Description: The medical scheme approach adopted by several African countries has failed to meet the needs of those in informal employment and rural communities. This is partly due to affordability amongst these individuals as well as a lack of awareness of how healthcare financing products work. Community based healthcare organisations have achieved greater levels of success in this regard by carefully incorporating the peculiarities of communities in benefit design and involving community members in the management of these healthcare solutions. There are lessons to be garnered from the countries where these have been implemented with some level of success. Even as countries aim towards universal health coverage, observing the unique needs of different communities within a country is essential to ensure resources are utilised efficiently and that healthcare needs are targeted effectively.

Description: The ACA’s Medical Loss Ratio Provisions

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: Through the sponsorship of the Robert Wood Johnson Foundation, The Society of Actuaries partnered with Wakely to use their health care data to study the effects of COVID-19 on overall health care claims for individuals with a COVID-19 diagnosis. The conclusion of the study is that individuals with COVID-19 claims had significant increases in health care costs leading up to their months of diagnosis, as well as in the months following their diagnosis. These effects were more pronounced for individuals who were hospitalized due to COVID-19 as well as for individuals with prior co-morbidities. Finally, the overall health care costs of these members plateaued at significantly higher levels than their pre-COVID baselines. In fact, all the main membership cohorts experienced claim levels that were at least 20% higher than their pre-COVID starting points.

Description: Feature article with helpful hints on video conferencing and more!

Description: Discover the key components of value-based care (VBC) contracts and their impact on provider credibility. Learn about benchmarks, measurement period results, and the unique challenges providers face in managing insurance risk. Gain insights into reducing costs and aligning financial incentives in the US healthcare market.

Description: A compilation of feedback from actuaries in the Health Section of the affects of the ACA.

Description: What is the difference between a Single-Payer and Universal Health Care System, and how could the U.S. implement a system that would reduce the growth of medical costs while increasing quality.

Description: Diagnostic coding in dental is in its infancy. This article explores the use of medical diagnostic coding and how it may transform dental care in various ways.