Cross Blue Shield Of Texas Research Articles

Geographic Variations and the Associated Factors in Adherence to and Persistence with Adjuvant Hormonal Therapy for the Privately Insured women Aged 18-64 with Breast Cancer in Texas.

The purpose of this study is to examine the geographical patterns of adjuvant hormonal therapy adherence and persistence and the associated factors in insured Texan women aged 18-64 with early breast cancer. A retrospective cohort study was conducted using 5-year claims data for the population insured by the Blue Cross Blue Shield of Texas (BCBSTX). Women diagnosed with early breast cancer who were taking tamoxifen or aromatase inhibitors (AIs) for adjuvant hormonal therapy with at least one prescription claim were identified. Adherence to adjuvant hormonal therapy and persistence with adjuvant hormonal therapy were calculated as outcome measures. Women without a gap between two consecutively dispensed prescriptions of at least 90 days were considered to be persistently taking the medications. Patient-level multivariate logistic regression models with repeated regional-level adjustments and a Cox proportional hazards model with mixed effects were used to determine the geographical variations and patient-, provider-, and area-level factors that were associated with adjuvant hormonal therapy adherence and persistence. Of the 938 women in the cohort, 627 (66.8%) initiated adjuvant hormonal therapy. Most of the smaller HRRs have significantly higher or lower rates of treatment adherence and persistence rates relative to the median regions. The use of AHT varies substantially from one geographical area to another, especially for adherence, with an approximately two-fold difference between the lowest and highest areas, and area-level factors were found to be significantly associated with the compliance of AHT. There are geographical variations in AHT adherence and persistence in Texas. Patient-level and area-level factors have significant associations explaining these patterns.

The Impact of Conversion From an Urgent Care Center to a Freestanding Emergency Department on Patient Population, Conditions Managed, and Reimbursement.

Freestanding emergency departments (FSEDs), EDs not attached to acute care hospitals, are expanding. One key question is whether FSEDs are more similar to higher-cost hospital-based EDs or to lower-cost urgent care centers (UCCs). Our aim was to determine whether there was a change in patient population, conditions managed, and reimbursement among three facilities that converted from a UCC to an FSED. Using insurance claims from Blue Cross Blue Shield of Texas, we compared outcomes of interest for three facilities that converted from a UCC to an FSED for 1year before and after conversion. There was no significant change in age, sex, and comorbidities among patients treated after conversion. Conditions were similar after conversion, though there was a small increase in visits for potentially more severe conditions. For example, the most common diagnoses before and after conversion were upper respiratory infections (42.8% of UCC visits, 26.0% of FSED visits), while chest pain increased from rank 30 to 10 (0.5% of UCC visits, 2.3% of FSED visits). Yearly number of visits decreased after conversion, while median reimbursement per visit increased (facility A: $148 to $2,153; facility B: $137 to $1,466; and facility C: $131 to $1,925) and total revenue increased (facility A: $1,389,590 to $1,486,203; facility B: $896,591 to $4,294,636; and facility C: $637,585 to $8,429,828). After three UCCs converted to FSEDs, patient volume decreased and reimbursement per visit increased, despite no change in patient characteristics and little change in conditions managed. These case studies suggest that some FSEDs are similar to UCCs in patient mix and conditions treated.

Association between financial burden and adjuvant hormonal therapy adherence and persistent use for privately insured women aged 18-64years in BCBS of Texas.

