Description: US pharmacy prices have entered a new era of growth driven by Specialty medications. A bevy of state and national regulations have been proposed to address pharmacy pricing, industry structure and transparency.Health actuaries will learn about US pharmacy pricing structure and how proposed legislation could affect future costs. Actuaries that have responsibility for pharmacy rate/budget setting, RFPs or trend projection will benefit from a deeper understanding of the US pharmacy market landscape and gain an international perspective.

Description: This is a case study session where the speakers will describe a project where a major health system converted its provider distinct reimbursement (i.e., separate physician IPA and hospital capitation) to an integrated reimbursement involving global capitation. The session will discuss the strategic issues considered by the parties and how they evaluated them in their decision process. This session will provide attendees an example of how to approach this type of decision.

Description: This session will explore the national landscape of state Medicaid risk adjustment program design & application and the key differences that drive effective managed care organization program management. Risk adjustment is a mechanism to adjust capitation rates between Managed Care Organizations to account for population morbidity differences. Although many states utilize this mechanism, the application of risk adjustment can vary significantly across states. The primary differences include populations, risk score models and data collection. These state application nuances affect the strategies and tactics utilized by MCOs for effective risk adjustment program management including provider financial alignment, encounter data submission and the capture of accurate diagnosis codes. The session is intended for Medicaid Managed Care Actuaries working to develop or support comprehensive risk adjustment program management functions.

Description: The presenters will provide insights into fraud and abuse risk in the health insurance industry, including an examination of traditional and predictive modeling techniques for both prevention and detection. Emphasis will be placed on current and emerging risks. Canadian examples and perspectives will be offered, but the applications for attendees to use in practice are non-nation specific.

Description: Review of reimbursement methodologies APGs, APCs, Medicare ASC, discount on charges, commercial hybrid, methods and trends in contracting, impact on trent, benchmarking. Issue No. 44.

Description: In this interview Dr. Reinhardt shares his thoughts on the role he believes actuaries should take in the health care system reforms.

Description: An edited written interview with two actuaries and a public health professional on issues related to the intersection between the two fields.

Description: This article discusses techniques used to create risk scores to help determine appropriate primary care panel sizes for a provider organization.

Description: This report evaluates alternative payment models that potentially could be instituted by healthcare payers and manufacturers.

Description: This report evaluates alternative payment models that potentially could be instituted by healthcare payers and manufacturers.