Description: This is one of a series of SOA-sponsored papers on the subject of Evaluating the Results of Care Management Interventions. This paper addresses the theory of measurement design and provides a practical evaluation of the most common designs for the practitioner.

Description: The article provides insights about the need for revolutionary actuaries in Saudi Arabia due to the reform that is happening across the kingdom under all sectors. Then I talk briefly about the health sector and the transformation that is happing in the sector, and how qualified health actuaries can contribute to this health reform.

Description: Answers to questions that have surfaced with regard to recent trends in the use of psychiatric medications, including relative effectiveness compared to prescribing patterns, drivers of prescribing patterns, classification and indications for recently publicized drugs, role of primary care providers, preventive use ofdementia medications, and new developments in the field.

Description: This article provides an overview of behavioral economic theory as it relates to health and welfare insurance plans and provides summaries of two sample applications of the theories: enrollment in health insurance exchanges created by the Patient Protection and Affordable Care Act, and product design considerations in light of vast health illiteracy.

Description: Discussion and Opinion on how randomness affects measurement of provider contracting risk-sharing agreements

Description: In the evolving realm of healthcare actuarial practice, value-based contracts are reshaping the landscape. This article explores the pivotal role of AI-enhanced Electronic Medical Records (EMRs) in empowering actuaries to navigate this dynamic sector. Despite challenges in data standardization, AI-enhanced EMRs offer a solution by extracting and standardizing diverse medical records. The article delineates how AI-EMR integration benefits actuaries and provider organizations, enabling more accurate forecasting, earlier shared savings prepayments, and real-time quality metric aggregation. Moreover, it discusses how this fusion addresses historical data limitations, can help project catastrophic claims, and can help identify risk score capture opportunities. Ultimately, it indicates the transformative potential of AI-EMR synergy, positioning actuaries at the forefront of healthcare analytics with unprecedented precision and insight.

Description: Coverage of Medicaid home and community-based services under the 1915(i) state plan option: Attractive features and important considerations

Description: Since health care reform has made accountable care organizations a hot topic, an SOA workgroup is addressing relevant questions, including provider risk under various ACO models, limitations of the Medicare model for motivating change in the health care delivery system, strategic priorities, attribution of members, meaurement, and the roles actuaries can play.

Description: On average, contracts receiving their first star rating receive 3.20 stars, compared to existing or established contracts receiving 3.90 stars on average. This 0.70 disparity in quality ratings creates significant hardship on new contracts when this lower star rating decreases their payments in the following calendar year. This article explores the disparity in Medicare Advantage Star Ratings between contracts receiving their first star ratings (“New” contracts) and existing contracts, including: 1. Understanding what happens to Medicare Advantage Payments when contracts receive lower star ratings? – What is the Star Rating cliff and why does it matter to new contracts? 2. Explaining when a contract receives their first star rating and how much enrollment this requires – When does the Star Rating cliff occur? 3. Noting which specific star measures “New” contracts struggle with, including those contracts under large parent organizations, contracts with rapid growth, and all other new contracts. – How can my contract avoid the Star Rating cliff?

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.