Description: This is a regular column highlighting articles of interest to Health Actuaries appearing in the North American Actuarial Journal.

Description: Explanation of Medicare Advantage STAR rating program as it relates to payment rates for MA bids. Also describes important features of the program from an actuarial perspective, how the components of the STAR rating are calculated and implications and considerations for actuaries.

Description: The article is a case study of various actuarial concepts invovled in the design and implementtion of the AQC - a global budget provider payment arrangement implemented by Blue Cross Blue Shield of MA.

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: Review of reimbursement methodologies APGs, APCs, Medicare ASC, discount on charges, commercial hybrid, methods and trends in contracting, impact on trent, benchmarking. Issue No. 44.

Description: A proposal to reform current health care market, from a 'preferred payer' system, in which Medicare and Medicaid pay less than the true cost while others must then pay more, to a 'value for money' system. This would be achieved by requiring providers to bill all patients the same rate for the same services, with a standard bundling format to make all providers' rate differences transparent. Differences between billed charges and what Medicare pays would be made up by the Medicare patient, rather than subsidized by those outside of Medicare.

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 describes the results of three years of work by Blue Shield of California to collaborate with hospitals and physician organizations to reduce cost and improve quality for commercial populations in targeted geographies.

Description: What you need to know about risk scores to be competitive in the Medicare Advantage market.

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