Description: This chapter focuses on creating practical models that aid in the prediction of the risk of readmission to a specific hospital within 30 days of discharge for Medicare patients, to aid in the identification and stratification of at-risk patients for hospitals considering building an intervention program in a cost-effective manner. For readers who wish to develop their own predictive model, a dataset is provided on the Actexmadriver.com website, and R code is provided in the appendix to this chapter.

Description: The article explores how integrating AI into insurer apps can address critical challenges in healthcare, such as patient no-shows, medication adherence, and cost management. These non-disruptive approaches aim to increase the effectiveness of patient interventions and improve medication adherence.

Description: ReMark's Global Consumer Study delivers 10 key insights to empower customers. Insurers can design products that meet customers' needs and enhance client experiences and add significant value to their business. At the same time with new products being launched seemingly continuously, it is important to take a step back and assess risk throughout the product management cycle.

Description: 2003 Valuation Actuary Symposium, San Diego, CA. The panel discussed the current challenges in the health reinsurance marketplace. Topics included traditional quota share reinsurance, employer and provider stop-loss coverage, difficulties in obtaining reliable and credible data from a ceding carrier and terrorism reinsurance.

Description: 1994 SOA Meeting, San Antonio. This session on physician reimbursements focused on arrangements that might be offered by managed care companies, such as HMOs. It included an overview of key definitions, concepts, and incentive compensation arrangements.

Description: Discover the key components of value-based care (VBC) contracts and their impact on provider credibility. Learn about benchmarks, measurement period results, and the unique challenges providers face in managing insurance risk. Gain insights into reducing costs and aligning financial incentives in the US healthcare market.

Description: 1994 SOA Meeting, San Antonio. This session was about provider network building in nonmetropolitan areas. Question addressed: 1. How can an effective delivery system be built to serve rural areas? 2. What influence will health care reform have on such systems? 3. Does a single-payer system make sense for such populations? 4. How does health care reform impact nonmetropolitan markets?

Description: Actuaries are leveraging predictive modeling and machine learning more and more as they strive to provide greater value to their stakeholders. Actuarial standards of practice provide guidance around modeling and data. The world has changed significantly over the last few years, so it is important these models be tested for fairness as well as any statistical biases. This article addresses some of the key issues actuaries need to be aware of as Corporations and society work through the responsible us of this technology and underlying data.

Description: On average, contracts receiving their first star rating receive 3.20 stars, compared to existing or established contracts receiving 3.90 stars on average. This 0.70 disparity in quality ratings creates significant hardship on new contracts when this lower star rating decreases their payments in the following calendar year. This article explores the disparity in Medicare Advantage Star Ratings between contracts receiving their first star ratings (“New” contracts) and existing contracts, including: 1. Understanding what happens to Medicare Advantage Payments when contracts receive lower star ratings? – What is the Star Rating cliff and why does it matter to new contracts? 2. Explaining when a contract receives their first star rating and how much enrollment this requires – When does the Star Rating cliff occur? 3. Noting which specific star measures “New” contracts struggle with, including those contracts under large parent organizations, contracts with rapid growth, and all other new contracts. – How can my contract avoid the Star Rating cliff?

Description: Methods and assumptions used in the valuation of savings by external care vendors