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: 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: 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: This is a review of literature about the development and application of medical risk adjustment models. The current Medicare model, principal inpatient diagnosis cost group [PIPDCG] and proposed enhancements are the subject of many articles. Risk adjustment is used for both provider payment and performance measurement.

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: 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: This dissertation by Tia Sawhney will help you understand this issue and start measuring it, or start promoting equitable public policy.

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.