ESBD_486865_1770151670387_3.17 - MAP 2024 AnnualReview.pdf
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- Solicitation number
- RFP-01-SBA-26-274
- Issued by
- Texas
About this file
This is a 2024 Annual Review document for the Blue Cross and Blue Shield of Texas 65 Plus Medicare Advantage Plan (PPO), detailing healthcare utilization and cost analysis for the Texas A&M University System for the reporting period January through December 2024. The document provides comprehensive medical claims data, enrollment demographics, and cost trend analysis for the self-insured employee group medical plan administered under this Medicare Advantage arrangement.
The plan served a predominantly older population with an average age of 76, consisting of 57.3% female and 42.7% male members. Total paid claims amounted to $1,097.82 per member per month (PMPM), with inpatient facility costs at $299.28 PMPM, outpatient facility costs at $354.14 PMPM, professional services at $430.54 PMPM, and Part B prescriptions at $13.87 PMPM. The top three disease cost drivers were circulatory conditions ($177.28 PMPM, 16.4% of total costs), neoplasms ($173.27 PMPM), and musculoskeletal conditions ($133.40 PMPM). In-network utilization was strong, with 79.9% of services and 85.4% of paid claims processed through network providers. Emergency room visits totaled 4,097 with 25% classified as potentially non-emergent, while 14% of ER claimants accounted for 34% of ER expenses. The analysis also identified significant chronic conditions, with hypertension being most prevalent at 610.4 claimants per 1,000 members, followed by hyperlipidemia at 578.4 per 1,000 and diabetes at 288.2 per 1,000. High-cost claimants significantly contributed to overall spending across all service categories, representing 62.8% of inpatient costs, 36.9% of outpatient costs, and 31.5% of professional service costs.
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Other files
| File | Type | Posted |
|---|---|---|
| ESBD_486865_1770151667603_Price Proposal Worksheet.docx | DOCX document | |
| ESBD_486865_1770151668359_3.16 - A&M System Claims Experience.xlsx | XLSX spreadsheet | |
| ESBD_486865_1770151668011_Detail Claims File Instructions.docx | DOCX document | |
| ESBD_486865_1770151667865_Sample Open Enrollment Calendar.pdf | ||
| ESBD_486865_1770151666968_Network.xlsx | XLSX spreadsheet | |
| ESBD_486865_1770154776343_AM Care Plans.xlsx | XLSX spreadsheet | |
| ESBD_486865_1771627457725_SBA-26-274 Addendum 1.pdf | ||
| ESBD_486865_1770151667310_Provider Reimbursement.xlsx | XLSX spreadsheet | |
| ESBD_486865_1770149799579_SBA-26-274 Self-Insured Employee Group Health Plan.pdf | ||
| ESBD_486865_1770154774348_Benefit Eligible.xlsx | XLSX spreadsheet |
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Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
65 Plus Medicare Advantage Plan (PPO) 2024 Annual Review April 24, 2025
• Average age was 76
• Predominately female population with 57.3%, compared to 42.7% male
Demographic and Enrollment Summary
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of
BCBSTX.
Paid PMPM $1,097.82Overall Summary
$299.28Inpatient Facility
$354.14Outpatient Facility
$430.54Professional
$13.87 Part B Prescriptions
In 2024, 79.9% of services and 85.4% of paid claims were In-Network
2024 Cost Trends
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of
Cost Trend: Top Three Disease Drivers
1 2 3
Musculoskeletal
$133.40 PMPM
in PY24
Circulatory
$177.28 PMPM
in PY24
Neoplasms
$173.27 PMPM
in PY24
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of BCBSTX.
Circulatory is the highest cost driver condition at $177.28 PMPM and accounted for 16.4% of total medical paid PMPM.
Inpatient Circulatory Top 5 Diagnosis by Paid PMPM
• Stroke
• High Blood Pressure
• Abnormal Heart Rhythm
• Heart Attack
• Coronary Heart Disease
Cost Trend: Top 3 Disease Drivers Circulatory #1
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of
Cost Trend: Top Three Disease Drivers Neoplasm is #2: 35.4% of members had a neoplasm diagnosis.
