Description: Risk adjustment is used to adjust the revenue stream to health insurers that sell ACA eligible plans and Medicare Advantage plans. This article compares and contrasts these risk adjustment programs.

Description: This article begins with a comparison of the commercial risk adjuster to the exisiting Medicare model, and goes on to discuss why the existing strategies employed by health plans will not work in a risk adjusted environment. The article elaborates on the importance of diagnosis coding, controlling member mix, and care management in order to mitigate risks and gain from newly created opportunities.

Description: This article will consider several issues arising from ACO budgeting and pricing of stoploss coverage, including: 1) attribution of members; 2) claim carve outs; 3) ambiguous stoploss terms; 4) providers gaming the system and 5) credibility of data.

Description: An economic analysis of bariatric surgery and health care costs supports the case for health plans to cover these procedures.

Description: Health care predictive analytics varies between payers and providers as well as being a powerful tool in business decision modeling.

Description: Introduction to additional actuarial research into development of and regulatory impact, economic impact and consumer impact of prescription drugs in the United States. Intended to further educate actuaries and others who work in this area and motivate more actuarial involvement to increase transparency, increase competition, better align stakeholder incentives and better mitigate total cost of care increases

Description: Social determinants of health (SDoH) have been a topic of growing interest in recent years, yet consensus about what the phrase represents and how health-related social needs should be studied or addressed by employers, health plans, providers and other stakeholders in the business of health care have been lacking. For many, low-income populations come to mind when considering the topic, yet SDoH include a wide range of factors beyond income. Many types of data are available, yet each presents distinct challenges and opportunities for analysis. In this article, we describe some of the underlying context for considering SDoH, as well as some of the potential data sources to consult and challenges to grapple with on this important topic.

Description: In this interview Dr. Reinhardt shares his thoughts on the role he believes actuaries should take in the health care system reforms.

Description: A discussion of permissible use and collection of genetic information for Health Risk Assessments and wellness programs under the Genetic Information Nondiscrimination Act of 2008.

Description: We propose using premiums and tax revenue to fund high-cost individuals in the Individual ACA market.