The objective of this study is to understand an impact of financial burden on the adjuvant hormonal therapy (AHT) adherence and persistence for insured women aged 18-64 with early breast cancer in Texas. We conducted a retrospective cohort study using claims data for population insured by Blue Cross Blue Shield of Texas from the year 2008 to 2013. Outcomes include adherence to adjuvant hormonal therapy, which was measured by medication possession ratio and persistence on AHT, which is the duration of time from initiation to discontinuation of therapy. Multivariate logistic regression models with repeated regional-level adjustments were used to explore the odds of AHT adherence. Cox proportional hazards model was conducted to assess time to the first 90+-day gap for persistence and a Kaplan-Meier curve were used to estimate probabilities to calculate the percentages of women who experienced 90+-day gaps in AHT. Of the 938 women in the cohort, 627 (66.8%) initiated the treatment. By year 1, 66.9% of women were adherent to the therapy, and by year 5, only 29% of those were adherent. The percentage of women with no gap in therapy greater than 90days was 80.8%. Both higher out-of-pocket costs spent on all prescription drugs except AHT and AHT-specific out-of-pocket costs were negatively associated with adherence to AHT as well as continuing AHT as recommended. Financial burdens including both non-AHT medication and AHT-specific out-of-pocket costs were significantly associated with adherence and persistence to the therapy.

What Factors are Associated With 90-day Episode-of-care Payments for Younger Patients With Total Joint Arthroplasty?

Total joint arthroplasty (TJA) has been identified as a procedure with substantial variations in inpatient and postacute care payments. Most studies in this area have focused primarily on the Medicare population and rarely have characterized the younger commercially insured populations. Understanding the inpatient and postdischarge care service-componentdifferences across 90-day episodes of care and factors associated with payments for younger patients is crucial for successful implementation of bundled payments in TJA in non-Medicare populations. (1) To assess the mean total payment for a 90-day primary TJA episode, including the proportion attributable to postdischarge care, and (2) to evaluate the role of procedure, patient, and hospital-level factors associated with 90-day episode-of-care payments in a non-Medicare patient population younger than 65 years. Claims data for 2008 to 2013 from Blue Cross Blue Shield of Texas were obtained for primary TJAs. A total of 11,131 procedures were examined by aggregating payments for the index hospital stay and any postacute care including rehabilitation services and unplanned readmissions during the 90-day postdischarge followup period. A three-level hierarchical model was developed to determine procedure-, patient-, and hospital-level factors associated with 90-day episode-of-care payments. The mean total payment for a 90-day episode for TJA was USD 47,700 adjusted to 2013 USD. Only 14% of 90-day episode payments in our population was attributable to postdischarge-care services, which is substantially lower than the percentage estimated in the Medicare population. A prolonged length of stay (rate ratio [RR], 1.19; 95% CI, 1.15-1.23; p ≤ 0.001), any 90-day unplanned readmission (RR, 1.64; 95% CI, 1.57-1.71; p ≤ 0.001), computer-assisted surgery (RR, 1.031; 95% CI, 1.004-1.059; p ≤ 0.05), initial home discharge with home health component (RR, 1.029; 95% CI, 1.013-1.046; p ≤ 0.001), and very high patient morbidity burden (RR, 1.105; 95% CI, 1.062-1.150; p ≤ 0.001) were associated with increased TJA payments. Hospital-level factors associated with higher payments included urban location (RR, 1.29; 95% CI, 1.17-1.42; p ≤ 0.001), lower hospital case mix based on average relative diagnosis related group weight (RR, 0.94; 95% CI, 0.89-0.95; p ≤ 0.001), and large hospital size as defined by total discharge volume (RR, 1.082; 95% CI, 1.009-1.161; p ≤ 0.05). All procedure, patient, and hospital characterizing factors together explained 11% of variation among hospitals and 49% of variation among patients. Inpatient care contributed to a much larger proportion of total payments for 90-day care episodes for primary TJA in our younger than 65-year-old commercially insured population. Thus, inpatient care will continue to be an essential target for cost-containment and delivery strategies. A high percentage of hospital-level variation in episode payments remained unexplained by hospital characteristics in our study, suggesting system inefficiencies that could be suitable for bundling. However, replication of this study among other commercial payers in other parts of the country will allow for conclusions that are more robust and generalizable. Level II, economic analysis.

