIES TENNESSEE TYPE 2 DIABETES REPORT

4 TENNESSEE AND NATION A1c TESTING AND EYE EXAM RATES EXCEED U.S. MARKS FOR TN TYPE 2 DIABETES PATIENTS Type 2 diabetes patients across were slightly more likely than their peers nationally to receive an A1c test (75.4% versus 73.9%) or ophthalmological exam (73.7% versus 69.7%) in Meanwhile, however, the portions of these patients who received a blood glucose, serum cholesterol, urine glucose, or urine microalbumin test were below corresponding national shares. INSULIN PEN FILL RATES AMONG TN TYPE 2 DIABETES PATIENTS TRAIL NATION S Compared with national rates, smaller percentages of Type 2 diabetes patients filled prescriptions for long-acting, rapid-acting, short-acting, or mixed insulin pens in However, the portions of Type 2 diabetes patients who received these insulin vials were above those of the nation. 1 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 2 who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. 3 Figures reflect the per-patient yearly payments for Type 2 diabetes patients receiving a particular type of therapy. These are the actual amounts paid by the insurer and patient for such prescriptions. mainly include copayments, but can also include tax, deductibles, and cost differentials where applicable. Percentage of Percentage of % 1 5% UTILIZATION: PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY SERVICE, % 73.9% A1c 1 PHARMACOTHERAPY: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING COMBINATION THERAPIES, % PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, Any Long-Acting Rapid-Acting Short-Acting Mixed 35.4% % 9.2% 8.7% 9.2% 10.3% 2.4% 3.6% NATION 34.3% 18.3% 9.6% 10.6% 7.3% 10.6% 8.6% 2.5% 2.7% AVERAGE ANNUAL PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, ,3 Any Long-Acting Rapid-Acting Short-Acting Mixed $3,046 $2,012 $1,978 $1,830 $2,005 $1,830 $1,944 $2,682 $1,891 NATION $3,151 $2,044 $2,060 $1,864 $2,064 $1,864 $2,023 $2,762 $1,852 PERCENTAGE OF AND AVERAGE ANNUAL PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING NON-INSULIN THERAPIES, ,3 Any Non- DPP-4 Antidiabetic Sensitizing Product Agents 6.2% 85.1% 86.7% 81. Blood 18.2% 6.9% 84.4% Serum Cholesterol 81.3% 83.9% Use of 2 Non- Use of 3 Non- Nation SGLT % $ % $ % $70 4.5% $ % $1, % $1,170 NATION 85.1% $ % $ % $77 5.1% $ % $2, % $1, % 59.8% 6.7% 71.4% Microalbumin Use of 2 Non Use of 3 Non % 73.7% Ophthalmologic Examination 7.2% Nation 69.7% Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. Sensitizing Agents Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting replacement product with a long duration of action. Mixed replacement product combining a short-acting and an intermediate-acting insulin product. Rapid-Acting replacement product with a rapid onset and shorter duration of action than short-acting insulin. Short-Acting replacement product with a short onset of action and duration. Sodium/ Cotransporter 2 (SGLT-2) Lower blood glucose concentration so that glucose is excreted instead of reabsorbed. Stimulate the release of insulin in the pancreas. 4 TENNESSEE TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

5 TENNESSEE MSA COMPARISONS DISTRIBUTION OF TYPE 2 DIABETES PATIENTS, BY PAYER, 2014 Commercial 1 Medicare Medicaid MARKET Chattanooga 49.4% 50.3% 43.8% 42.8% 6.8% 6.8% Knoxville Tri-Cities Jackson Memphis Nashville NATION 49.2% 48.9% 40.5% 39.7% 10.4% 11.5% DISTRIBUTION OF TYPE 2 DIABETES PATIENTS, BY A1c LEVEL RANGE, % >9. MARKET Chattanooga % 19.2% 18.2% 13.7% 12.3% 17.2% 16. Knoxville Tri-Cities Jackson Memphis Nashville NATION 49.5% 47.2% 20.8% 21.5% 13.4% 14.1% 16.3% 17.2% Percentage of 6 45% 3 15% 52.2% 18.7% 16.1% 13.1% Chattanooga DISTRIBUTION OF TYPE 2 DIABETES PATIENTS, BY A1c LEVEL RANGE FOR COMMERCIAL PAYERS, ,2 47.3% 44.1% 23.2% 22.4% % 14.6% 15.6% 46.3% 19.4% 20.5% % > % 22.2% 18.2% 48.8% 20.7% 16.6% 48.1% 20.5% 17.5% 46.4% 21.8% 17.5% 13.8% 13.8% 13.9% % Knoxville Tri-Cities Jackson Memphis Nashville Nation COMMERCIAL SHARES OF TYPE 2 DIABETES PATIENTS ARE ELEVATED IN THREE TN MARKETS In Chattanooga (50.3%), Knoxville (51.3%), and Tri-Cities (50.5%) markets, the percentages of Type 2 diabetes patients with commercial coverage exceeded 48.9% the corresponding national share in Meanwhile, the Medicare-covered shares of Type 2 diabetes patients in Chattanooga, Jackson, Memphis, Nashville, and the state of topped the nation s (39.7%). MORE THAN ONE IN FIVE MEMPHIS TYPE 2 DIABETES PATIENTS HAVE A1c >9. In 2014, nearly 21 Memphis Type 2 diabetes patients had an A1c level greater than 9. on their most recent test, a slight increase from 20.1% the prior year, and well above the corresponding state and national shares in both years. This percentage also topped that of the nation in Tri-Cities (18.2%). From (17.9%) to 2014 (17.), the percentage of Type 2 diabetes patients across the state of with an A1c level in this highest range dipped below the U.S. rate of 17.2% in Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. 