Description: Discussion of direct primary care and how it helps with several challenges in health care today. DPC improves care coordination, improves outcomes, improves doctor and patient satisfaction, and reduces spending. DPC successes promote the view that primary care should not be covered by insurance; rather, it should be paid for directly.

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: Methods and assumptions used in the valuation of savings by external care vendors

Description: This session will explore the national landscape of state Medicaid risk adjustment program design & application and the key differences that drive effective managed care organization program management. Risk adjustment is a mechanism to adjust capitation rates between Managed Care Organizations to account for population morbidity differences. Although many states utilize this mechanism, the application of risk adjustment can vary significantly across states. The primary differences include populations, risk score models and data collection. These state application nuances affect the strategies and tactics utilized by MCOs for effective risk adjustment program management including provider financial alignment, encounter data submission and the capture of accurate diagnosis codes. The session is intended for Medicaid Managed Care Actuaries working to develop or support comprehensive risk adjustment program management functions.

Description: Yi-Ling Lin, FSA, MAAA, FCA, started the SOA’s Predictive Analytics Certificate Program to keep pace with the impact big data and predictive modeling is having on the health care industry

Description: Discussion of how to mature value-based contracts between health insurers and provider organizations to improve population health and financial sustainability. Centers around contract parameter consistency, revenue predictability and risk assessment. Intended audience are health plan and ACO actuaries and leaders. Authors are writing from the provider perspective in value-based contracts.

Description: Essential Health Benefits and Actuarial Value

Description: Affordable Care Act and Payment Reform

Description: The presenters will provide insights into fraud and abuse risk in the health insurance industry, including an examination of traditional and predictive modeling techniques for both prevention and detection. Emphasis will be placed on current and emerging risks. Canadian examples and perspectives will be offered, but the applications for attendees to use in practice are non-nation specific.

Description: A Regulatory Perspective on Rate Review Before and After the Affordable Care Act