Health Care Cost Trends Research Reports

If you’re looking for health care cost trends research projects, you’ve come to the right place. The SOA Research Institute has a wide variety of research available for download.

2024

Getzen Model of Long-Run Medical Cost Trends: Update for 2025 - 2035+
September
The Getzen Model is a long-term medical cost trend projection model based on 30+ years of observation.
Medicaid Managed Care Underwriting Margin Model
July
This report and the accompanying Excel model are intended to be used in their entirety by qualified actuaries setting rates or evaluating rates for Medicaid Managed Care programs to develop the underwriting margin component of the capitation rates.
Reimagining Pharmacy Financing
March
This paper discusses an alternative to policy solutions: reimagining pharmacy financing in the commercial space using a value-based reimbursement model. The model aims to increase transparency in drug pricing, encourage pharmaceutical competition, align stakeholder incentives and mitigate total cost of care (TCOC) increases. This paper demonstrates that it is possible to implement such a methodology under the current infrastructure but acknowledges potential limitations.
Using Interpretable Machine Learning Methods: An Application to Health Insurance Fraud Detection
January
This project establishes a foundational framework for implementing interpretable machine learning techniques in the context of health insurance fraud detection. Machine learning algorithms excel at constructing intricate models by discerning patterns in data, yet the risk of overfitting to training data necessitates rigorous testing by modelers and users. While certain validation practices for linear models apply to machine learning, the challenge of interpretability remains pronounced. This report endeavors to enhance transparency and understanding in the realm of health insurance fraud detection through interpretable machine learning.
Calculated Risk: Driving Decisions Using the 5/50 Research
January
The purpose of this research is to introduce the concept of total risk analysis (TRA), which is designed to help the decision-maker answer key questions at the time the decision is made. This paper will focus on a specific example of a typical healthcare decision: setting a budget for claims in the upcoming year. In addition to explaining TRA and providing a case study, this paper presents quantitative research regarding cost distributions for health care costs.

2023

Health Care Provider Consolidation and Shortages
December
This paper explores the recent trends, current landscape and reasons for provider consolidations and provider shortages, as well as their impact on health care morbidity, specifically on health care costs and utilization.
Getzen Model of Long-Run Medical Cost Trends: Update for 2024 - 2034+
October
Inflation and the possibility of recession are major factors affecting health care cost increases over the next five years. Insurance and medical organization will continue to evolve but are unlikely to create major shifts in the short run. However, over the long run structural changes in providers and payment mechanisms will determine future trends – raising or lowering the health share of GDP depending upon public choices and private decisions.
Modeling the Impact of the Great Unwinding on State Medicaid Programs
October
This report provides actuaries and other finance professionals with an example of running the Medicaid Unwinding model with results at the national level on projected changes in both acuity and enrollment for Medicaid and Children’s Health Insurance Program.
Pharmacy Partnership Forum - Reimagining Pharmacy Finance
June
This report shares the insights and learnings that emerged from this group of health economics outcomes researchers, clinical pharmacists, medical doctors, health actuaries, benefits consultants and brokers, and their collective thoughts on advancing this exploration for society’s benefit.
Digital Health: After the COVID Boom
June
The COVID-19 pandemic initially caused some health care services to shift away from in-person transactions to a digital form, including telehealth, e-mails, remote patient monitoring and other forms of communication. If sustained, numerous effects and counter-effects both in the cost and quality of care as well as long-term outcomes for patient health may emerge.
Guide to Domestic and International Paid Family and Medical Leave Programs
June
The SOA Research Institute along with the International Section, and the Social Insurance and Public Finance Section are pleased to make available a research report that compares international and domestic mandated paid family and medical leave programs.
A Summary of the 2023 Wall Street Journal Health Forum
June
On March 6, 2023, The Wall Street Journal hosted its Health Forum, a hybrid all-day event. The sessions were informative and fast-paced, with each one providing a quick hit of relevant and cutting-edge information around health care. This white paper focuses on those events.
Quantifying Long Term Effects of COVID-19 on Health Care Costs
April
Through the sponsorship of the Robert Wood Johnson Foundation, The Society of Actuaries partnered with Wakely to use their health care data to study the effects of COVID-19 on overall health care claims for individuals with a COVID-19 diagnosis. The conclusion of the study is that individuals with COVID-19 claims had significant increases in health care costs leading up to their months of diagnosis, as well as in the months following their diagnosis. These effects were more pronounced for individuals who were hospitalized due to COVID-19 as well as for individuals with prior co-morbidities. Finally, the overall health care costs of these members plateaued at significantly higher levels than their pre-COVID baselines. In fact, all the main membership cohorts experienced claim levels that were at least 20% higher than their pre-COVID starting points.
Social, Physical and Cultural Determinants of Health: Their Incorporation into Actuarial Data and Workstreams
April
This report provides actuaries and other professionals working with risk, data and analytics or program evaluation in the health care space with considerations and frameworks related to the use of determinants of health (DOH) in data and actuarial work streams. Such frameworks can leverage new data sources to enrich health care data analysis to move beyond traditional data elements, such as age, gender, zip code or health diagnosis.
Evaluating Risk Adjustment and Medicare Advantage
February
The use of Risk Adjustment in Medicare Advantage (MA) has come under scrutiny due in part to a higher rate of cost increases relative to Traditional Medicare as well as inequities in the current system. This brief evaluates the current MA risk adjustment methodology and enumerates different steps that can be taken to mitigate those issues. Actuaries are deeply entrenched in understanding and applying risk adjustment. To that end, their experience and expertise can help lead to a better application of Risk Adjustment within Medicare.

