Description: Gain a clearer understanding as a provider and a payer discuss the insights gained from being involved in value-based care. Learn about the payer's perspectives on how to develop a value-based contract, the negotiation process and the support they provide the provider. Discover the provider's perspectives on how value-based contracts have impacted them, the analytics they are developing and the collaboration with the payer.

Description: The use of Risk Adjustment in Medicare Advantage (MA) has come under scrutiny due in part to a higher rate of increase of costs of its participating Health plans relative to traditional Medicare despite statutory requirements that reimbursement for these two programs must be actuarially equivalent.

Description: This report is presented in the form of a Tableau dashboard and is the sixth public release from this report series and contains the results of an excess mortality analysis for the fourth quarter of 2021. Data from 30 companies representing approximately 69% of the industry’s face amount inforce were included in the analyses in this report. A total of 3.2 million death claims from individual life policies from 2015 through December 31, 2021 make up the basis of the analyses. The report also compares the experience under COVID-19 of the insured population versus the general population.

Description: Numerous behavioral finance theories have emerged in recent years, many of which apply to insurance. The presenters look at key theories and their use in explaining, predicting and inducing behavior from the perspective of the health insurance customer journey.

Description: Update on Health Section research projects and topics, including health care reform, complexity science, and strategic planning.

Description: Read the December 2019 issue of Health Watch, published by the Health Section. Practical information for actuaries, articles impact sections, section activities.

Description: Any prudent organization that is obligated to cover health claims will consider the risk that those medical claims vastly exceed expectations. This is true for an employer self-funding employee health benefits, a health system contracted with two-way risk (e.g., Accountable Care Organizations ACOs), and a small or mid-sized health insurance company. Without protection, these risk bearers can incur ruinous losses. Interestingly, the forms of insurance sold to cover such large medical claims, although quite similar, sometimes go by different names depending upon the buyer. • Employer Stop-loss (ESL): self-funded employers who want protection against large unanticipated claims • Provider Excess (PXS): at-risk health systems who have taken delegated risk from a public or private payer and desire protection against large unanticipated claims • Medical Excess/HMO Reinsurance (HMO Re): health insurers (including HMOs) who desire protection against large unanticipated claims The concepts we discuss in this article apply to all three categories of large claim risk.

Description: When designing and pricing a healthcare product, it is not only important to know how to model frequency and severity, but it is essential to understand human behavior. Of course, the issue of anti-selection in medical insurance is well known as individuals know more about their health and prior expenditures than an insurer does. This type of behavior is certainly rational, and to be expected.

Description: Inspired by other financial savings products available to Canadians, this article describes a potential solution for financing future health expenses with the creation of a Registered Health Savings Account (RHSA). This solution has been thought on the basis of four premises : 1- Individual Accountability for Health Expenses; 2- Early Savings Leads to More Accumulation; 3-PreferredTax Treatment for Personal Health Savings; 4- Complementing current public and private health systems; Main elements of the RHSA are described (Contributions, Accumulation, Utilization of account, Management by financial institutions).RHSA'S expected balances and some other results under three scenarios (a person in good health, one in poor health, and one with unexpected death at age 45) are summarized in a table. Health expenses deducted yearly from RHSA's balance were estimated using total, per capita, provincial government health expenditures by age-band for Canada, in 2020, from the Canadian Institute of Heath Information’s (CIHI), which account for 71.8% of total expenditures, that is public + private. Thus 28.2% of total expenditures were used for private health expenditures, then forecasted to 2024 and projected using a 4% annual trend. Some objections to the solution explored were anticipated as well as some refutations to these objections.

Description: CMS has pioneered innovative strategies for Medicare and Medicaid to address Social Determinants of Health (SDOH). Employers can learn from these models to implement similar approaches for their employee populations. Learn how employers can understand and address SDOH, the incentives for doing so, and the broader benefits.