Description: Can Direct-to-Provider Contracting Achieve Value-Based Care for Employer-Sponsored Plans? Direct-to-provider contracting is a strategy in which a self-insured entity negotiates a contract directly with a provider of healthcare services rather than through a third-party administrator (TPA), often with the goal of driving value-based care. This article discusses the considerations for employers and providers with direct-to-provider contracting.

Description: What can the United States learn from other countries' health care systems? How are other countries more efficient? We selected five countries that have been among those debated as having some of the most efficient health care systems to explore what the United States can learn from these examples.

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: Health insurance company assets and liabilities have evolved since the Patient Protection and Affordable Care Act (ACA) was signed into law in March 2010. The ACA fundamentally rearranged how commercial health insurance is funded by integrating federal premium subsidies and pass-throughs together with a marketplace interwoven with transfer payments among stakeholders. The impacts of these programs can be seen in specific accounting items on the balance sheets of health insurance companies over the past 10 years. Their emergence follows three primary trends: (1) balance sheet items tend to be larger and take longer to settle, (2) there are more interactions among items, and (3) the final settlement amounts are more uncertain.

Description: Discusses challenges faced by the people living in the remote town of Brewster, Nebraska.

Description: This article is intended to inform readers about the current state of mental health and health care in the US, as were it's heading moving forward.

Description: Two years ago, before COVID-19 changed everything about how we provide and receive health care, telehealth was largely provided by third-party vendors to treat a narrow range of acute one-and-done conditions. The value proposition was simple: a fast and easy member experience would drive satisfaction and engagement; high member satisfaction and engagement would drive health plan savings and member retention. Clearly, from the perspective of utilization, telehealth—as a viable alternative to in-person care during a pandemic—worked. And with COVID-19’s nudge—or was that a push?—toward cultural acceptance, the health care system is in a better position to capitalize on telehealth’s original promise of expanded access, lower cost and better outcomes than it was two years ago. But in the wake of the pandemic, it is just as clear to us that if telehealth is to live up to its full potential, some changes are needed. The rest of this article presents five ideas for improving the delivery of telehealth going forward.

Description: Blockchain technology has the potential to significantly improve the quality of life and overall health of the members of a health system, while also adding to administrative efficiencies. For the first time, we will have access to members’ entire diagnoses and prescription history, consumer behavioral attributes, and other socio-economic determinants which that are valuable inputs to designing appropriate benefits and proper care management plans. Through the blockchain, we will be able to access data not just of the existing members of the health system but also of potential enrollees and new entrants. The data can be accessed by querying the blockchain through a permissioned granted by the member. This information can be very useful in performing feasibility studies for evaluating entry into newer markets and/or newer products, developing customized care plans, and designing efficient value-based contracts. By executing smart contracts on the blockchain, we will be able to achieve administrative efficiencies like never before. The applications of blockchain technology are numerous and ground-breaking. Organizations that do not pay heed to the benefits that blockchain can bring may find themselves left behind as the rest of the industry marches forward in its quest for efficiency and member satisfaction.

Description: The coming wave of biosimilars could dramatically affect prescription drug costs and benefit strategies over the next several years. The launch of many Humira biosimilars in 2023 is the Big Event that will largely determine the impact of the biosimilar wave. Payers have many decisions to make about coverage and formulary tiers. What factors will drive payer decision-making?

Description: Read the November 26 2019 issue of Health Watch, published by the Health Section. Practical information for actuaries, articles impact sections, section activities.