2 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentages of Type 2 diabetes patients who have had at least one A1c test in a given year. NOTE: Throughout this report, the Tri-Cities market includes Johnson City, Kingsport, and Bristol. MANAGED CARE DIGEST SERIES TENNESSEE TYPE 2 DIABETES REPORT

6 TENNESSEE MSA COMPARISONS IP PROVIDER CHARGES FOR MEMPHIS TYPE 2 DIABETES PTS. EDGE ABOVE OTHER MKTS. Despite a slight drop to $4,002 in 2014 from $4,081 in, inpatient provider charges were highest, by profiled market, in Memphis in These charges were higher than the U.S. average in six of seven profiled markets in PROFESSIONAL CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, Inpatient Outpatient Ambulatory Surgery Center Emergency Room Office/ Clinic MARKET Chattanooga $3,556 $3,918 $1,476 $1,684 $3,832 $3,771 $1,268 $1,596 $2,558 $2,708 Knoxville 2,901 3,691 1,165 1,496 3,174 3,293 1,465 1,824 1,844 2,422 Tri-Cities 3,241 3,462 1,021 1,316 2,471 2, ,012 1,878 2,078 Jackson 3,533 3,998 1,313 1,532 2,724 3, ,547 2,742 Memphis 4,081 4,002 1,014 1,030 3,139 3, ,116 2,325 2,382 Nashville 3,094 3,390 1,162 1,275 3,011 3,399 1,398 1,632 2,325 2,758 3,226 3,502 1,101 1,217 3,038 3,336 1,162 1,402 2,194 2,459 NATION $3,005 $3,433 $1,175 $1,299 $2,724 $3,143 $1,088 $1,280 $2,024 $2,203 PROFESSIONAL OFFICE/CLINIC CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, $3,000 $2,500 $2,000 $1,500 $1, $2,547 $2,422 $2,325 $2,382 $2,459 $2,325 $2,194 $2,203 $2,078 $2,024 $2,558 $2,708 $2,742 $2,758 $1,844 $1,878 Chattanooga Knoxville Tri-Cities Jackson Memphis Nashville Nation INPATIENT FACILITY CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, $48,000 $41,000 $34,000 $27,000 $20, $43,679 $45,559 $42,425 $42,911 $35,283 $35,725 $36,695 $35,622 $36,546 $38,675 $32,456 $31,917 $26,902 $26,966 $27,574 $25,883 Chattanooga Knoxville Tri-Cities Jackson Memphis Nashville Nation INPATIENT FACILITY CHARGES FOR TYPE 2 DIABETES PATIENTS, OVERALL VS. TYPE 2 DIABETES PATIENTS WITH CARDIOVASCULAR DISEASE, ,3 $52,000 $44,000 $36,000 $28,000 $20,000 Overall w/ Cardiovascular Disease $49,571 $45,559 $47,308 $42,619 $42,911 $40,047 $38,675 $35,252 $35,725 $35,622 $35,902 $26,966 $27,574 $25,883 $27,530 Chattanooga Knoxville Tri-Cities Jackson Memphis Nashville Nation 1 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 2 Figures reflect the charges generated for Type 2 diabetes patients by the facilities that delivered care. Facility charge data include charges for all services rendered, including prevention and charges associated with the treatment of other diseases. The data also reflect the average amounts charged in Type 2 diabetes patient claims, not the amount paid. 3 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, and retinopathy. NOTE: Some facility charge data were unavailable for Chattanooga. 6 TENNESSEE TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

7 TENNESSEE: PERSISTENCY TYPE 2 DIABETES PATIENTS USING VARIOUS INSULIN PRODUCTS, TENNESSEE, 2014 Percentage of 10 85% 7 55% 4 Long-Acting : Pens Short-Acting : Pens Rapid-Acting : Pens Mixed : Pens Long-Acting : Vials Short-Acting : Vials Rapid-Acting : Vials Mixed : Vials Mo. 1 Mo. 2 Mo. 3 Mo. 4 Mo. 5 Mo. 6 Mo. 7 Mo. 8 Mo. 9 Mo. 10 Mo. 11 Mo. 12 TYPE 2 DIABETES PATIENTS OVERALL VS. TYPE 2 DIABETES PATIENTS WITH HYPOGLYCEMIA, VARIOUS INSULIN THERAPIES, TENNESSEE, Percentage of 10 87% 74% 61% 48% Long-Acting Rapid-Acting Short-Acting Mixed Overall Overall Overall Overall w/ Hypoglycemia w/ Hypoglycemia w/ Hypoglycemia w/ Hypoglycemia Mo. 1 Mo. 2 Mo. 3 Mo. 4 Mo. 5 Mo. 6 Mo. 7 Mo. 8 Mo. 9 Mo. 10 Mo. 11 Mo. 12 TYPE 2 DIABETES PATIENTS USING VARIOUS NON-INSULIN ANTIDIABETIC PRODUCTS, TENNESSEE, 2014 Percentage of 10 86% 72% 58% 44% DPP-4 GLP-1 Receptor Agonists Sensitizing Agents SGLT-2 Mo. 1 Mo. 2 Mo. 3 Mo. 4 Mo. 5 Mo. 6 Mo. 7 Mo. 8 Mo. 9 Mo. 10 Mo. 11 Mo. 12 TYPE 2 DIABETES PATIENTS OVERALL VS. TYPE 2 DIABETES PATIENTS WITH HYPOGLYCEMIA, VARIOUS NON-INSULIN ANTIDIABETIC THERAPIES, TENNESSEE, Percentage of 10 82% 64% 46% 28% DPP-4 GLP-1 Receptor Agonists Sensitizing Agents SGLT-2 Overall w/ Hypoglycemia