Comparing Utilization and Costs of Care in Freestanding Emergency Departments, Hospital Emergency Departments, and Urgent Care Centers

We compare utilization, price per visit, and the types of care delivered across freestanding emergency departments (EDs), hospital-based EDs, and urgent care centers in Texas. We analyzed insurance claims processed by Blue Cross Blue Shield of Texas from 2012 to 2015 for patient visits to freestanding EDs, hospital-based EDs, or urgent care centers in 16 Texas metropolitan statistical areas containing 84.1% of the state's population. We calculated the aggregate number of visits, average price per visit, proportion of price attributable to facility and physician services, and proportion of price billed to Blue Cross Blue Shield of Texas versus out of pocket, by facility type. Prices for the top 20 diagnoses and procedures by facility type are compared. Texans use hospital-based EDs and urgent care centers much more than freestanding EDs, but freestanding ED utilization increased 236% between 2012 and 2015. The average price per visit was lower for freestanding EDs versus hospital-based EDs in 2012 ($1,431 versus $1,842), but prices in 2015 were comparable ($2,199 versus $2,259). Prices for urgent care centers were only $164 and $168 in 2012 and 2015. Out-of-pocket liability for consumers for all these facilities increased slightly from 2012 to 2015. There was 75% overlap in the 20 most common diagnoses at freestanding EDs versus urgent carecenters and 60% overlap for hospital-based EDs and urgent care centers. However, prices for patients with the same diagnosis were on average almost 10 times higher at freestanding and hospital-based EDs relative to urgent care centers. Utilization of freestanding EDs is rapidly expanding in Texas. Higher prices at freestanding and hospital-based EDs relative to urgent care centers, despite substantial overlap in services delivered, imply potential inefficient use of emergency facilities.

Abstract 20032: Outpatient Exposure to Potentially Harmful Drugs in Patients With Heart Failure

Background: Several drugs have the potential to cause or decompensate heart failure (HF). Objective: To evaluate the frequency of potentially harmful drug exposure after hospital discharge in patients with heart failure. Methods: This was a retrospective analysis of Blue Cross Blue Shield of Texas (BCBSTX) claims data (2008-2013) which contains information for medical and pharmacy services. We included patients with at least one admission with a primary or secondary diagnosis for heart failure as defined by ICD-9 codes. We then analyzed all pharmaceutical claims for those patients as of day of discharge. Exposure to potentially harmful drugs (PHD) was defined as the use of non-steroidal anti-inflammatory agents (NSAIDS), Thiazolidinediones (TZD), Alpha-blockers (AB), Antiarrhythmic (AA) and non-dihydropyridine calcium channel blockers (non DPCCB) as recorded in pharmaceutical claims using AHFS Pharmacologic-Therapeutic Classification. Results: A total of 35317 discharges with a primary or secondary diagnosis of heart failure were identified, of which we analyzed a subset of 13,926 discharges from a total of 9,784 patients who had pharmacy coverage through BCBSTX. We found that of 5,730 (69%) had a prescription for at least one PHD after discharged. NSAIDS were the most common category 77% (4430) followed by AA 781(13.6%), non DPCCB 322 (5.6%), TZD 103 (1.8%) and AB 94 (1.6%). Most cases were recorded as new prescription claims with a relatively short interval between discharge and prescription. (Table 1) Conclusion: In patients discharged from the hospital with a primary or secondary diagnosis of heart failure, exposure to potentially harmful drugs is not uncommon, especially NSAIDS. Further research to define the consequences of this exposure is needed.

Longitudinal Analysis of Opioid Analgesic Dose and Diabetes Quality of Care Measures.

