Description: Discussion and Opinion on how randomness affects measurement of provider contracting risk-sharing agreements

Description: This article outlines and summarizes research from Swiss Re about the prevalence of the Health Protection Gap throughout Asia, with a particular focus on China. Authors Robert Burr and David Zhang share key statistics on the scope of the gap, which is more than 800Bn USD in China alone, and discuss the role that technology and private-public partnership can play in reducing this gap over time. Readers will come away with an understanding of the scale of the problem within the Asia region as well as new ideas on how to solve similar problems within their own region.

Description: Letter from the Editor - Mary van der Heijde

Description: The coming wave of biosimilars could dramatically affect prescription drug costs and benefit strategies over the next several years. The launch of many Humira biosimilars in 2023 is the Big Event that will largely determine the impact of the biosimilar wave. Payers have many decisions to make about coverage and formulary tiers. What factors will drive payer decision-making?

Description: This article lists the top priority issues for SOA health committees for 2003 and their support for the Healthcare System in Crisis project, which is focused on giving the public an actuarial perspective on the dynamics and interrelationships of the healthcare system.

Description: This article looks at obesity in the United States and presents strategies for an Obesity Care Management Program. From Health Watch Newsletter, May 2006, Issue No. 52.

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

Description: This article is about the cost-benefit relationship of advances in longevity and taking personal responsibility for one's own wellness.

Description: PBMs are positioned in the healthcare delivery system as the only entity that is not regulated for profitability. The Commercial Fully Insured Health Insurance Plans are heavily regulated by the State Insurance Commissioner who allows only 2%-3% profit margin. The self-funded Health Plans are regulated by ERISA fiduciary responsibility that prohibits excessive compensation. PBMs are classed as a service provider and are not regulated by either. This allows PBMs to implement large, unreasonable mark ups for profit. PBMs are massive commercial entities, states are trying to sue under antitrust law. PBMs found a sweet spot in the regulation. Large Insurance Carries understood that and either acquired large PBMs or merged with them. It is likely that a combination of measures will be needed to regulate PBMs. The most direct approach would be for Congress to pass a law establishing PBM as a fiduciary under ERISA just like an “investment advisor” providing advice for a fee. Establishing PBM as a fiduciary will help Courts and other Federal Agencies ensure that PBMs do not unfairly retain rebates and inflate the prices of Rx drugs sold to employer health plans, and the US population in general.

Description: Coverage of Medicaid home and community-based services under the 1915(i) state plan option: Attractive features and important considerations