Overall w/ Hypoglycemia Overall w/ Hypoglycemia Overall w/ Hypoglycemia Mo. 1 Mo. 2 Mo. 3 Mo. 4 Mo. 5 Mo. 6 Mo. 7 Mo. 8 Mo. 9 Mo. 10 Mo. 11 Mo A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, and retinopathy. NOTE: Persistency measures whether patients maintain their prescribed therapy. It is calculated by identifying patients who filled a prescription for the reported drug class in the four months prior to the reported year, and then tracking prescription fills for those same patients in each of the months in the current reported year. If a patient fills a prescription in a month, they are reported among the patients who have continued or restarted on therapy. Continued means that the patient has filled the drug group in each of the preceding months. Restarted means that the patient did not fill in one or more of the preceding months. Continuing and restarting patients are reported together. Persistency data track patients who are New-to-Brand, meaning they have not filled a prescription for their cohort product during the six months prior to initiation of therapy on that product. MANAGED CARE DIGEST SERIES TENNESSEE TYPE 2 DIABETES REPORT

8 DIABETES AND CARDIOVASCULAR DISEASE DIABETES AFFECTS LARGE SHARES OF CARDIOVASCULAR INPATIENTS IN TENNESSEE Among inpatients with any of five primary cardiovascular diagnoses, notable percentages had a secondary diagnosis of diabetes mellitus in. For example, 18.9 inpatients with a primary diagnosis of hypertension also had diabetes mellitus that year, a slightly lower rate than that of the nation (19.7%). Among inpatients with a primary diagnosis of stroke in, 11.3% also had a diagnosis of diabetes mellitus, fractionally above the corresponding national rate (10.8%). NEARLY 7% OF TN INPATIENTS WITH PRIMARY DIABETES DX UNDERGO VENOUS CATH. inpatients with a primary diagnosis of diabetes mellitus were most likely, by procedure, to receive a venous catheterization, not elsewhere classified, in, at 6.8%. Just over 6 these inpatients underwent hemodialysis in, a lower share than that reported among these inpatients nationally (6.7%). Percentage of Inpatients Percentage of Inpatients 2 15% 1 PERCENTAGE OF INPATIENTS WITH A SECONDARY DIAGNOSIS OF DIABETES MELLITUS, BY FIVE PRIMARY CARDIOVASCULAR DIAGNOSES, TENNESSEE, 5% 8% 6% 4% 2% 18.9% 19.7% Hypertension 13.3% 11.3% Intermediate Coronary Syndrome (ICS) 12.7% Angina 10.4% 11.6% Deep Vein Thrombosis (DVT) Nation 11.3% 10.9% 10.8% Stroke MOST COMMON PROCEDURES FOR INPATIENTS WITH A PRIMARY DIAGNOSIS OF DIABETES MELLITUS, TENNESSEE, 6.8% 6.5% 6.1% 6.7% % 3.6% % 3.7% 1.7% Nation 2.4% Venous Catheterization Not Elsewhere Classified Hemodialysis 1 Central Venous Catheter Placement with Guidance Transfusion of Packed Cells Excisional Debridement of Wound, Infection, or Burn Arteriography of Femoral and Other Lower Extremity Arteries 1 Hemodialysis is a procedure for removing metabolic waste products or toxic substances from the bloodstream by dialysis. NOTE: Secondary diagnoses and procedures data come from IMS Health s Procedure/Diagnosis (HPD) database and are current as of calendar year. 8 TENNESSEE TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

9 DIABETES AND CARDIOVASCULAR DISEASE PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY TYPE OF COMPLICATION, Cardiovascular MARKET Disease Neuropathy Nephropathy Retinopathy Hypoglycemia Chattanooga 64.5% 34.9% 38.8% 9.3% 6.2% Knoxville Tri-Cities Jackson Memphis Nashville NATION 56.2% 34.3% 32.9% 18.2% 8.8% PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY TYPE OF COMORBIDITY, Congestive Dysmetabolic Hypertension Hyperlipidemia Obesity MARKET Heart Failure Syndrome Chattanooga 86.2% 64.5% 14.3% 16.6% 1.3% Knoxville Tri-Cities Jackson Memphis Nashville NATION 79.6% 63.1% 12.4% % Percentage of 44% 33% 22% 11% MARKET % DISTRIBUTION OF LIPID DISORDERS PATIENTS, BY NUMBER OF STATINS, >2 Chattanooga 29.8% 59.5% 9.6% 1.1% Knoxville Tri-Cities Jackson Memphis Nashville NATION 27.8% 60.6% 10.5% 1.1% PERCENTAGE OF LIPID DISORDER PATIENTS, BY PATIENT TYPE, % Chattanooga % 21.1% 37.1% 33.9% 20.6% % Diabetes >2 Comorbidities No Comorbidities % 14.1% 31.3% 29.7% 21.1% 35.3% 32.5% 18.3% 34.1% Knoxville Tri-Cities Jackson Memphis Nashville Nation RATES OF CV DISEASE ARE HIGH FOR TYPE 2 DIABETES PTS. IN CHATTANOOGA, JACKSON The percentages of Type 2 diabetes patients in Chattanooga (64.5%) and Jackson (72.) with a complication of cardiovascular (CV) disease were notably higher than those statewide (57.5%) and across the nation (56.2%) in The rates of CV disease in Memphis (59.8%) and Knoxville (56.3%) also were higher than the national share. DIABETIC SHARE OF LIPID DISORDER PATIENTS ECLIPSES NATION S IN TN MARKETS In Chattanooga (36.), the Tri-Cities (37.1%), Memphis (39.), and (35.3%), the shares of lipid disorder patients who had a diagnosis of diabetes were higher than that of the nation (34.1%) in Moreover, in all of the profiled markets, the shares of lipid disorder patients with more than two comorbidities were above the national average. 