Use of big data by Blue Cross and Blue Shield of North Carolina.
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The health care industry is grappling with the challenges of working with and analyzing large, complex, diverse data sets. Blue Cross and Blue Shield of North Carolina provides several promising examples of how big data can be used to reduce the cost of care, to predict and manage health risks, and to improve clinical outcomes. (+info)
Use of a preferred provider by employees of the preferred provider.
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Little is known about the use of services in a preferred provider organization. We studied Pacific Medical Center (PMC) in Seattle which offered a preferred provider arrangement to its employees who selected a Blue Cross-Blue Shield type of plan. PMC offered to waive copayments and reduce deductibles for those employees when they (or their dependents) used PMC. PMC was thus a preferred provider. In the first 16 months of this program, 632 subjects made at least one claim; of these, 444 (70 percent) used the preferred provider at least once. The use of PMC was highest for male employees (84 percent had at least one visit), next for female employees (74 percent), and lowest for dependents (58 percent). Approximately one-third (32 percent) used PMC exclusively, 30 percent used other providers exclusively, and 37 percent used a combination of PMC and other providers. These may be thought of as best-case estimates, since the subjects--particularly the male employees--had a high level of familiarity with the program and ease of access, while the dependents had high familiarity but less convenient access. Female employees may have used PMC less because of relationships already established with other physicians. Outpatient and inpatient charges were more than twice as high for those who used both PMC and other providers as for those who used one provider exclusively. It may be that the preferred provider arrangement encourages higher charges or, alternatively, that it provides additional flexibility for those who have the most need for care. (+info)
Demand for outpatient mental health services in a heavily insured population: the case of the Blue Cross and Blue Shield Association's Federal Employees Health Benefits Program.
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This article presents the results of a study of the impact of an increase in coinsurance on the demand for outpatient mental health services. The study population was a set of fully employed subscribers enrolled in the Blue Cross and Blue Shield Association's Federal Employees Health Benefits Program at some time during the period 1979 through 1981. A two-part model was used to examine the determinants of both the probability of mental health service use and the level of use. Our results indicate little price sensitivity in either part of the model, but substantial and significant income elasticities. Our results concerning the role of various sociodemographic and environmental variables are also reported. (+info)
Health services research as a scientific process: the metamorphosis of an empirical research project from grant proposal to final report.
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The process of health services research is rarely examined; attention is usually focused on results and policy implications. Large and small decisions made during the execution of a study, however, can have major impacts on its outcomes. This article describes a project that underwent major changes because of problems discovered in the basic data and threats to the valid interpretation of econometric results uncovered by qualitative case studies. Although the combination of difficulties encountered in this project may be unusual, it is likely that many similar problems and opportunities occur in other empirical studies. (+info)
Hospital case mix and average charge per case: an initial study.
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The use of case mix to explain hospital costs has been refined in previous research on the cost of hospital-based health care. This study demonstrates the significance of hospital case mix in explaining charges for health care treatment. By assuming that the variables which influence cost should also influence charges, an evaluative function is added to the basic investigative analysis potential of the hospital production process model. The relationship between case mix and charges is found to be weaker than the relationship between case mix and costs. This difference is qualified by methodological variation and possibly explained by cross-subsidization of patient services and lack of adequate controls on charge determination. Further, the relationship between case mix and charges is found to differ between Medicare and Blue Cross patients. This evidence suggests that hospital accounting may not be recovering costs evenly and equitably from clients. (+info)
Factors affecting choice of health care plans.
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The research reported here examined the factors which affected the decision to remain with either Blue Cross of Washington and Alaska or Group Health Cooperative of Puget Sound, or to change to an independent practice association (IPA) in which the primary care physicians control all care. The natural setting allowed examination of the characteristics of families with experience in structurally different plans; a decision not influenced by premium differentials; the importance of the role of usual provider; and a family-based decision using multivariate techniques. An expected utility model implied that factors affecting preferences included future need for medical care; access to care; financial resources to meet the need for care; and previous level of experience with plan and provider. Analysis of interview and medical record abstract data from 1,497 families revealed the importance of maintaining a satisfactory relationship with the usual sources of care in the decision to change plans. Adverse selection into the new IPA as measured by health status and previous utilization of medical services was not noted. (+info)
Utilization of dental services in the United States and an insured population.
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Dental service utilization rates among 1.2 million Pennsylvania Blue Shield dental insureds are compared to rates in the US population. Insurance appears to stimulate the utilization of dental services above national norms; children appear to be a major beneficiary of insurance's incentive effect on dental service use. The implications of these findings for health planners and dental insurance providers are discussed. (+info)
Insuring preventive dental care: are sealants included?
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Lack of third-party reimbursement for pit and fissure sealants has been cited as a barrier preventing increased adoption rates. The extent to which commercial insurance companies and Blue Cross/Blue Shield Associations provide reimbursement for dental sealants is examined with data from a telephone survey. Results indicate that the majority of such third-party payers did not provide reimbursement for sealants. (+info)