Description: US pharmacy prices have entered a new era of growth driven by Specialty medications. A bevy of state and national regulations have been proposed to address pharmacy pricing, industry structure and transparency.Health actuaries will learn about US pharmacy pricing structure and how proposed legislation could affect future costs. Actuaries that have responsibility for pharmacy rate/budget setting, RFPs or trend projection will benefit from a deeper understanding of the US pharmacy market landscape and gain an international perspective.

Description: This is a case study session where the speakers will describe a project where a major health system converted its provider distinct reimbursement (i.e., separate physician IPA and hospital capitation) to an integrated reimbursement involving global capitation. The session will discuss the strategic issues considered by the parties and how they evaluated them in their decision process. This session will provide attendees an example of how to approach this type of decision.

Description: The presenters will provide insights into fraud and abuse risk in the health insurance industry, including an examination of traditional and predictive modeling techniques for both prevention and detection. Emphasis will be placed on current and emerging risks. Canadian examples and perspectives will be offered, but the applications for attendees to use in practice are non-nation specific.

Description: As value-based solutions evolve, it is more important than ever for providers to understand their performance and how it is measured, along with the drivers of success. Presenters will cover the evolution of past risk-transfer programs such as Medicare Shared Savings Program and Next Generation ACO. They will also discuss the new Primary Care First and Direct Contracting models recently announced by CMS.

Description: The presenters will focus on best practices in drug claim management in North America. The presentation is geared toward Canadian practice and insights, but is useful for practitioners in the U.S. and elsewhere, as well.

Description: Changes introduced by various Medicare Alternative Payment Models and the Medicare Access and CHIP Reauthorization Act (MACRA) have accelerated an existing market trend of shifting some of what has traditionally been considered “insurance risk” to providers. The Provider Risk Sharing Boot Camp will give attendees deeper insights into methods, current thinking, and alternative solutions that actuaries can use to help providers understand and manage the financial and actuarial risks that they are taking, many for the first time.

Description: This teaching session explores how variability in charges and costs can be measured so direct comparisons between institutions can be developed and how information can be used to develop reasonable reimbursement levels. Topics include creating & using outpatient hospital fee schedules, using relative value fee schedules to benchmark costs to aid in medical management and hospital tiering. From the Record of the Society of Actuaries, Volume 28, No. 2, Session 48

Description: This session will explore the various contracting techniques that CMS, providers, and employers are using to achieve their strategic objectives across both the Commercial and Medicare markets.

Description: The presenters will cover the variation in risk adjustment approaches used across state Medicaid programs and compare them to other Federal programs. Additionally, recent developments, such as the use of OCR to extract data from medical charts for risk adjustment, will be discussed.