Description: In the current value-based care marketplace, there are various reimbursement models that tie payments for care delivery to the quality of the care provided. The purpose is clear – change reimbursement to focus on value by rewarding better outcomes and lower spending. However, implementation it is complex, and many challenges emerge during this transition for both providers and payers.Providers often lack sophisticated actuarial capabilities or clear understanding of the connection between finance and clinical operations. For these reasons, they enter risk arrangements without knowing how to strategically manage and mitigate risks and fully transfer the reimbursement changes into clinical decisions. For payers, a truly viable value-based payment model that rewards the most valuable providers needs a multidisciplinary approach and a solid financial model. Such a model also requires transparency and a clear transitional road map for providers to encourage participation and collaboration. In this session, we will discuss lessons learned through case studies of working with both providers and payers on value-based care issues. We will illustrate the current state of the complex financial structures by presenting examples of value-based financial models, feasibility analyses, and strategies to design a payment model beneficial to both providers and payers. We will also explore the clinical collaboration necessary to make it all work, as well as present some best practice strategies to facilitate strong payer-provider collaboration.

Description: A fact sheet about the Long-Term Care (LTC) Experience Study Aggregate Database 2000-2011 Report.

Description: This survey is intended to share insurance company risk management practices and perspectives, so that these stakeholders may have a common understanding when discussing fraud, waste and abuse in LTC insurance claims.

Description: This is the conference report that documents the inaugural event for Initiative 18|11, which was held in Washington, DC, on March 7, 2018. Initiative 18|11 is a joint venture between the Society of Actuaries and the Kaiser Family Foundation. It is focused on determining action steps that can be taken to address the rising cost of health care in the United States.

Description: In May 2019, the Centers for Medicare and Medicaid Services (CMS) released an Informational Bulletin clarifying how payments to subcontracted vendors should be accounted for in the medical loss ratio (MLR) calculation required by 42 CFR §438.8 as established by the Medicaid and Children’s Health Insurance Program managed care final rule published in May 2016. In the bulletin, CMS focuses on the responsibilities of a subcontractor in providing data and the proper accounting of subcontractor payments for purposes of MLR reporting. While the provisions outlined in this bulletin apply to all subcontractor relationships, CMS specifically highlights pharmacy benefit manager arrangements that may include “spread pricing” and rebate retention.

Description: One of the Health Section's key focuses in 2019 is Initiative 18/11. Last year the SOA joined forces with the Kaiser Family Foundation (KFF) and the Healthcare Financial Management Association (HFMA) to answer the nagging question: “What can we do about the cost of healthcare?” A steering group has been formed to lead a research project as to what managed care companies can do to reduce costs without sacrificing quality. The project [called Managed Care 3.0 in the 18/11 paper] will examine historical models that have worked as well as investigate the impact that new technologies and care models may have on cost and quality, with the goal of better understanding the current environment and identify­ing potential risks and opportunities.

Description: View the 2019 Board Member Candidate page for Robert Eaton for the 2019 SOA Elections.

Description: This two part session will review some examples of public and population health initiatives and their economic and business case. It will also talk about the work of the SOA's Public Health Task force and how actuaries can get involved in their communities. We will also provide an update on Social Security

Description: Read the Q&A with an Experienced Insurance Professional New to Long-Term Care: An Interview with Sean Pena.

Description: Column from the chairperson of the Long Term Care Section.