Description: Can Direct-to-Provider Contracting Achieve Value-Based Care for Employer-Sponsored Plans? Direct-to-provider contracting is a strategy in which a self-insured entity negotiates a contract directly with a provider of healthcare services rather than through a third-party administrator (TPA), often with the goal of driving value-based care. This article discusses the considerations for employers and providers with direct-to-provider contracting.

Description: Presenter describes many of the desirable characteristics of a health care financing system, and alternative health care financing systems as they are found in other parts of the world. The advantages and disadvantages of each alternative system are also discussed. From the Record of the Society of Actuaries, Vol. 24, No. 2.

Description: A discussion of fraud and abuse in the Medicare payment system, and steps to address these problems.

Description: May 2013 issue of the Health Watch newsletter

Description: Read the June 2017 issue of Health Watch, published by the Health Section. Practical information for actuaries, articles impact sections, section activities.

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

Description: What you need to know about risk scores to be competitive in the Medicare Advantage market.

Description: Compares the healthcare system of the US to the universal systems of selected other countries. Relies primarily on information compiled annually by The Commonwealth Fund. Will give the reader an understanding of the difference between universal healthcare, socialized medicine, and single-payer healthcare and how various national systems fall within these categories.

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: Discussion of how to mature value-based contracts between health insurers and provider organizations to improve population health and financial sustainability. Centers around contract parameter consistency, revenue predictability and risk assessment. Intended audience are health plan and ACO actuaries and leaders. Authors are writing from the provider perspective in value-based contracts.