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: Actuaries are leveraging predictive modeling and machine learning more and more as they strive to provide greater value to their stakeholders. Actuarial standards of practice provide guidance around modeling and data. The world has changed significantly over the last few years, so it is important these models be tested for fairness as well as any statistical biases. This article addresses some of the key issues actuaries need to be aware of as Corporations and society work through the responsible us of this technology and underlying data.

Description: Response to March 2021 Practice Note on ASOP 6

Description: Chris Smith, vice chair of the Actuary of the Future section, had the privilege of attending the SOA Health meeting in Seattle for the first time this year. Read about his experience and thoughts on why you should plan to attend an SOA-sponsored conference for your career growth.

Description: Critical illness insurance is a popular supplemental health insurance product in the U.S. market. This article discusses how carriers have recently sought to add value by expanded the benefits offered in their critical illness products. Specifically, the article discusses the consumer need and development considerations of adding benefits for autism Spectrum Disorder, Mental health disorders, Specified Disease Coverage, and enhance Cancer Coverage to a critical illness contract.

Description: Social determinants of health (SDoH) have been a topic of growing interest in recent years, yet consensus about what the phrase represents and how health-related social needs should be studied or addressed by employers, health plans, providers and other stakeholders in the business of health care have been lacking. For many, low-income populations come to mind when considering the topic, yet SDoH include a wide range of factors beyond income. Many types of data are available, yet each presents distinct challenges and opportunities for analysis. In this article, we describe some of the underlying context for considering SDoH, as well as some of the potential data sources to consult and challenges to grapple with on this important topic.

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: An overview of key considerations for benefit triggers in critical illness products

Description: This article details the medical stop-loss coverages purchased by HMOs, small insurers and providers taking delegated financial risk in payor agreements. Along the way we will identify strategies purchasers often use to save money on medical stop-loss.

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.