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: Using the Health Care Cost Institute (HCCI) database, we examined which characteristics best predict and describe high-cost members.

Description: Transcript of the Q&A period from Session 6B: Health Status and its Impact on Mortality

Description: This is a final report to help individual health plans evaluate and manage their potential exposure during a specific pandemic. It examines the potential impact of pandemic influenza on different payers in the U.S. health care system.

Description: Article reviews the data a year into the unwinding of continuous coverage provisions in Medicaid, the impact on enrollment counts, how capitation rates have been adjusted, and compares those results to what has been modeled with the SOA Mediciad Unwinding model.

Description: Appendixes for the Evaluating ACO Efficiency: Risk Adjustment within Episodes study. The study aims to answer the question of how much of an episode’s cost and use of specific services can be attributed to the patient’s own health status, as opposed to being driven by other factors such as the care setting, patient preference, and provider practice patterns. In other words, do episode costs vary so widely because of patient characteristics, including health status, or are they related to other, nonclinical factors?

Description: Using the Health Care Cost Institute (HCCI) database, we examined which characteristics best predict and describe high-cost members.

Description: This article begins with a comparison of the commercial risk adjuster to the exisiting Medicare model, and goes on to discuss why the existing strategies employed by health plans will not work in a risk adjusted environment. The article elaborates on the importance of diagnosis coding, controlling member mix, and care management in order to mitigate risks and gain from newly created opportunities.

Description: Chapter 2 reviews previous research in the area of health risk assessment. From A Comparative Analysis of Methods of Health Risk Assessment, M-HB96-1.

Description: The author discusses the Genetic Information Nondiscrimination Act of 2008 GINA and its ultimate effect on the long-term care industry in general, and on current and future insureds, specifically.