BCBS of Texas Uses Epidose Grouper
CHALLENGE
Blue Cross Blue Shield of Texas, the state’s largest health plan with more than four million members, wanted to offer clients a more affordable option by introducing a PPO network comprising physicians and healthcare providers that met an appropriate Risk-Adjusted Cost Index.
BCBS TX needed a sound, clinically based methodology to fairly compare the cost of providers’ care in order to determine which providers had the ability to manage care at or below the cost of peers while maintaining high quality.
SOLUTION
To account for severity of illness and the impact of co-morbid conditions, the plan applied a methodology using both the Disease Staging Model in Medical Episode Grouper (MEG) and the Diagnostic Cost Grouper (DCG) Relative Risk Scores available in the Medstat Advantage Suite® database.
By measuring affordability using average cost per episode and adjusting these costs by DCG risk score, the plan created a level field for comparing the costs and quality of physicians and professional providers.
RESULTS
- Adjusting for patient risk avoids overcompensating physicians with healthier patients and under-compensating those with sicker patients.
- This methodology is both robust and clinically based – helping to gain buy-in with physicians and professional providers.
- 76 percent of physicians and professional providers in the PPO network evaluated were eligible for this new, more affordable network.
- This network offering provided an affordable option, especially to small employer groups focused on cost, which represented a significant premium savings over the primary statewide PPO network.
To request the MEG white paper, information guide, and two published articles, visit www.medstat.com/meg4, or call 734-913-3000.