Description: As actuaries in health care, we spend most of our time focused on reviewing claims, enrollment and clinical data. That information is captured while patients are in health care facilities. Yet most people spend only a small fraction of their time in these facilities. This article explores what types of data are available to actuaries the provide a more holistic view of the member so that a members physical and emotional needs, the social determinants of health can be taken into consideration along with their clinical needs. Two uses cases are presented so actuaries can see how these types of analyses can be leveraged to improve clinical, operational, and financial performance of risk bearing health entities. Understanding the customer (member) not just the patient enables actuaries to provide new insights and values to our stakeholders across a wide range of business and risk applications.

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: The article describes the insurance industry's preparation for pandemic events and the public finance response.

Description: Identifying and submitting all appropriate ICD-9 diagnosis codes to CMS will result in a higher risk score for the member and increased payments to Medicare Advantage plans. Milliman's HCC prevalence study illustrates the significant variations in HCC prevalence rates by age/gender, geography, and population type and will assist plans in benchmarking the effectiveness of their own diagnosis code capture efforts.

Description: The CMS Risk adjustment model allows actuaries to apply our analytical skills and business knowledge to solve risk and revenue challenges within Health Plans.

Description: Highlights of two 2018 health events organized by the Colombian Association of Actuaries and sponsored by the Colombian Government. Seminar on Risk Adjustment and Predictive Modeling in Health. Seminar on Risk Management for the Health Insurers

Description: This article is illustrates the implications of the managed care organization MCO risk based capital RBC formula adopted by NAIC and compares it to the health organization risk based capital HORBC formula. From The Actuary, Nov 1997, Vol. 31, Issue 9