Description: This session explores the far-reaching changes to how clinical data will be sourced, processed and consumed in many payer use cases including risk adjustment, quality measurement, care management, claims adjudication, prior authorizations, and other payer functions. Robust, interoperable data exchange is a prerequisite for value-based care. Clinical data will be increasingly accessible to augment administrative (claims) data via standardized Fast Health Interoperability Resources (FHIR, pronounced 'fire'), at a fraction of the cost of a accessing a traditional medical record and in real-time. On May 1, 2020, HHS issued a final rule implementing interoperability and the patient access provisions of the 21st Century Cures Act of 2016, although enforcement has been delayed into 2021 because of the COVID-19 pandemic. The new regulations promote, “HHS’s vision and strategy for achieving a health information ecosystem within which all individuals, their personal representatives, their health care providers, and their payers are able to send, receive, find, and use electronic health information in a manner that is appropriate, secure, timely, and reliable to support the health and wellness of individuals through informed, shared decision-making, as well as to support consumer choice of payers and providers.”Once enforcement begins, CMS and the Office of the National Coordinator for Health Information Technology (ONC), have the authority to mandate adoption of interoperability requirements, and also penalize payers and providers for non-compliance or the delay and withholding of data.This ‘digital transformation’ of the clinical data ecosystem has far-reaching implications for enabling technologies including Natural Language Processing (NLP) and entire segments of services and vendors. It will eliminate many departmental barriers, duplication and error sources for health plans and impact every department and the underlying economics of delivering and managing care.

Description: Summary of results of a 2010 Health Section survey of actuaries and Medicare population, on ways to bend the cost trend curve downward. Issues included transparency, quality measures, fraud and abuse, provider payment, malpractice, medical errors, consumer education, and the pros and cons of employer-sponsored coverage.

Description: A preview of the contents of the latest issue, including essays & interviews related to health care reform, provider reimbursements, rate filing review, and medical errors.

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: This session discussion is about under 25 life group medical reform, model bills, state variations, congressional proposal, community rate implications, effect of RBRVS on provider fees and plan cost. From Record of Society of Actuaries Vol. 17, No. 4A.

Description: This is a discussion of the medical loss ratio, the confusion and debate over the calculation method under the new MLR requirement, and the opportunities it presents to consulting actuaries.

Description: Reviews the book, HMOs and the Politics of Health System Reform, by Joseph Falkson which discusses HMOs' legislative and regulatory structuring.

Description: Part II of a two-part series discussing individual market evolution from before the ACA through President Trump's first term.

Description: Feature article discussing actuaries’ view of the perfect health care reform package with an emphasis on funding/financing. Part 4 of a 4-part series.

Description: A review of the 2009 Health Spring Meeting, which included speakers & sessions on the future of the SOA, U.S. health care reform, claims data issues & improvements, predictive modeling, underwriting principles, employer stoploss, cost trends, LTD & disability, and mental health parity regulations.