1 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, and retinopathy. 2 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes may include, but are not limited to, congestive heart failure, dysmetabolic syndrome, hyperlipidemia, hypertension, and obesity. 3 A comorbidity is a condition a lipid disorder patient may also have. Comorbidities were narrowed down to a subset of conditions that are typically present in patients with lipid disorders. NOTE: Therapy percentages are representative of those patients with a diagnosis of interest in the most recent two years, who filled prescriptions within each drug category in the reporting year. Throughout this report, pharmacotherapy percentages do not include over-thecounter medications. MANAGED CARE DIGEST SERIES TENNESSEE TYPE 2 DIABETES REPORT

10 CARDIOVASCULAR DISEASE DISCHARGES JACKSON HOSPITALS TREAT LARGE NUMBERS OF CV OUTPATIENT CASES Of the profiled markets, Jackson had the highest numbers of outpatient congestive heart failure, hyperlipidemia, hypertension, and stroke cases per hospital in. For example, the average Jackson hospital discharged 27,314.5 outpatient hypertension cases in, more than three times the national average of 8, The mean number of stroke outpatient cases in Jackson hospitals more than doubled the state average that year: versus TN OUTPATIENT CV CASES ARE MORE APT TO BE IN EDs THAN SIMILAR CASES NATIONALLY Compared with national rates, higher percentages of outpatient acute myocardial infarction (AMI), heart failure, hyperlipidemia, hypertension, or stroke cases were in emergency rooms in. For example, 49. of outpatient AMI cases were in emergency departments (EDs) in, versus 38.5% in hospitals nationally. The ED share of outpatient hypertension cases in was 45.4% in, 10 percentage points above the corresponding U.S. NUMBER OF OUTPATIENT CASES PER HOSPITAL PER YEAR, AMI Congestive Heart Failure Hyperlipidemia Hypertension Stroke MARKET Chattanooga , , , Knoxville , , , Tri-Cities , , Jackson 7.0 4, , , Memphis , , , Nashville , , , , , , NATION , , , Percentage of Cases 52% 39% 26% 13% EMERGENCY DEPARTMENT PERCENTAGE OF OUTPATIENT CASES, 49. AMI 38.5% 32.3% Congestive Heart Failure 25.7% 25.5% Hyperlipidemia Hypertension Stroke NUMBER OF INPATIENT CASES PER HOSPITAL PER YEAR, AMI Congestive Heart Failure Hyperlipidemia Hypertension Stroke MARKET Chattanooga , Knoxville , , , Tri-Cities , , , Jackson , , , Memphis , , , Nashville , , , , NATION , , % 45.4% 35.4% 11.9% Nation 11. share of 35.4% that year. NOTE: Outpatient and inpatient discharge data on pages 10 and 11 come from IMS Health s Procedure/Diagnosis (HPD) database and are current as of end-of-year. AMI is acute myocardial infarction. 10 TENNESSEE TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

11 CARDIOVASCULAR DISEASE DISCHARGES AVERAGE LENGTH OF STAY PER INPATIENT CASE, AMI Congestive Heart Failure Hypertension Stroke MARKET Chattanooga Knoxville Tri-Cities Jackson Memphis Nashville NATION AVERAGE CHARGES PER INPATIENT CASE, 1 AMI Congestive Heart Failure Hyperlipidemia Hypertension Stroke MARKET Chattanooga $69,532 $34,941 $21,430 $35,193 Knoxville 67,868 31,989 $29,289 17,277 30,206 Tri-Cities 82,788 33,353 15,669 36,827 Jackson 66,960 29,877 18,056 34,841 Memphis 100,092 44,003 41,972 26,569 48,326 Nashville 87,732 45,065 20,766 46,532 78,253 35,443 38,775 19,695 38,172 NATION $92,018 $41,806 $31,639 $22,385 $44,734 Percentage Readmitted 24% 2 16% 12% DAY HOSPITAL READMISSION RATES, 23.2% 13.6% Heart Attack Heart Failure Stroke All-Cause 15.8% 17.8% 22.7% 13.3% 15.6% ALOS FOR CV CASES IN JACKSON AND MEMPHIS EXCEED STATE, NATION AVGS. In both Jackson and Memphis, the average lengths of stay (ALOS) per inpatient (IP) case exceeded both the and overall national averages for three of the four featured cardiovascular diagnoses in (hypertension excepted). For example, the ALOS per congestive heart failure inpatient case in both Jackson and Memphis (5.4 days) surpassed that of (4.1) by 1.3 days, and that of the nation (4.6) by 0.8 