CervicalMelanoma SkinLymphomaLeukemiaColonLungBreastProstate
Non- Melanoma
Skin 0.10%1.50%1.50%2.40%2.50%3.10%8.60%10.90%43.70%Claimants 0.00%1.70%1.70%1.90%4.20%6.40%7.70%8.60%7.30%Paid
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of
Key Musculoskeletal Conditions
• Spinal Fusion
• Knee Replacement
• Hip Replacement
Musculoskeletal paid PMPM accounted for 12.3%_of the total medical paid PMPM
Cost Trend: Top Three Disease Drivers #3 is Musculoskeletal and Connective Tissue
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of
Emergency Room Leading Diagnosis
Top ER Diagnoses for Jan 2024 - Dec 2024
%Visits Potentially Non- Emergent *VisitsClaimantsPaidER Diagnosis
2.4%886738$678,968Injury/Poisoning
41.2%643562$610,735Symptoms/Ill-Defined
16.4%602514$681,059Circulatory
51.7%331288$178,190Musculoskeletal
64.2%321260$279,336Genitourinary
25.3%292254$321,353Digestive
43.8%265230$245,252Respiratory
14.3%196139$204,505Nervous
5.1%136128$117,057Infectious/Parasitic
0.8%123112$141,243Endocrine
12.7%347298$222,553All Others
24.8%4,0972,480$3,680,252Summary
• 25% of ER visits were potentially non-emergent in the current reporting._
• The conditions with the highest volume of ER visits in the current reporting period were Injury/Poisoning, Symptoms/Ill-Defined, and Circulatory.
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of BCBSTX. 11
Frequent Users of Emergency Room
• 14%_of ER claimants visited the ER three or more times in the current reporting period.
• Claimants with 3 or more ER visits accounted for 34% of the ER paid expenses in the current reporting period.
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of BCBSTX.
Jan 2024 - Dec 2024Reporting Period
$38,536,016Paid $299.28Paid PMPM $111.40Non-High Cost $187.88High Cost
2,385Admissions 222.3Admissions/1,000
1,850.5Days/1,000 8.3Average Length of Stay
$16,158Paid/Admission 91.9%In-Network Paid % 92.5%In-Network Admissions %
.Inpatient Facility Overview
• High Cost Claimants accounted for 62.8% of total inpatient spend.
• Circulatory was the most costly diagnostic category for inpatient services in the current reporting period.
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of BCBSTX.
Inpatient Facility – Details by Top 5 Service Types
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of BCBSTX. 14
Jan 2024 - Dec 2024Reporting Period
$45,599,908Paid $354.14Paid PMPM $223.32Non-High Cost $130.82High Cost 103,966Visits 9,689.0Visits/1,000
$439Paid/Visit 86.8%In-Network Paid % 80.4%In-Network Visits %
• High Cost Claimants accounted for 36.9% of total outpatient spend.
• Neoplasms was the most costly diagnostic category for outpatient services in the current reporting period.
Outpatient Facility Overview
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of BCBSTX.
• Surgical was the service type with the highest paid PMPM for outpatient services in the current reporting.
• Other Outpatient Services had the highest rate of visits/1,000 in the current reporting period.
• Surgical had the highest amount paid per visit in the current reporting period.
Outpatient Facility – Details by Top 5 Service Types
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of BCBSTX.
Jan 2024 - Dec 2024Reporting Period $55,437,644Paid
$430.54Paid PMPM $295.09Non-High Cost $135.44High Cost 25,649.1Visits/1,000 52,065.4Services/1,000
$201Paid/Visit $99Paid/Service
79.9%In-Network Paid % 79.6%In-Network Visits %
• High Cost Claimants accounted for 31.5%_of total professional spend.
• Neoplasms was the most costly diagnostic category for professional services in the current reporting period.
Professional Services Overview
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of BCBSTX.
• Evaluation & Management was the service type with the highest paid PMPM for professional services in the current reporting period.
• Evaluation & Management had the highest rate of services/1,000 in the current reporting period.
• Other – Prof had the highest amount paid per service in the current reporting period.
Professional – Details by Top 5 Service Types
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of BCBSTX.
Jan 2024 - Dec 2024Metric $1,786,596Paid
$13.87Paid PMPM
0.9%Member Cost Share %
$351.83Paid/Claimant
$18.09Paid/Day
11,779Prescriptions
1,097.7Prescriptions/1000
5,078Claimants
473.2Claimants/1000
2.3Scripts/Claimant
7.5%Generic Dispensing Rate
1.0Rx Retail as % of Prescriptions
0.7%Specialty % of Total Prescriptions
20.0%Specialty % of Pharmacy Cost
Medicare Drug Overview
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of BCBSTX.