To examine associations of opioid analgesic dose with quality of care for diabetes mellitus. Longitudinal statewide cohort. Subjects with diabetes filled one or more prescriptions for Schedule II/III opioids for noncancer pain in Blue Cross Blue Shield of Texas from 2008 through 2012. Opioid dose and outcomes were assessed in 6-month intervals after first filled prescription. Two morphine equivalent dose measures were daily dose and quartiles of total dose from all filled prescriptions. In fixed effects models adjusted for clinical and treatment variables, associations of opioid measures were examined for five outcomes: hemoglobin A1c (HbA1c) test, low density lipoprotein cholesterol (LDL) test, any hospitalization, any diabetes-related preventable hospitalization, and any emergency department (ED) visit. All daily and total opioid doses were associated (P < 0.05) with poorer outcomes for all five measures. For HbA1c testing, adjusted odds ratios (AORs) were reduced by 19% for high daily dose (≥100 mg) and highest quartile total dose (>900 mg), respectively, vs no opioids but >900 mg total dose had the lowest AOR for LDL testing (0.74 [CI 0.68, 0.80]). The AORs of any hospitalization or diabetes-related hospitalization were, respectively, 8.19 (CI 7.21, 9.30) and 2.76 (CI 2.19, 3.48) for >900 mg total dose but only 6.22 (CI 4.94, 7.83) and 2.16 (CI 1.34, 3.48) for >100 mg daily dose. Both opioid measures had nonmonotonic associations with ED use. Daily opioid dose but especially total dose of opioids was strongly associated with poorer diabetes quality of care in a statewide cohort.

Physician Self-Referral of Physical Therapy Services for Patients with Low Back Pain: Implications for Use, Types of Treatments Received and Expenditures.

Prior research on treatment of low back pain has documented large increases in use of spinal surgery, MRIs and lumbosacral injections linked to physician self-referral arrangements. No recent research has examined whether physician ownership of physical therapy services results in greater use of physical therapy to treat low back pain. The objective of this study is to investigate whether physician ownership of physical therapy services affects frequency of use, visits and types of physical therapy services received by patients with low back pain. Using claims records from insured patients covered by Blue Cross Blue Shield of Texas (2008-2011) we compared several metrics of use of physical therapy services for low back pain episodes controlling for self-referral status. We identified 158,151 low back pain episodes, 27% met the criteria to be classified as "self-referral." Only 10% of "non-self-referral" episodes received physical therapy compared to 26% of self-referral episodes (p<0.001). The unadjusted and regression adjusted self-referral effect was identical - about 16 percentage point difference (p<0.001). Among patients who received some physical therapy, self-referral episodes were comprised of 2.26 fewer visits and 11 fewer physical therapy service units (p<0.001). Non-self-referring episodes included a significantly higher proportion of "active" (hands on or patient engaged) as opposed to "passive" treatments (p<0.001). The regression-adjusted difference was 30 percentage points when measured as actual counts and 29 percentage points when measured in RVUs (p<0.001). Total spending on back-related care was 35% higher for self-referred episodes compared to their non-self-referred counterparts (p<0.001). Ownership of physical therapy services influence physicians' referral to initiate a course of physical therapy to treat low back pain, but also affect the types of physical therapy services a patient receives.

Effect of Public Reporting on MR Imaging Use for Low Back Pain.

To determine whether magnetic resonance (MR) imaging examination rates for low back pain before conservative therapy in the Medicare and privately insured populations changed after introduction of a Centers for Medicare & Medicaid Services public reporting initiative. Institutional review board approval was obtained, with waiver of informed consent. A retrospective study was performed by using fee-for-service claims data from Medicare and a commercial carrier (Blue Cross Blue Shield of Texas [BCBSTX]) for Texas enrollees. OP-8 was calculated, which is a publicly reported measure as of 2009 of the proportion of MR imaging examinations performed for low back pain without history of conservative therapy. For 330 463 MR imaging examinations, OP-8 rates, trends, and regional variation were analyzed for 2008-2011 within different outpatient settings-outpatient hospital department (OHD) and nonhospital outpatient department (NOD)-according to payer. Largest-volume hospitals were also evaluated within the Medicare population. No significant reduction was found in annual OP-8 values for Medicare or BCBSTX (Medicare OHD, 0.35 for 2008 vs 0.36 for 2009 [P = .01]; BCBSTX OHD, 0.42 for 2008 vs 0.44 for 2009 [P = .03]; Medicare NOD, 0.33 for 2008 vs 0.35 for 2009 [P < .0001]; and BCBSTX NOD, 0.43 for 2008 vs 0.42 for 2009[P = .23]). These changes were not sustained during subsequent years in the BCBSTX population, and there were no further changes in Medicare rates. Among hospitals with highest Medicare volumes, those with the highest OP-8 rates in 2008 were associated with the highest decrease in their measure. (The annual change rate was negative for all years, with 2008 as the reference [P < .0001 for 2009-2011].) Hospitals with the lowest OP-8 rates had increases in OP-8 rates, which persisted in following years (P = .006 for 2009, P = .037 for 2010, and P = .004 for 2011). Hospitals with baseline OP-8 rates in the 25th-75th percentile remained relatively steady over time. No evidence was found that public reporting (OP-8) reduced MR imaging rates for low back pain without conservative therapy in either Medicare or commercially insured populations in hospital or nonhospital settings.

