BCBSTXBlue Cross/Blue Shield of Texas
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The OOP cost is determined by computing the difference between the total paid dollar amount and allowed dollar amount listed in the BCBSTX Pharmacy member claim file.
This study expands previous work by using newly available and more detailed claims data to measure market-level prices, utilization, and health risk among the BCBSTX privately insured population in Texas.
For each hospital referral region (HRR) in Texas, we measure spending per person among BCBSTX enrollees and among Medicare fee-for-service beneficiaries.
The principal data source was claims data on 3,829,083 BCBSTX members, all the BCBSTX members residing in Texas in 2011, or approximately one third of all commercial sector enrollments in Texas.
The BCBSTX data come from four files: claims, enrollment, physician, and pharmacy.
We created two BCBSTX spending measures, one that excludes prescription drugs and another that includes prescription drugs.
Health status for the BCBSTX population was computed at the patient level using the Adjusted Clinical Groups (ACG) scores.
Using the BCBSTX data, we computed a spending index for each HRR and decomposed it into a price index and a quantity (utilization) index.
The health status index was calculated for each HRR using the health status score of each individual in the HRR weighted by the number of months of BCBSTX enrollment.
The Medicare standardized costs are similar in concept to the quantity measures we calculated with the BCBSTX data ([[bar.
While our study has the usual limitations of studies using claims data and BCBSTX data represent the privately insured population in only one state, BCBSTX is the largest insurer in Texas, which is a large and under-studied state with wide diversity in its socio-demographics and composition of health care markets.
Although HCSC has essentially completed its turnaround of BCBSTX and of Rio Grande HMO Inc.