Description: Session 10B: Comprehensive PBM Performance Evaluations Including TCOC Impact

Description: Similar to how states had made adjustments to their capitation rates to reflect acuity adjustments caused by the onset of the pandemic, states will need to modify the rates to reflect the unwinding since utilization patterns and average acuity per enrolled member will change. When the continuous coverage requirements set forth by the COVID-19 Public Health Emergency (PHE) ended, Medicaid-managed care programs across the country adopted various approaches to phasing out maintenance of effort (MOE) as a result of changes to the PHE-era continuous eligibility requirements. Phasing out the MOE requirement will ultimately result in members who no longer meet eligibility requirements losing their Medicaid coverage. Further, states are facing a wide variety of circumstances and are implementing diverse approaches to the MOE phase-out. This topic will be of significant interest to all actuaries and stakeholders of the capitation rate development process for Medicaid-managed care programs. Join us as we discuss the operationalization of the PHE unwind while referencing the SOA's research project which models the effects of the unwinding on Medicaid eligibility and population costs. You will learn about the various approaches that different states have adopted to manage the unwinding process, which will be instrumental for accurately pricing managed care rates.

Description: Dive into a summary focused on the discussion from the Health Section's Pharmacy Partnership Forum in March 2023 entitled 'Reimagining Pharmacy Financing' where a multi-disciplinary group of clinicians, health economists, academics, and actuaries met and discussed the following questions: - How do we define the value of prescription drugs? - How do we measure the value of prescription drugs? - How do we scalably and meaningfully apply the answers?

Description: Discover a comparison of U.S. and international mandated leave programs which mandate employers to provide a minimum level of benefits to employees for qualifying leaves of absence, such as parental leave or medical leave.

Description: How well can we predict ACA HHS Risk Adjustment Data Validation (HRADV) results? Put another way, how susceptible is the current HRADV process to small sample volatility? What potential remedies are there to the current model's shortcomings? Every plan, regardless of how many members they have above the 1000 minimum, count equally if they qualify for an HRADV with how the result is interpreted, and the subsequent HRADV risk transfer ($330M in 2023).

Description: A panel of leading reinsurance executives provide perspective on topics to include cell and gene therapy, structured reinsurance, reinsurance demand for value based care arrangements, and how reinsurers view a variety of risk transfer opportunities.

Description: This session will discuss what is meant by 'bias' and 'fairness', the regulatory environment, how to identify and mitigate bias in models, and proper oversight and governance of model building. The session will include a case study.

Description: Actuaries historically modeled new launches in pharmaceuticals by anticipating the expected change to the market basket. This became more complicated with the recent launches of gene and cell therapies as they address rare diseases. Rare conditions have low total member volume to study and some do not currently have a diagnosis code to identify them within claims data. Addressing this modeling challenge has been growing more important in the recent years with the number of therapies launching. What has the health care industry, and more specifically health care, done to enhance modeling and how should this be altered for the future? Additionally, historic modeling has sometimes incorporated a level of direct medical treatment cost offsets where studies have shown lower treatment costs are achievable. Can gene and cell financial modeling include cost offsets as well? And if so, what are suggested precautions or limitations to this effort?

Description: A panel of leading reinsurance executives will provide an overview of the health reinsurance market that explores existing reinsurance transactions reported under Schedule S, large claim research drawing insight from the latest five-year Merative Commercial MarketScan Research Database, stop-loss reinsurance options for Accountable Care Organizations (ACOs), and other reinsurance applications being seen in the market.

Description: Cover a variety of topics centered around the unsupervised learning technique called 'clustering'. The presenters will take you through a wide array of topics that range from 'What is Clustering?' to 'How can I use this technique to solve problems I didn't even know existed?' In the health care industry, everyone is looking for an edge in reducing total spend-cluster analysis finds the unambiguous in an ambiguous framework of results.