Medicare and private spending trends from 2008 to 2012 diverge in Texas.

The recent relatively slow growth in health care spending masks significant differences among payers, clinical settings, and geographic areas. To better understand the spending slowdown, we focus on 2008-2012 trends in Texas among Medicare fee-for-service beneficiaries and enrollees in Blue Cross Blue Shield of Texas (BCBSTX). Spending per person for Medicare grew only 1.5% per year on average, compared with 5.2% for BCBSTX. In Medicare, utilization rates were relatively flat, while prices grew more slowly than input prices. In BCBSTX, spending growth was driven by increases in negotiated prices, in particular hospital prices. We find that geographic variation declined sharply in Medicare, due to drops in spending on post-acute care in two notoriously high-spending regions but rose slightly in BCBSTX. The aggregate spending trends mask two divergent stories: spending growth in Medicare is very slow, but price increases continue to drive unsustainable spending growth among the privately insured.

The use of sequential pattern mining to predict next prescribed medications

BackgroundTherapy for certain medical conditions occurs in a stepwise fashion, where one medication is recommended as initial therapy and other medications follow. Sequential pattern mining is a data mining technique used to identify patterns of ordered events. ObjectiveTo determine whether sequential pattern mining is effective for identifying temporal relationships between medications and accurately predicting the next medication likely to be prescribed for a patient. DesignWe obtained claims data from Blue Cross Blue Shield of Texas for patients prescribed at least one diabetes medication between 2008 and 2011, and divided these into a training set (90% of patients) and test set (10% of patients). We applied the CSPADE algorithm to mine sequential patterns of diabetes medication prescriptions both at the drug class and generic drug level and ranked them by the support statistic. We then evaluated the accuracy of predictions made for which diabetes medication a patient was likely to be prescribed next. ResultsWe identified 161,497 patients who had been prescribed at least one diabetes medication. We were able to mine stepwise patterns of pharmacological therapy that were consistent with guidelines. Within three attempts, we were able to predict the medication prescribed for 90.0% of patients when making predictions by drug class, and for 64.1% when making predictions at the generic drug level. These results were stable under 10-fold cross validation, ranging from 89.1%–90.5% at the drug class level and 63.5–64.9% at the generic drug level. Using 1 or 2 items in the patient’s medication history led to more accurate predictions than not using any history, but using the entire history was sometimes worse. ConclusionSequential pattern mining is an effective technique to identify temporal relationships between medications and can be used to predict next steps in a patient’s medication regimen. Accurate predictions can be made without using the patient’s entire medication history.

