Description: As actuaries in health care, we spend most of our time focused on reviewing claims, enrollment and clinical data. That information is captured while patients are in health care facilities. Yet most people spend only a small fraction of their time in these facilities. This article explores what types of data are available to actuaries the provide a more holistic view of the member so that a members physical and emotional needs, the social determinants of health can be taken into consideration along with their clinical needs. Two uses cases are presented so actuaries can see how these types of analyses can be leveraged to improve clinical, operational, and financial performance of risk bearing health entities. Understanding the customer (member) not just the patient enables actuaries to provide new insights and values to our stakeholders across a wide range of business and risk applications.

Description: Savings from biosimilars have accelerated significantly in the past few years. There has been a number of relatively recent biosimilar launches that can help to shape our expectations of the financial impact that could result from this year’s big event. Savings from biosimilars have accelerated significantly in the past few years. There has been a number of relatively recent biosimilar launches that can help to shape our expectations of the financial impact that could result from this year’s big event.

Description: ACA risk adjustment is intended to "bridge the gap" between allowed rates and actuarial rates. If risk adjustment methodology is not bridging that gap & becomes an additional input to pricing formulae, it is not serving its intended purpose.

Description: Actuaries are currently familiar with the impact of new technologies used primarily by clinicians and health care providers, such as new drugs and devices. The common theme emerging from many of the articles points to a technological revolution in health care accelerated by the COVID-19 crisis this year. Actuaries need to understand these technologies, their impact, learn how to drive this technological change and guide the response of their profession and their own health care organizations.

Description: Discussion and Opinion on how randomness affects measurement of provider contracting risk-sharing agreements

Description: There have been a variety of proposals related to expanding eligibility for Medicare, ranging from a publicly funded program to a full buy-in option. This session will explore the actuarial implications of various buy-in proposals and the potential impact that such policy changes could have on the health care market landscape. In particular, we will discuss the ways in which program eligibility requirements, plan designs, provider reimbursement arrangements, network design, rating rules, and subsidies could affect premium levels and membership volume in a Medicare buy-in market, as well as the potential side effects on providers and existing health care markets.

Description: The Triple Aim is a vision to improve the health of populations, create a better quality of life, and reduce per capita spending for the benefit of communities.(http://www.ihi.org/Topics/TripleAim/Pages/default.aspx) While much public attention on wellness has focused on topics such as obesity and smoking, it would be beneficial if greater emphasis was placed on raising the bar of oral health. The mouth plays an important role in overall health and wellness. Routine oral care helps prevent dental problems and appears to positively affect chronic conditions before they develop into complex, more expensive ones. This purpose of this session is to increase awareness of the importance of oral health, the consequences of poor oral health, and the link with socioeconomic characteristics. This session will explore and highlight studies completed in this space by both researchers and payers. Actuaries interested in learning more about the impact of oral health and overall health, relevant interventions that have been undertaken, areas for potential financial savings, and issues relating to public policy applicable to oral health would benefit from attending this session.

Description: The big event of 2023 is the launch of multiple Humira biosimilars, which began in January with the arrival of Amgen’s Amjevita on the market. The launch of Amjevita kicks off the process of changing the specialty drug marketplace in the United States. The expectation of the full impact of this big event is very hopeful, but there is still uncertainty several months after its beginning. Humira is the highest-selling drug in the world and has been since 2013 (Figure 1)—except for when COVID-19 projects temporarily surpassed it. The world is eagerly awaiting the launch of multiple biosimilar drugs to compete with Humira and hopefully bring more competitive pricing to the benefit of payers and patients everywhere.

Description: More and more providers are desiring risk-based contracts instead of traditional FFS-based contracts. This session is intended to outline some of the actuarial best practices in risk-based contracting related to the many flavors of the CMS ACO programs, as well as Commercial risk-based contracts.