Description: A rethinking of current provider reimbursement, focusing on incentives instead of simply cutting fees. The recommended 2-pronged approach would feature integrated provider organizations as well as evidence-based decision making organized around episodes of care.

Description: As providers are considering accountable and value based care models, it is critical to strategically think through how to achieve a sustainable business model into the future. This requires actuarial and clinical/provider capabilities to assess the care management and financial levers to help a client through the transition.

Description: This article from major US payers describes palliative care as a scaleable means of improving quality and reducing costs during serious and complex illness.

Description: Read the February 2018 issue of Health Watch, published by the Health Section. Practical information for actuaries, articles impact sections, section activities.

Description: This article provides an in-depth discussion of how subsidies are an integral part of affordability for individual health insurance under the Affordable Care Act, and, ultimately, impact the viability of the market.

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.

Description: This is a review of literature about the development and application of medical risk adjustment models. The current Medicare model, principal inpatient diagnosis cost group [PIPDCG] and proposed enhancements are the subject of many articles. Risk adjustment is used for both provider payment and performance measurement.

Description: This dissertation by Tia Sawhney will help you understand this issue and start measuring it, or start promoting equitable public policy.

Description: Risk adjustment is used to adjust the revenue stream to health insurers that sell ACA eligible plans and Medicare Advantage plans. This article compares and contrasts these risk adjustment programs.

Description: This is a regular column highlighting articles of interest to Health Actuaries appearing in the North American Actuarial Journal.