Description: En el seminario hablaremos sobre los nuevos flujos de tarificación, y nos enfocaremos en la inclusión del análisis geográfico en el proceso de modelado para optimizar la extracción del riesgo en modelos de Machine Learning.

Description: "Risk adjustment is an important aspect of establishing appropriate capitation rates. When a set of services is carved out for specific management under a sub-capitation, establishing appropriate adjustments for varying levels of underlying risk is more complicated. Dive into analytical and operational challenges and resolutions as presenters share more about developing a risk adjustment model specific to the carve-out of behavioral health services through a real-life case study. You will further explore a definition of the use case, availability of historical data sets, selection of the modeling approach, learnings from the iterative modeling process, and the potential application of the results. After attending this session, you will be able to: Understand why a behavioral health specific-risk adjustment model has business value Understand the unique challenges related to developing risk adjustment on member and cost subsegments Understand the impact of trade-offs between model complexity and interpretability in the context of implementation Increase awareness of data nuances and requirements unique to this type of project Describe analytic techniques that can be investigated for use in projects of similar business objectives"

Description: As health insurance self-funding becomes more popular among smaller group sizes, risk is evolving for the MGUs, stop loss writers, and reinsurers that cover them. Assessing more small groups at lower attachment points means rethinking traditional stop loss underwriting techniques.

Description: Risk adjustment (RA) is a key component for CMS Medicare Advantage program and California Medicaid Managed Care program. While both RA programs follow generally accepted basic principles at a high level, their underlying methodologies and assumptions are also quite different. Due to recent events such as COVID-19 Public Health Emergency and Medicaid redetermination delay and restart, it adds complexity to Risk Adjustment. This is a hot topic in the industry and has significant impact to health plans. Keeping current with risk adjustment program changes and understanding the commonalities and differences of these two government risk adjustment programs is important to our health actuaries. Compare these two risk adjustment programs so you can learn key elements of a risk adjustment program, similarities and differences in methodology and assumptions , as well as special considerations due to serving different populations.

Description: Can you answer the question, 'What are the chances we will lose more than $1 million?' without saying, 'It depends'? If you miss a projection, can you estimate the chances that the miss was due to random variation versus an incorrect projection? Listen in as presenters demonstrate how to answer these questions and others using total risk analysis. Total risk analysis includes quantifying both the random variation risk and the projection risk associated with actuarial functions like pricing and reserving. After attending this session, you will be able to describe total risk analysis and to apply to many health actuarial functions.

Description: This session includes a new idea based on dynamic treatment regime work (OWL) and integrating cost into this work. This will enable identifying the best treatment for a patient based on both outcomes and cost. This is novel for actuaries because in previous analysis we have used cost only in the after-analysis, whereas here we use it in the actual analysis and treatment identification. Moreover, this analysis provides a way to consider multiple treatments for a patient (including the no treatment option) and choosing among those multiple treatments, for both outcomes and cost. This session will share the background theory and set up a case study. The case study will parallel what is in the analysis in the book by Ian Duncan 'Predicting Hospital Readmission with Case Management Recommendation.' This analysis will then go further to compare a situation where there are multiple potential case managers. Also, this will potentially explore care pathways and choosing the best care pathway for a patient based on health outcomes and cost combined.

Description: "A crucial importance in forecasting is to be able to distinguish cases when temporary slowdowns in health care utilization are followed by a “rebound” period of higher utilization. Come explore an analysis of a new mathematical model describing the return-of-care process. By means of simulation and case studies using the R programming language, the relationship between the visibility of these effects and the endogenous variance of the utilization time series is explored. After attending this session, you will be able to: Describe the parameters and mathematical form of the model Apply the model to real-world utilization data"

Description: This webcast will walk through several statistical methods for imputing race and ethnicity from U.S. datasets, highlighting their strengths and weaknesses, talking about how to use them and evaluating their accuracy, and telling you where you can get code packages as well as a free dataset to try the methods out.

Description: CMS has required hospitals to publish their chargemaster rates, cash discounts and negotiated rates as of January 1, 2021. Our panel is comprised of a data strategist, an executive from a large hospital system and an actuary.

Description: This session will examine bias from a social science perspective. It will discuss the three types of systemic biases using the National Institute of Standards and Technology (NIST) model. The NIST model details the three types as historical bias, societal bias, and institutionalbias. The session will also provide several examples of each type to provide a framework for identifying the social structure of bias.