Description: While there are many approaches currently being taken to transform health care, to be successful, we know that leading and planning for quality improvement is a science. Data is the common denominator as healthcare organizations establish best-practices, and ultimately overcome unintended variation through strong analytic systems. Health care leaders require specialized data analysis education and training to hone their skills in understanding and managing clinical variation. The problem with unexplained variation in healthcare is that it negatively impacts clinical outcomes, increases the cost of care, and diminishes value for patients. In this session, Dr. Ted James (BIDMC and Harvard Medical School Faculty) will explain how actuaries can offer practical solutions that provide insights into variations in clinical practice that cannot be explained by differences in medical conditions or patient preferences.

Description: Presented at August 2011 46th Actuarial Research Conference. Discussion of research in progress which examines and validates the use of PRIDIT as a hospital quality measure. PRIDIT is an unsupervised learning technique developed as a fraud detection method.

Description: In the current value-based care marketplace, there are various reimbursement models that tie payments for care delivery to the quality of the care provided. The purpose is clear – change reimbursement to focus on value by rewarding better outcomes and lower spending. However, implementation it is complex, and many challenges emerge during this transition for both providers and payers.Providers often lack sophisticated actuarial capabilities or clear understanding of the connection between finance and clinical operations. For these reasons, they enter risk arrangements without knowing how to strategically manage and mitigate risks and fully transfer the reimbursement changes into clinical decisions. For payers, a truly viable value-based payment model that rewards the most valuable providers needs a multidisciplinary approach and a solid financial model. Such a model also requires transparency and a clear transitional road map for providers to encourage participation and collaboration. In this session, we will discuss lessons learned through case studies of working with both providers and payers on value-based care issues. We will illustrate the current state of the complex financial structures by presenting examples of value-based financial models, feasibility analyses, and strategies to design a payment model beneficial to both providers and payers. We will also explore the clinical collaboration necessary to make it all work, as well as present some best practice strategies to facilitate strong payer-provider collaboration.