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: Presented at April 1985 Spring Meeting. Addresses questions being asked about the future of health care financing: 1. Will the traditional insurer-based program be the predominant financing mechanism in the future? 2. Will Preferred Provider Organizations, Health Maintenance Organizations or other mechanisms displace current approaches? What additional institutions will enter this field? 3. What major factors will determine the outcome?

Description: Presented at June 1986 Spring Meeting. This session discussion is about the status of state and federal regulations regarding the development of PPOs and other alternate delivery systems and anti-trust laws affecting PPO development.

Description: Presented at October 1986 Annual Meeting. This session discussion is about joint ventures between Health Maintenance Organizations 'HMOs' and insurance companies, dual or triple option rating strategies, how these ventures are structured from a financial standpoint, and how separate organizational objectives are met.

Description: Summary of testimony by an AAA Board member before a congressional subcommittee, as an expert on risk assessment and adjustment, especially in relation to Medicare risk contracting and HMO payments. She recommended: mitigating the geographical region values, credibility weights for payments to health plans, carving out high cost claim segments, reengineering the ACR methodology, shifting AAPCC methodology from fee-for-service toward competitive bidding, and further projects to improve risk methods.

Description: The traditional informal care of/by family has faced increasing geographic and economic challenges from changing family households and sources of family income. Financial planning and risk protection tools provide important resource in the changing retirement landscape toward optimal family support and crisis management, that is, with less duress and financial burden to affected family caregivers. Ultimately, maintaining family values and close communications through evolving family structures are key to a healthy society and economic welfare of the people.

Description: The International Actuarial Association Health Section, the Society of Actuaries International Section, and American Academy of Actuaries (AAA) published the report “International Health Care Funding 2020”. This article highlights the features of the report.

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: 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: US pharmacy prices have entered a new era of growth driven by Specialty medications. A bevy of state and national regulations have been proposed to address pharmacy pricing, industry structure and transparency.Health actuaries will learn about US pharmacy pricing structure and how proposed legislation could affect future costs. Actuaries that have responsibility for pharmacy rate/budget setting, RFPs or trend projection will benefit from a deeper understanding of the US pharmacy market landscape and gain an international perspective.