Pharmacy: Top Therapeutic Drug Classes
Top 10 Specialty Drugs by Ingredient Cost: 2024
Specialty Claimants
Avg. Ingredient Cost/ Prescription PrescriptionsIngredient CostSpecialty ClassBrand Name
1$20,772.3511$228,496PULMONARY HYPERTENSIONTYVASO RF KT SOL 0.6MG/ML
1$6,478.3912$77,741IMMUNE GLOBULINSGAMMAPLEX INJ 10%
1$5,014.554$20,058IMMUNE GLOBULINSGAMUNEX-C INJ 20GM/200
1$6,499.231$6,499IMMUNE GLOBULINSGAMMAPLEX INJ 10%
1$1,253.644$5,015IMMUNE GLOBULINSGAMUNEX-C INJ 5GM/50ML
1$822.086$4,932CYSTIC FIBROSISTOBRAMYCIN NEB 300/5ML
3$363.0511$3,994CANCERCAPECITABINE TAB 500MG
6$284.5513$3,699CANCERCAPECITABINE TAB 500MG
1$2,608.981$2,609LUNG DISORDERSOHTUVAYRE SUS 3/2.5ML
1$2,069.621$2,070CYSTIC FIBROSISTOBRAMYCIN NEB 300/5ML
5$334.0215$5,010All Other
17$4,558.5179$360,123Summary
Top 10 Non-Specialty Drug Classes by Ingredient Cost: 2024
Rank by Volume% Generic
Avg. Ingredient Cost/ Prescription
(Current)Ingredient CostPrescriptionsPlan Therapeutic Class
Current/ Prior Rank
1$99.49$810,2388,144Viral Vaccines1 3$113.86$117,1581,029Diabetic Supplies2 4$249.10$97,898393Bacterial Vaccines3 2$56.77$62,9011,108Diagnostic Tests4 596.5%$115.67$40,138347Sympathomimetics5 695.6%$98.80$26,974273Immunosuppressive Agents6 795.6%$148.93$20,404137Steroid Inhalants7 879.3%$291.62$16,91458Bronchodilators - Anticholinergics8
10$69.16$3,32048Insulin9 11$43.78$1,79541Toxoid Combinations10
52.5%$23.82$2,906122All Other 7.2%$102.62$1,200,64511,700Summary
Medical Top 10 Drug Analysis
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of BCBSTX. 21
Disease Category Ranking
• Neoplasms was the most costly diagnostic category._
• The top 4 diagnostic categories accounted for 52.3% of total medical costs.
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of BCBSTX.
Jan 2024 - Dec 2024
97.1CHF
186.3CAD
288.2DiabetesClaimants/1,000
578.4Hyperlipidemia
610.4Hypertension
No Chronic Conditions
$25,599CHF
$18,982CAD
$14,278DiabetesPaid/Claimant
$11,160Hyperlipidemia
$13,054Hypertension
No Chronic Conditions
$207.16CHF
$294.69CAD
$342.97DiabetesPaid PMPM
$537.88Hyperlipidemia
$664.01Hypertension
No Chronic Conditions
• Hypertension was the most prevalent chronic condition.
• CHF was the most costly chronic condition on a Paid/Claimant basis.
* For a member to be included in one of these chronic condition categories, they must be 18 years or older and have had at least two claims for one of the chronic condition categories that were incurred within 180 days of each other and paid within the last 39 months. Paid per claimant and Paid PMPM rates are for those members in each chronic condition category for the most current reporting period. Costs include the total claimant cost and are not limited to the cost of the chronic condition. This report includes medical and pharmacy claims where applicable. Claimants and their claim spend can be counted in more than one chronic condition category in this report. CAD: Coronary Artery Disease; CHF: Chronic Heart Failure.
Per the American Heart Association, three of the seven key health factors that increase the risks for heart disease and stroke include: High Blood Pressure (Hypertension), High Cholesterol (Hyperlipidemia) and High Blood Glucose (Diabetes). The below chart and bar graphs show key metrics for THE TEXAS A&M UNIVERSITY SYSTEM - GPD GPD03TAMU: ALL for five types of chronic conditions* along with comparative data for members who did not have any known type of chronic condition.
Adult Chronic Conditions Analysis
Proprietary and Confidential Information of Blue Cross and Blue Shield of Texas. Not for use or disclosure outside of BCBSTX or employer, except with written permission of BCBSTX.
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