days. CHARGES PER CV IP CASE ARE HIGH IN MEMPHIS VERSUS STATE AND NATION In, average charges per inpatient case in Memphis were higher than both the corresponding statewide and national averages across all five of the featured cardiovascular diagnoses. CV 30-DAY READMISSION RATES IN TN HOSPITALS EDGE ABOVE THOSE OF THE NATION Thirty-day hospital readmission rates for heart attack (18.), heart failure (23.2%), stroke (13.6%), and all causes (15.8%) were fractionally higher in hospitals than at all hospitals nationwide in. 8% Nation 1 Charge data are per-case averages for inpatients with a particular diagnosis of interest. Charges may be for treatment related to other diagnoses. Data reflect the total charges billed by the hospital for the entire episode of care, and may include accommodation, pharmacy, laboratory, radiology, and other charges not billed by the physician. Data do not necessarily indicate final amounts paid. NOTE: Outpatient and inpatient discharge data on pages 10 and 11 come from IMS Health s Procedure/Diagnosis (HPD) database and are current as of end-of-year. AMI is acute myocardial infarction. Some charge data were unavailable for the selected markets. MANAGED CARE DIGEST SERIES TENNESSEE TYPE 2 DIABETES REPORT

12 EAST: CHATTANOOGA AGE AND GENDER, Distribution of Type 2 Diabetes Chattanooga AGE GROUP % 0.3% 0.3% 0.4% GENDER Male 44.8% 45.4% 45.8% 45.1% Female COMORBIDITIES AND COMPLICATIONS, ,3 Percentage of Type 2 Diabetes Chattanooga ACTUAL COMORBIDITIES Depression 7.5% 7.8% 9.7% 10.4% Hyperlipidemia Hypertension Obesity ACTUAL COMPLICATIONS Cardiovascular Disease 63.7% 64.5% 57.8% 57.5% Hypoglycemia Nephropathy Neuropathy CHARGES CLIMB FOR CHATTANOOGA INPATIENT DIABETES MELLITUS CASES From 2012 to, average charges per inpatient (IP) diabetes mellitus case treated in Chattanooga hospitals grew 15.7%, to $34,533 from $29,856. Such charges averaged $32,416 across in. RATE OF CV DISEASE AMONG CHATTANOOGA TYPE 2 DIABETES PATIENTS RISES The percentage of Chattanooga Type 2 diabetes patients with a complication of cardiovascular disease resulting from their diabetes grew to 64.5% in 2014 from 63.7% in, and was notably higher than the share of 57.5% in CHATTANOOGA TYPE 2 DIABETES PATIENTS ARE MORE APT TO HAVE HYPERLIPIDEMIA Although the share of Chattanooga Type 2 diabetes patients with a comorbidity of hyperlipidemia fell to 64.5% in 2014 from 65.6% in, it remained higher than that of (64.) in Average Length of Stay (Days) AVERAGE LENGTH OF STAY PER INPATIENT DIABETES MELLITUS CASE, $4,000 $3,000 $2,000 $1,000 $0 4.5 Chattanooga 2012 CHARGES PER INPATIENT DIABETES MELLITUS CASE, ,5 PROFESSIONAL CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, COMMERCIAL INSURANCE PAYERS, ,7 $3,317 $3,284 Inpatient $2, Chattanooga 4.0 $1,376 $1,487 $1,029 Outpatient Chattanooga Chattanooga $2,514 $2,315 $2,299 Ambulatory Surgery Centers $1,144 $1,147$1,113 Emergency Rooms $2,123 $2,242 $1,924 Office/ Clinic 1 On pages 12 13, the percentages are representative of the universe of Type 2 diabetes patients on whom claims data have been collected in a given year. 2 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, congestive heart failure, dysmetabolic syndrome, hyperlipidemia, hypertension, and obesity. 3 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, and retinopathy. 4 Average length of stay (ALOS) and hospital inpatient charge data come from IMS Health s Procedure/Diagnosis (HPD) database and are current as of end-of-year. 5 Charge data are per-case averages for inpatients with a particular diagnosis of interest. Charges may be for treatment related to other diagnoses. Data reflect the total charges billed by the hospital for the entire episode of care, and may include accommodation, pharmacy, laboratory, radiology, and other charges not billed by the physician. Data do not necessarily indicate final amounts paid. 6 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. $35,000 $32,500 $30,000 $27,500 $25,000 $29,856 Chattanooga 2012 $34,533 Chattanooga $32,416 7 Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. 12 TENNESSEE TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

