Description: This article is based on a third party administrator study and explores the relationships between family structure, spare capacity and health care utilization.

Description: Read the November 2016 issue of Health Watch published by the Health Section. Newsletters provide practical information for the working actuary, articles on trends that impact sections and news about section activities.

Description: This session is about the details of the inception and implementation of the Oregon Health Plan. From Record of Society of Actuaries Vol. 18, No. 1B.

Description: An actuarial model that provides financial incentives to providers to offer patients an approach that can reverse chronic disease and reduce health care costs

Description: A proposal to address provider payment issues by gradually moving to accountable care organizations. Capitations would be risk-adjusted, non-capitated costs would be covered by hospitalization fund and stoploss, incentives for quality & effective preventive care would be tied to the amount remaining in the fund, and government involvement would be through incentives rather than mandate.

Description: An overview of the issues behind reimbursing providers on a bundled or packaged basis. The article presents the potential advantages offered by the proponents as well as the criticisms and obstacles to implementing this type of payment system.

Description: The medical scheme approach adopted by several African countries has failed to meet the needs of those in informal employment and rural communities. This is partly due to affordability amongst these individuals as well as a lack of awareness of how healthcare financing products work. Community based healthcare organisations have achieved greater levels of success in this regard by carefully incorporating the peculiarities of communities in benefit design and involving community members in the management of these healthcare solutions. There are lessons to be garnered from the countries where these have been implemented with some level of success. Even as countries aim towards universal health coverage, observing the unique needs of different communities within a country is essential to ensure resources are utilised efficiently and that healthcare needs are targeted effectively.

Description: This paper will examine why CSR defunding produces pricing uncertainty and how regulators can alleviate these risks when insurers price 2020 premiums.

Description: Explanation of Medicare Advantage STAR rating program as it relates to payment rates for MA bids. Also describes important features of the program from an actuarial perspective, how the components of the STAR rating are calculated and implications and considerations for actuaries.

Description: A proposal to reform the health care provider payment system through: a national fee schedule, shifting more reimbursements to primary care providers, better integration of hospital & physician fees, evidence based care, pay for performance, and a better provider risk sharing mechanism.