Description: Any prudent organization that is obligated to cover health claims will consider the risk that those medical claims vastly exceed expectations. This is true for an employer self-funding employee health benefits, a health system contracted with two-way risk (e.g., Accountable Care Organizations ACOs), and a small or mid-sized health insurance company. Without protection, these risk bearers can incur ruinous losses. Interestingly, the forms of insurance sold to cover such large medical claims, although quite similar, sometimes go by different names depending upon the buyer. • Employer Stop-loss (ESL): self-funded employers who want protection against large unanticipated claims • Provider Excess (PXS): at-risk health systems who have taken delegated risk from a public or private payer and desire protection against large unanticipated claims • Medical Excess/HMO Reinsurance (HMO Re): health insurers (including HMOs) who desire protection against large unanticipated claims The concepts we discuss in this article apply to all three categories of large claim risk.

Description: During the past few years, performance, cost, and risk trends for Medigap products have undergone substantial changes. Some of these trends could ease cost pressures on Medigap insurers, while others might increase them. Part 1 of this Issue Brief article discusses current changing trends and considerations around about how they are impacting Medigap.

Description: This article explores the disruptive applications of blockchain, an emerging technology, and its impact on the pharmacy benefit space, and pharmacy benefit managers (PBM).

Description: Discussion and Opinion on how randomness affects measurement of provider contracting risk-sharing agreements

Description: The big event of 2023 is the launch of multiple Humira biosimilars, which began in January with the arrival of Amgen’s Amjevita on the market. The launch of Amjevita kicks off the process of changing the specialty drug marketplace in the United States. The expectation of the full impact of this big event is very hopeful, but there is still uncertainty several months after its beginning. Humira is the highest-selling drug in the world and has been since 2013 (Figure 1)—except for when COVID-19 projects temporarily surpassed it. The world is eagerly awaiting the launch of multiple biosimilar drugs to compete with Humira and hopefully bring more competitive pricing to the benefit of payers and patients everywhere.

Description: Discusses areas health actuaries could expand into. Issue No. 47.

Description: Savings from biosimilars have accelerated significantly in the past few years. There has been a number of relatively recent biosimilar launches that can help to shape our expectations of the financial impact that could result from this year’s big event. Savings from biosimilars have accelerated significantly in the past few years. There has been a number of relatively recent biosimilar launches that can help to shape our expectations of the financial impact that could result from this year’s big event.

Description: In preparing claims reserves in the annual statement, health insurers and their opining actuaries will generally include a provision for adverse deviation (PAD) in their reserved amount in order to satisfy language in both in the National Association of Insurance Commissioners (NAIC) Health Annual Statement Instructions and in Actuarial Standards of Practice. This article explores the total level of PAD (both implicit and explicit margin combined) included in the reported claims reserves by examining NAIC filing data from 2016 through 2022.

Description: Article explores why many integrated delivery systems are struggling and what actions they need to take to succeed.

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