13 EAST: CHATTANOOGA Percentage of UTILIZATION: PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY SERVICE, 2014 CHATTANOOGA TYPE 2 Chattanooga Chattanooga DIABETES PTS. ARE MORE LIKELY TO RECEIVE TESTING SERVICES 77.9% 75.9% 75.4% A1c % 85.1% 82.8% 81.6% %82.7% 81.3% Blood Serum Cholesterol % 59.8% Microalbumin PHARMACOTHERAPY: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING VARIOUS NON-INSULINS THERAPIES, % 70.9% 73.7% Ophthalmologic Examination The percentages of Chattanooga Type 2 diabetes patients who had an A1c (75.9%), blood glucose (86.5%), serum cholesterol (81.6%), or urine glucose (82.7%) test in 2014 were higher than the corresponding shares for Type 2 diabetes patients across. Percentage of 2 15% 1 5% 16.6% 4.6% 16.4% Chattanooga Use of 2 Non- Use of 3 Non- 18.4% 5.6% Use of 2 Non Use of 3 Non % 6.9% 6.2% 1 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 2 who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. 3 Figures reflect the per-patient yearly payments for Type 2 diabetes patients receiving a particular type of therapy. These are the actual amounts paid by the insurer and patient for such prescriptions. mainly include copayments, but can also include tax, deductibles, and cost differentials where applicable. PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, Long-Acting Rapid-Acting Short-Acting Mixed Any Chattanooga 37.8% 17.5% 13.9% 10.5% 10.6% 10.5% 12.5% 1.7% 2.5% Chattanooga % % 9.2% 8.7% 9.2% 10.3% 2.4% 3.6% AVERAGE PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, ,3 Long-Acting Rapid-Acting Short-Acting Mixed Any Chattanooga $2,334 $1,463 $1,386 $1,505 $1,544 $1,505 $1,473 $2,241 $1,632 Chattanooga ,997 1,894 1,908 2,013 1,930 2,013 1,817 2,501 1, $3,046 $2,012 $1,978 $1,830 $2,005 $1,830 $1,944 $2,682 $1,891 PERCENTAGE OF AND AVERAGE ANNUAL PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING NON-INSULIN THERAPIES, ,3 Any Non- Antidiabetic Product Sensitizing Agents DPP-4 SGLT-2 Chattanooga $ % $ % $81 3.7% $ % $1, % $694 Chattanooga , , $ % $ % $70 4.5% $ % $1, % $1,170 Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. Sensitizing Agents Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting replacement product with a long duration of action. Mixed replacement product combining a short-acting and an intermediate-acting insulin product. Rapid-Acting replacement product with a rapid onset and shorter duration of action than short-acting insulin. Short-Acting replacement product with a short onset of action and duration. Sodium/ Cotransporter 2 (SGLT-2) Lower blood glucose concentration so that glucose is excreted instead of reabsorbed. Stimulate the release of insulin in the pancreas. MANAGED CARE DIGEST SERIES TENNESSEE TYPE 2 DIABETES REPORT

14 EAST: KNOXVILLE AGE AND GENDER, Distribution of Type 2 Diabetes Knoxville AGE GROUP % 0.3% 0.3% 0.4% GENDER Male 46.7% 46.6% 47.2% 45.1% Female COMORBIDITIES AND COMPLICATIONS, ,3 Percentage of Type 2 Diabetes Knoxville ACTUAL COMORBIDITIES Depression 13.5% 14.9% 9.7% 10.4% Hyperlipidemia Hypertension Obesity ACTUAL COMPLICATIONS Cardiovascular Disease 57.9% 56.3% 57.8% 57.5% Hypoglycemia Nephropathy Neuropathy COMORBIDITY RATES GROW AMONG TYPE 2 DIABETES PATIENTS IN KNOXVILLE From to 2014, the percentages of Type 2 diabetes patients in Knoxville who had any of the four profiled comorbidities increased. Concurrently, the percentages of such patients in Knoxville who were diagnosed with a complication of hypoglycemia, nephropathy, or neuropathy as a result of their diabetes also rose. PROVIDER CHARGES RISE FOR KNOXVILLE TYPE 2 DIABETES PTS. WITH COMMERCIAL INS. Across all five of the profiled settings, professional charges for Knoxville Type 2 diabetes patients with commercial insurance rose from to In both the hospital outpatient and office/ clinic settings, such charges expanded by at least 28., accounting for the two largest such increases that year. In 2014, provider charges for these Knoxville patients exceeded the overall averages in four of the five settings (office/clinic excepted). Average Length of Stay (Days) AVERAGE LENGTH OF STAY PER INPATIENT DIABETES MELLITUS CASE, $3,200 $2,400 $1,600 $800 $ Knoxville 2012 CHARGES PER INPATIENT DIABETES MELLITUS CASE, ,5 PROFESSIONAL CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, COMMERCIAL INSURANCE PAYERS, ,7 $2,493 $2,877 $2,731 Inpatient Knoxville $1,068 $1, $1,029 Outpatient Knoxville Knoxville $2,224 $2,357 $2,299 Ambulatory Surgery Centers $1,538 $1,597 Emergency Rooms 1 On pages 14 15, the percentages are representative of the universe of Type 2 diabetes patients on whom claims data have been collected in a given year. 2 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, congestive heart failure, dysmetabolic syndrome, hyperlipidemia, hypertension, and obesity. 3 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, and retinopathy. 