Texas SLPs Score Insurance Victory

You have accessThe ASHA LeaderASHA News1 Dec 2009Texas SLPs Score Insurance Victory Barbara Samfield andMA, CCC-SLP Gretchen BebbMA, CCC-SLP Barbara Samfield Google Scholar More articles by this author , MA, CCC-SLP and Gretchen Bebb Google Scholar More articles by this author , MA, CCC-SLP https://doi.org/10.1044/leader.AN1.14162009.3 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In The Texas Speech-Language-Hearing Association (TSHA) scored an unprecedented victory for the state’s private practice speech-language pathologists in October, when it challenged—and negotiated with—Blue Cross Blue Shield of Texas (BCBS/TX) to stop efforts to recoup payments going back three years. BCBS/TX attempted to recoup payment from private practitionersacross the state for the primary speech treatment code 92507, claiming overpayments for services billed. BCBS/TX stated that the code is an untimed unit that could not be billed in multiple units and sought the return of reimbursement for such billing. This effort could have forced many private practitioners into bankruptcy. This code is considered an “untimed” code by the Centers for Medicare and Medicaid Services. However, private practitioners offered evidence that BCBS/TX representatives had advised them to bill in multiple units as part of provider contract negotiations, advice that led many providers to accept the BCBS/TX fee schedule arrangements. The TSHA executive board rallied to the defense of its members and coordinated efforts with legal counsel Mark Hanna to meet with representatives of the insurer. Hanna reviewed numerous provider contracts, recoupment notices, and BCBS/TX notification policies and, with the TSHA Executive Board, designed an action plan based on common contractual elements, BCBS/TX policies, and other payers’ acceptance of time units. TSHA’s primary objectives were to stop the retroactive collection process, return any recouped monies to the providers, and obtain a 90-day notification about the change in 92507 reimbursement practices. In October, Hanna and several other TSHA leaders including Keri Gonzalez, vice president for professional services, presented TSHA’s case in a conference call with two BCBS/TX vice presidents. The carefully crafted dialogue began with introductions, a review of key issues, and discussion of selected points. A significant negotiation point was BCBS/TX’s discussions of multiple-unit billing during contract negotiations with practitioners. The final step was to ask BCBS/TX to halt the recoupment process, refund recouped monies, and give providers the required 90-day notification of the intent to pay 92507 as an untimed code. The amicable discussion ended humorously with one BCBS/TX executive commenting about the “articulate” communication skills of TSHA’s SLPs. Negotiation Success A few days later after the conference call, BCBS/TX agreed to TSHA’s requests, with only the 90-day notification date remaining undetermined. TSHA clearly scored a win for its private-practice members—and for all SLPs in the state who are BCBS/TX providers. TSHA stepped up to the plate and took an important stand for the profession. Although negotiations with BCBS/TX were successful, important issues remain. TSHA looks forward to continued dialogue with its private-practice clinicians and the insurers regarding coding and reimbursement issues. Author Notes Barbara Samfield, MA, CCC-SLP, is co-chair of the TSHA Private-Practice Issues Task Force. Contact her at [email protected]. Gretchen Bebb, MA, CCC-SLP, is chair of the TSHA Reimbursement Task Force. Contact her at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 14Issue 16December 2009 Get Permissions Add to your Mendeley library History Published in print: Dec 1, 2009 Metrics Downloaded 61 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2009 American Speech-Language-Hearing AssociationLoading ...

Barriers to First-Week Follow-up of Newborns: Findings from Parent and Clinician Focus Groups

Monitoring newborns within the first week is critical to assess the adequacy of feeding and weight gain and to identify instances of hyperbilirubinemia. As systems of maternal and newborn care have become increasingly fragmented, infants are at increased risk of poor outcomes because of poor follow-up. Structured focus groups were conducted in June--July 2001 to provide information about the barriers to timely newborn follow-up and strategies to address them. One focus group for physicians and one for nurses were held at the Henry Ford Health System, Detroit, and two focus groups of parents were recruited by Blue Cross Blue Shield of Texas, Dallas. Barriers were identified in communication and information, systems and processes of care, and parental knowledge and education. Concerns raised by clinicians and parents were consistent and complementary. Some organizations have begun implementing some of the suggested strategies to achieve timely follow-up. Implementing the AAP guideline and improving safe care in the first week of newborn life will require attention to linkages and transitions between these various microsystems.