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: The last three decades have witnessed an important rise in number of people with diabetes in Asia, especially Type 2 Diabetes. Like no other common condition, numerous innovations are currently entering the healthcare system that will soon have a significant impact on management of the condition. This presentation explores the role played by sensors/wearables, artificial intelligence, new drugs and diabetes apps. We assess the realistic potential of such advancements and give an outlook on medium-term pricing and product development.

Description: This is a case study session where the speakers will describe a project where a major health system converted its provider distinct reimbursement (i.e., separate physician IPA and hospital capitation) to an integrated reimbursement involving global capitation. The session will discuss the strategic issues considered by the parties and how they evaluated them in their decision process. This session will provide attendees an example of how to approach this type of decision.

Description: In the current value-based care marketplace, there are various reimbursement models that tie payments for care delivery to the quality of the care provided. The purpose is clear – change reimbursement to focus on value by rewarding better outcomes and lower spending. However, implementation it is complex, and many challenges emerge during this transition for both providers and payers.Providers often lack sophisticated actuarial capabilities or clear understanding of the connection between finance and clinical operations. For these reasons, they enter risk arrangements without knowing how to strategically manage and mitigate risks and fully transfer the reimbursement changes into clinical decisions. For payers, a truly viable value-based payment model that rewards the most valuable providers needs a multidisciplinary approach and a solid financial model. Such a model also requires transparency and a clear transitional road map for providers to encourage participation and collaboration. In this session, we will discuss lessons learned through case studies of working with both providers and payers on value-based care issues. We will illustrate the current state of the complex financial structures by presenting examples of value-based financial models, feasibility analyses, and strategies to design a payment model beneficial to both providers and payers. We will also explore the clinical collaboration necessary to make it all work, as well as present some best practice strategies to facilitate strong payer-provider collaboration.

Description: US pharmacy prices have entered a new era of growth driven by Specialty medications. A bevy of state and national regulations have been proposed to address pharmacy pricing, industry structure and transparency.Health actuaries will learn about US pharmacy pricing structure and how proposed legislation could affect future costs. Actuaries that have responsibility for pharmacy rate/budget setting, RFPs or trend projection will benefit from a deeper understanding of the US pharmacy market landscape and gain an international perspective.