Description: Risk Adjustment continues to be a hot topic in Health Insurance since its emergence. This mechanism came into being as a means of reducing the risk of selection, particularly in marketplaces where underwriting is not allowed, and rating factors are significantly restricted. Risk adjustment serves to adjust premiums to reflect the risk of individual members or overall members as a whole within a particular cohort of a health plan. Risk adjustment is not perfect, as it does not perfectly predict future costs or perfectly adjust for the differences in expected costs. Different marketplaces have different challenges with risk adjustment.

Description: On September 14, 2022, The Wall Street Journal hosted its ‘Future of Health’ event, which was a virtual event featuring three sessions on some emerging cutting-edge topics that could impact the future healthcare environment as well as health care actuaries. This report summarizes the event.

Description: The COVID-19 pandemic initially caused some health care services to shift away from in-person transactions to a digital form, including telehealth, e-mails, remote patient monitoring and other forms of communication. If sustained, numerous effects and counter-effects both in the cost and quality of care as well as long-term outcomes for patient health may emerge.

Description: This study of socioeconomic inequalities in mortality builds on a previous report in which we identified a large and growing gradient in life expectancy between 1982 and 2019 across U.S. counties classified into 10 socioeconomically homogeneous categories. In this report, we seek to identify the particular causes of death contributing to the growing disadvantage in mortality between populations in the least and most affluent deciles as previously defined.

Description: Gather with members and non-members in the China actuarial community to discuss recent topics and related issues in areas such as macroeconomic sharing, pension, investment, product strategy, and more.

Description: The momentum in value-based care has produced an opportunity for actuaries to become pioneers in health care

Description: This report explores AI bias in insurance and health data, highlighting the ethical role of actuaries and offering cross-disciplinary guidance for fairer decision-making systems.

Description: ACA risk adjustment has now been in play for years. The original intent of risk adjustment was to help stabilize the market through measuring risk levels of each issuer. However, the risk adjustment program may have introduced additional uncertainty due to annual market shifts and model changes, making risk adjustment estimation is a difficult task. This article analyzes the results over time, including impacts from market changes and model changes.

Description: In the evolving realm of healthcare actuarial practice, value-based contracts are reshaping the landscape. This article explores the pivotal role of AI-enhanced Electronic Medical Records (EMRs) in empowering actuaries to navigate this dynamic sector. Despite challenges in data standardization, AI-enhanced EMRs offer a solution by extracting and standardizing diverse medical records. The article delineates how AI-EMR integration benefits actuaries and provider organizations, enabling more accurate forecasting, earlier shared savings prepayments, and real-time quality metric aggregation. Moreover, it discusses how this fusion addresses historical data limitations, can help project catastrophic claims, and can help identify risk score capture opportunities. Ultimately, it indicates the transformative potential of AI-EMR synergy, positioning actuaries at the forefront of healthcare analytics with unprecedented precision and insight.

Description: 2014 marked a new beginning for small group(SG) health insurance market ushered in with adjusted community rated products priced from a single risk pool. It was anticipated that the mandated pooling of the risk would result in higher rates, especially for healthier groups. It is the aim of this article to show whether that view bears out in the actual market rates and if it is higher, then by how much. The article provides a point in time(1st quarter 2025) comparison of premium rates under two segments of the small group market, namely Qualified Health Plans(QHP) available under the small group ACA market versus self-insured Multiple Employer Welfare Arrangements(MEWA) plans.