Description: The U.S. health care industry has gone through a dramatic change during the past several years. The business model has moved from a risk selection model to a risk management model. People can shop online for their health care coverage. Everyone is welcome! Annual and lifetime dollar limits, underwriting and the pre-existing conditions exclusion are all in the history book now. Facing the challenges of the post-reform era, many health insurance carriers began using big data analytics on all aspects of their decision-making processes. The goal is to be able to compete on analytics in this quickly changing environment. However, becoming an analytics competitor is not easy. It requires the belief from the leadership and a group of dedicated analytical professionals to solve emergent business problems that existing strategies cannot address in an evolving market. These problems include marketing for acquisition and retention, coding accuracy, revenue growth, health care disparity, payment integrity, quality of care, health care cost reduction and, ultimately, personalized care management. In this section, audience will learn a basic understanding of the role of predictive analytics in US Healthcare marketplace.

Description: MACRA not only impact providers, it will impact the entire healthcare market. MACRA published studies and commentary to date have primarily focused on providers, with the majority of the information addressing the impacts to clinicians. However, our investigation indicates MACRA has far reaching impacts to payers as well as providers. MACRA is impacting each geographic market and line of business in a unique way, and health payers will have multiple strategic decisions to consider given the changing market dynamics.

Description: Companies with the intention of being the top, trusted source(s) in an information overloaded world.

Description: Read the October 2019 issues of Health Watch, published by the Health Section. Practical information for actuaries, articles impact sections, section activities. This is the second digital-only issue of the newsletter.

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: Bringing managed care concepts into LTC claims management could benefit insurers, policyholders, and providers. This article outlines the case for doing so, and articulates the benefits to each stakeholder in the LTC claims process.

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: This is a case study session where the speakers will describe a project where a major health system converted its provider distinct reimbursement (i.e., separate physician IPA and hospital capitation) to an integrated reimbursement involving global capitation. The session will discuss the strategic issues considered by the parties and how they evaluated them in their decision process. This session will provide attendees an example of how to approach this type of decision.

Description: On December 21, 2018, the Centers of Medicare & Medicaid Services (CMS) released the final rule for Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program. 'Pathways to Success' makes sweeping changes and will push ACOs to assume financial risk more quickly. This session will discuss the key changes in the final rule, reasons why providers would remain in the program while being forced to downside risk, and how actuaries can add value to providers who will be taking on millions of dollars of risk in the coming years.

Description: Read the June 2019 issue of Health Watch, published by the Health Section. Practical information for actuaries, articles impact sections, section activities.