Description: Results of an SOA survey regarding the expectation for 2015 accruals for 3Rs and cost sharing reduction payments

Description: Discover the key components of value-based care (VBC) contracts and their impact on provider credibility. Learn about benchmarks, measurement period results, and the unique challenges providers face in managing insurance risk. Gain insights into reducing costs and aligning financial incentives in the US healthcare market.

Description: In Medicaid rate development, actuaries have not historically shared models that developed the margin (i.e., underwriting gain) assumption. This is unfortunate, given the margin assumption is one of the most critical components of the rate development in ensuring financial solvency of the Medicaid managed care organizations (MCOs). In this session, we will discuss the primary components of the this assumption and will share working models that help actuaries quantify these components—including the cost of capital and risk (or contingency) margin. We expect a lively discussion as we “open the black box” and discuss these actuarial assumptions in the public for the first time.

Description: This chapter focuses on creating practical models that aid in the prediction of the risk of readmission to a specific hospital within 30 days of discharge for Medicare patients, to aid in the identification and stratification of at-risk patients for hospitals considering building an intervention program in a cost-effective manner. For readers who wish to develop their own predictive model, a dataset is provided on the Actexmadriver.com website, and R code is provided in the appendix to this chapter.

Description: This article takes a comparative review on Medicare and Private Health Insurance and examines the cost of administration. From Health Watch Newsletter, May 2006, Issue No. 52.

Description: With the medical insurance market experiencing health care inflation of 10 to 13 percent and medical costs averaging above $8,000 per year per employee less for single employees and more for employees with families, employers are looking at alternative options. Politicians and regulators are as well.

Description: This session will explore the various methods of determining the credibility levels that are given to various size employer groups and Medicare plans. The background and theory of the methods that have commonly been used will be explained and then some new data-driven research in the area and possible alternatives will be discussed.

Description: This report describes the results of a survey on reflecting risk in pricing. The survey expands on one conducted in 2003 and was expanded to include life, health, P&C, and non-North American insurance companies.

Description: Healthcare risk adjustment methodologies have become increasingly complex, largely due to the belief that complexity enhances accuracy. However, a disconnect exists between how healthcare risk is assessed and how payments are adjusted. This article explores the stark difference between measuring the accuracy of a risk assessment model at a member level, and that of a risk adjustment mechanism at the health plan level. I show that a highly simplified approach that does not use diagnosis codes can have similar accuracy on risk adjusted payments to models that do. These findings suggest that accuracy is not a barrier to developing simpler risk adjustment methodologies, which can improve payment accuracy and reduce the financial incentive for coding diagnoses.