4 Average length of stay (ALOS) and hospital inpatient charge data come from IMS Health s Procedure/Diagnosis (HPD) database and are current as of end-of-year. 5 Charge data are per-case averages for inpatients with a particular diagnosis of interest. Charges may be for treatment related to other diagnoses. Data reflect the total charges billed by the hospital for the entire episode of care, and may include accommodation, pharmacy, laboratory, radiology, and other charges not billed by the physician. Data do not necessarily indicate final amounts paid. 6 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 7 Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. $34,000 $31,000 $28,000 $25,000 $22,000 $24,714 Knoxville 2012 $1,113 $26,314 Knoxville $1,476 $1,896 $1,924 Office/ Clinic $32, TENNESSEE TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

15 EAST: KNOXVILLE Percentage of UTILIZATION: PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY SERVICE, % 72.8%72.5% A1c % 82.1%82. Blood 79.5%79.3% % 78.4% 81.3% Serum Cholesterol Knoxville Knoxville % 59.8% Microalbumin PHARMACOTHERAPY: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING VARIOUS NON-INSULIN THERAPIES, % 73.7% Ophthalmologic Examination KNOXVILLE TYPE 2 DIABETES PTS. HAVE LOWER TESTING RATES THAN PTS. ACROSS TN In 2014, Type 2 diabetes patients in Knoxville were less likely than their counterparts across the state of to receive an A1c test (72.5% versus 75.4%), blood glucose test (82. versus 85.1%), serum cholesterol test (79.3% versus 81.), or urine glucose test (78.4% versus 81.3%). Percentage of 2 15% 1 5% 17.6% Use of 2 Non- Use of 3 Non- 18.4% 17.4% 6.8% 5.9% Knoxville Use of 2 Non Use of 3 Non % 6.9% 6.2% 1 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 2 who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. 3 Figures reflect the per-patient yearly payments for Type 2 diabetes patients receiving a particular type of therapy. These are the actual amounts paid by the insurer and patient for such prescriptions. mainly include copayments, but can also include tax, deductibles, and cost differentials where applicable. PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, Long-Acting Rapid-Acting Short-Acting Mixed Any Knoxville 37.4% % 10.8% 9.5% 10.8% 11.5% 2.5% 3. Knoxville % % 9.2% 8.7% 9.2% 10.3% 2.4% 3.6% AVERAGE PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, ,3 Long-Acting Rapid-Acting Short-Acting Mixed Any Knoxville $2,583 $1,676 $1,694 $1,389 $1,691 $1,389 $1,602 $2,479 $1,884 Knoxville ,307 2,187 2,293 1,777 2,050 1,777 1,958 2,970 2, $3,046 $2,012 $1,978 $1,830 $2,005 $1,830 $1,944 $2,682 $1,891 PERCENTAGE OF AND AVERAGE ANNUAL PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING NON-INSULIN THERAPIES, ,3 Any Non- Antidiabetic Product Sensitizing Agents DPP-4 SGLT-2 Knoxville $ % $ % $81 4.7% $ % $1, % $662 Knoxville , , $ % $ % $70 4.5% $ % $1, % $1,170 Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. Sensitizing Agents Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting replacement product with a long duration of action. Mixed replacement product combining a short-acting and an intermediate-acting insulin product. Rapid-Acting replacement product with a rapid onset and shorter duration of action than short-acting insulin. Short-Acting replacement product with a short onset of action and duration. Sodium/ Cotransporter 2 (SGLT-2) Lower blood glucose concentration so that glucose is excreted instead of reabsorbed. Stimulate the release of insulin in the pancreas. MANAGED CARE DIGEST SERIES TENNESSEE TYPE 2 DIABETES REPORT

16 EAST: TRI-CITIES AGE AND GENDER, Distribution of Type 2 Diabetes Tri-Cities AGE GROUP % 0.4% 0.4% 0.4% GENDER Male 44.3% % 45.1% Female COMORBIDITIES AND COMPLICATIONS, ,3 Percentage of Type 2 Diabetes Tri-Cities ACTUAL COMORBIDITIES Depression 11.4% 13.9% 9.7% 10.4% Hyperlipidemia Hypertension Obesity ACTUAL COMPLICATIONS Cardiovascular Disease % 57.8% 57.5% Hypoglycemia Nephropathy Neuropathy TRI-CITIES TYPE 2 DIABETES PTS. HAVE HIGHER RATES OF COMMON COMORBIDITIES AVERAGE LENGTH OF STAY PER INPATIENT DIABETES MELLITUS CASE, CHARGES PER INPATIENT DIABETES MELLITUS CASE, ,5 The percentages of Tri-Cities Type 2 diabetes patients with a comorbidity of depression (13.9%), hyperlipidemia (67.1%), or obesity (15.7%) in 2014 were all higher than the corresponding shares of their counterparts across. Average Length of Stay (Days) Tri-Cities Tri-Cities 4.0 $34,000 $32,000 $30,000 $28,000 $26,000 $28,120 $28,180 Tri-Cities 2012 Tri-Cities $32,416 ALOS FALLS FOR TRI-CITIES DIABETES