Description: With the mandated health plan transparency files, health plans and providers are now able to substantially enhance their provider contracting efforts. Although the files are large and cumbersome they are market disruptors and provide new insights for provider contracting efforts. Explore a demonstration on the type of information now available and how it can be used to enhance this from both a health plan and health care provider perspective.

Description: In this report, we explore the impact of clustering using the Medical Expenditure Panel Study (MEPS) data for children (aged 5 to 17) to build a bridge between oral health and overall health using dental and medical expenditures. We include social determinants of health as cluster input variables using the Partitioning around Medoids (PAM) method to identify children and their families who could potentially benefit from population health management related to oral health.

Description: This article summarizes what is new with the Academy health practice council. Issue No. 59

Description: The evolving specialty pharmacy environment has created difficulties for actuaries pricing and forecasting pharmacy coverage. Unpredictable specialty pharmacy trends have increased insurers' earnings volatility and affected members' health care affordability. The presenters will highlight the current specialty drug development pipeline and explore specialty pharmacy drug trend management strategies. They will also provide concepts to help manage the coming wave of gene and cell therapies.

Description: This is a series of 4 articles designed to address fundamental concepts such as GAAP rules and their application to some of the major accident and health lines of business offered by insurers. The first article begins with a review of the structure/hierarchy of generally accepted accounting principles GAAP. From Society of Actuaries Financial Reporting Monograph, M-AS99-1.

Description: This session series is sponsored by Zelis Claim analytics produces valuable insights about provider cost, quality, and referral patterns. Provider networks can be created around high-value providers to improve clinical outcomes while lowering the cost of care. Programs to improve provider performance and/or incentivize members to choose high-value providers exist, but how do you bring all of this together to achieve desired outcomes? Join us to learn how to leverage provider level analytics to build and optimize a network with high-value providers at the center. Analyze the network for competitiveness and adequacy and demonstrate progress toward network cost saving goals to key stakeholders by modeling claim data for a member population. Finally, ensure the success of your network through an incentive program that shifts utilization to those high performing providers. By attending this session, you will be able to: - Build a realistic provider network with high-value providers at the center. - Evaluate the overall financial impact of network build and optimization efforts. - Learn about an innovative member incentive program.

Description: This research project offers guidance and a model for actuaries to use when performing their professional services related to Medicaid (Title XIX) and Children’s Health Insurance Program (CHIP or Title XXI) managed care capitation rate setting, including, but not limited to, their certification on behalf of a state in accordance with the requirements for actuarial soundness as set forth in law, federal regulation, and CMS guidance, as well as the actuary’s professional obligations under the Actuarial Standard of Practice (ASOP) 49 issued by the Actuarial Standards Board.

Description: Cover a variety of topics centered around the unsupervised learning technique called 'clustering'. The presenters will take you through a wide array of topics that range from 'What is Clustering?' to 'How can I use this technique to solve problems I didn't even know existed?' In the health care industry, everyone is looking for an edge in reducing total spend-cluster analysis finds the unambiguous in an ambiguous framework of results.

Description: This research project offers guidance and a model for actuaries to use when performing their professional services related to Medicaid (Title XIX) and Children’s Health Insurance Program (CHIP or Title XXI) managed care capitation rate setting, including, but not limited to, their certification on behalf of a state in accordance with the requirements for actuarial soundness as set forth in law, federal regulation, and CMS guidance, as well as the actuary’s professional obligations under the Actuarial Standard of Practice (ASOP) 49 issued by the Actuarial Standards Board.