Description: Direct Primary Care (DPC) is a newer model of primary care delivery in which patients or employers pay for care directly on a membership basis; insurance and other third-party payment is not used. Early studies show significantly improved patient health outcomes and lower expenditures for DPC patients compared with similar patients receiving traditionally delivered primary care. Additional research is needed to better understand physician perspectives about the model and the role of patient selection in early results.In this session we discuss research projects that may shed light on the DPC model and on whether early results indicate more about the model or about the patients who use it.We discuss an SoA research project that interviews DPC physicians to better understand their views about the model and its early results. We also discuss a paper that analyzes characteristics of patients who receive primary care from a DPC physician and compares them to characteristics of patients who receive primary care in more traditional ways. This cross-sectional study surveys all adult patients of a convenience sample of several DPC practices. Variables include demographics, socio-economic status (SES), type of additional coverage (if any), whether DPC fees are paid by an employer, and self-reported health status. The Medical Expenditure Panel Survey is the main source of comparison data. For a given cohort of demographics and additional coverage, we determine whether DPC patients have similar health status, demographics and SES as non-DPC patients. This study will provide insight into the degree of selection into DPC by observable patient characteristics.

Description: The last three decades have witnessed an important rise in number of people with diabetes in Asia, especially Type 2 Diabetes. Like no other common condition, numerous innovations are currently entering the healthcare system that will soon have a significant impact on management of the condition. This presentation explores the role played by sensors/wearables, artificial intelligence, new drugs and diabetes apps. We assess the realistic potential of such advancements and give an outlook on medium-term pricing and product development.

Description: This session will explore the national landscape of state Medicaid risk adjustment program design & application and the key differences that drive effective managed care organization program management. Risk adjustment is a mechanism to adjust capitation rates between Managed Care Organizations to account for population morbidity differences. Although many states utilize this mechanism, the application of risk adjustment can vary significantly across states. The primary differences include populations, risk score models and data collection. These state application nuances affect the strategies and tactics utilized by MCOs for effective risk adjustment program management including provider financial alignment, encounter data submission and the capture of accurate diagnosis codes. The session is intended for Medicaid Managed Care Actuaries working to develop or support comprehensive risk adjustment program management functions.

Description: In Medicaid rate development, actuaries have not historically shared models that developed the margin (i.e., underwriting gain) assumption. This is unfortunate, given the margin assumption is one of the most critical components of the rate development in ensuring financial solvency of the Medicaid managed care organizations (MCOs). In this session, we will discuss the primary components of the this assumption and will share working models that help actuaries quantify these components—including the cost of capital and risk (or contingency) margin. We expect a lively discussion as we “open the black box” and discuss these actuarial assumptions in the public for the first time.

Description: The interplay between technology and design to create safe, comfortable and thriving environments for aging in place and managing care costs.

Description: The advent of machine learning algorithms has taken predictive analytics and risk scoring to a new level. From gradient boosting machines to k-nearest neighbors regression, the use of these techniques has gained significant traction in healthcare - including health systems like the Cleveland Clinic. This session will discuss the use of predictive analytics to go beyond just assessing the risk of a patient, and instead focus on prescribing a specific intervention of care. In practice, the recommendation of a care plan goes beyond just attributing a score to a patient. It provides physicians and care coordinators the most probabilistic options - e.g. referral to social worker, depression screening, weight-loss program - for positively impacting a patient's future healthcare outcome.

Description: In late 2018, the Society of Actuaries held a long-term care medical symposium. This meeting assembled a small group of medical experts to discuss the key medical issues facing the aging population with a focus on their impact on long-term care insurance. This session will provide an overview of the symposium, key outcomes and next steps for future updates.

Description: While there are many approaches currently being taken to transform health care, to be successful, we know that leading and planning for quality improvement is a science. Data is the common denominator as healthcare organizations establish best-practices, and ultimately overcome unintended variation through strong analytic systems. Health care leaders require specialized data analysis education and training to hone their skills in understanding and managing clinical variation. The problem with unexplained variation in healthcare is that it negatively impacts clinical outcomes, increases the cost of care, and diminishes value for patients. In this session, Dr. Ted James (BIDMC and Harvard Medical School Faculty) will explain how actuaries can offer practical solutions that provide insights into variations in clinical practice that cannot be explained by differences in medical conditions or patient preferences.

Description: In the current value-based care marketplace, there are various reimbursement models that tie payments for care delivery to the quality of the care provided. The purpose is clear – change reimbursement to focus on value by rewarding better outcomes and lower spending. However, implementation it is complex, and many challenges emerge during this transition for both providers and payers.Providers often lack sophisticated actuarial capabilities or clear understanding of the connection between finance and clinical operations. For these reasons, they enter risk arrangements without knowing how to strategically manage and mitigate risks and fully transfer the reimbursement changes into clinical decisions. For payers, a truly viable value-based payment model that rewards the most valuable providers needs a multidisciplinary approach and a solid financial model. Such a model also requires transparency and a clear transitional road map for providers to encourage participation and collaboration. In this session, we will discuss lessons learned through case studies of working with both providers and payers on value-based care issues. We will illustrate the current state of the complex financial structures by presenting examples of value-based financial models, feasibility analyses, and strategies to design a payment model beneficial to both providers and payers. We will also explore the clinical collaboration necessary to make it all work, as well as present some best practice strategies to facilitate strong payer-provider collaboration.

Description: One of the Health Section's key focuses in 2019 is Initiative 18/11. Last year the SOA joined forces with the Kaiser Family Foundation (KFF) and the Healthcare Financial Management Association (HFMA) to answer the nagging question: “What can we do about the cost of healthcare?” A steering group has been formed to lead a research project as to what managed care companies can do to reduce costs without sacrificing quality. The project [called Managed Care 3.0 in the 18/11 paper] will examine historical models that have worked as well as investigate the impact that new technologies and care models may have on cost and quality, with the goal of better understanding the current environment and identify­ing potential risks and opportunities.