MELLITUS CASES From 2012 (4.1 days) to (3.9), the average length of stay (ALOS) per inpatient diabetes mellitus case dipped. In, ALOS for such cases was 4.0 days in. INPATIENT CHARGES RISE SLIGHTLY FOR TRI-CITIES DIABETES MELLITUS CASES The average charges per Tri-Cities inpatient diabetes mellitus case grew just 0.2% from 2012 ($28,120) to ($28,180), and remained well below the average ($32,416) in. $3,200 $2,400 $1,600 $800 $0 PROFESSIONAL CHARGES PER YEAR FOR TYPE 2 DIABETES PATIENTS, COMMERCIAL INSURANCE PAYERS, ,7 $2,798$2,585 $2,731 Inpatient $1,031 $1,029 $858 Outpatient Tri-Cities Tri-Cities $2,047 $2,088 $2,299 Ambulatory Surgery Centers $1,078 $1,158 $1,113 Emergency Rooms $1,565 $1,662 $1,924 Office/ Clinic 1 On pages 16 17, the percentages are representative of the universe of Type 2 diabetes patients on whom claims data have been collected in a given year. 2 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, congestive heart failure, dysmetabolic syndrome, hyperlipidemia, hypertension, and obesity. 3 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy, and retinopathy. 4 Average length of stay (ALOS) and hospital inpatient charge data come from IMS Health s Procedure/Diagnosis (HPD) database and are current as of end-of-year. 5 Charge data are per-case averages for inpatients with a particular diagnosis of interest. Charges may be for treatment related to other diagnoses. Data reflect the total charges billed by the hospital for the entire episode of care, and may include accommodation, pharmacy, laboratory, radiology, and other charges not billed by the physician. Data do not necessarily indicate final amounts paid. 6 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 7 Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. 16 TENNESSEE TYPE 2 DIABETES REPORT 2016 MANAGED CARE DIGEST SERIES

17 EAST: TRI-CITIES Percentage of UTILIZATION: PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY SERVICE, % A1c % 83.1% 81.2% 85.1% Blood Tri-Cities Tri-Cities % 79.5% 81. Serum Cholesterol 79.9% 80.3% 81.3% 60.9% 60.6% 59.8% Microalbumin PHARMACOTHERAPY: PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING VARIOUS NON-INSULIN THERAPIES, % 76.7% 73.7% Ophthalmologic Examination A1c TESTING RATE AMONG TRI-CITIES TYPE 2 DIABETES PATIENTS DECLINES From (75.) to 2014 (71.3%), the percentage of Tri-Cities Type 2 diabetes patients who received an A1c test decreased. Furthermore, such Tri-Cities patients were less likely than their counterparts across the state of (75.4%) to receive an A1c test in Percentage of 2 15% 1 5% 17.7% Use of 2 Non- Use of 3 Non- 18.4% 16.6% 5.6% 4.9% Tri-Cities Use of 2 Non Use of 3 Non % 6.9% 6.2% 1 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 2 who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. 3 Figures reflect the per-patient yearly payments for Type 2 diabetes patients receiving a particular type of therapy. These are the actual amounts paid by the insurer and patient for such prescriptions. mainly include copayments, but can also include tax, deductibles, and cost differentials where applicable. PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, Long-Acting Rapid-Acting Short-Acting Mixed Any Tri-Cities % 13.2% 9.4% 9.4% 9.4% 11.7% % Tri-Cities % % 9.2% 8.7% 9.2% 10.3% 2.4% 3.6% AVERAGE PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, ,3 Long-Acting Rapid-Acting Short-Acting Mixed Any Tri-Cities $2,694 $1,715 $1,766 $1,527 $1,885 $1,527 $1,885 $2,577 $2,032 Tri-Cities ,371 2,177 2,359 1,868 2,182 1,868 2,250 2,856 2, $3,046 $2,012 $1,978 $1,830 $2,005 $1,830 $1,944 $2,682 $1,891 PERCENTAGE OF AND AVERAGE ANNUAL PAYMENTS FOR TYPE 2 DIABETES PATIENTS USING NON-INSULIN THERAPIES, ,3 Any Non- Antidiabetic Product Sensitizing Agents DPP-4 SGLT-2 Tri-Cities $ % $ % $94 4.9% $ % $1, % $685 Tri-Cities , , $ % $ % $70 4.5% $ % $1, % $1,170 Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. Sensitizing Agents Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting replacement product with a long duration of action. Mixed replacement product combining a short-acting and an intermediate-acting insulin product. Rapid-Acting replacement product with a rapid onset and shorter duration of action than short-acting insulin. Short-Acting replacement product with a short onset of action and duration. Sodium/ Cotransporter 2 (SGLT-2) Lower blood glucose concentration so that glucose is excreted instead of reabsorbed. Stimulate the release of insulin in the pancreas. MANAGED CARE DIGEST SERIES TENNESSEE TYPE 2 DIABETES REPORT