2022

Getzen Model of Long-Run Medical Cost Trends: Update for 2023 - 2033+
November
The aftershocks of the COVID pandemic will pass eventually. Government subsidies and spending soared in 2020 to meet the challenges of the pandemic. Health expenditures leapt from 17.6% of GDP to 19.7%, and then dropped to 18.8% in 2021, and will fall again to 18.2% (projected) in 2022, but are expected to return to the long-run trend by 2024 and gradually rise thereafter. However, during the next few years most attention will be paid to dealing with complex aftershocks from the flood of Covid funding in 2020 and 2021, a surge of inflation in 2022, and a looming recession in 2023.
A Summary of the 2022 Wall Street Journal Future of Health
October
On September 14, 2022, The Wall Street Journal hosted its ‘Future of Health’ event, which was a virtual event featuring three sessions on some emerging cutting-edge topics that could impact the future healthcare environment as well as health care actuaries. This report summarizes the event.
Interactions of Health Care Rating Factors with Race, Ethnicity and Socioeconomic Factors
July
A study of whether tobacco, area and industry rating in one state may be reflecting unintended factors such as race, ethnicity or socioeconomic status. This study does not consider whether the rating factors accurately reflect underlying claims costs.
Medicaid Managed Care Underwriting Margin Model
June
This research project offers guidance and a model for actuaries to use when performing their professional services related to Medicaid (Title XIX) and Children’s Health Insurance Program (CHIP or Title XXI) managed care capitation rate setting, including, but not limited to, their certification on behalf of a state in accordance with the requirements for actuarial soundness as set forth in law, federal regulation, and CMS guidance, as well as the actuary’s professional obligations under the Actuarial Standard of Practice (ASOP) 49 issued by the Actuarial Standards Board.
A Summary of the 2022 Wall Street Journal Health Care Forum
April
On March 22, 2022, the Wall Street Journal hosted its annual Health Forum, a virtual all-day event which included several sessions. This session was attended by experts across the healthcare space and attendees included many from the healthcare technology companies. This report summarizes the event.
A 2022 Health Care Industry Outlook from the Association Forum Health Care Collaborative
March
On February 15, 2022, the Association Forum Health Care Collaborative, a collection of metropolitan Chicago based Healthcare associations, held its winter event. This virtual gathering featured two sessions titled: “Healthcare Policy Perspective” and “Megatrends and Tipping Points that will Define Success in the "New Normal".
How Does Where You Live Impact Your Health?
March
How does where you live impact your health? The following research considers this question through the lens of social determinants of health (SDOH), which are factors relating to where you live or work that may impact your health. In the United States, there are geographical differences in SDOH which contribute to wide disparities in health status and outcomes. In particular, individuals who are negatively affected by SDOH may have an increased burden of disease, leading to a relatively high total cost of care and worse quality of life.

2021

A Two-Part Model of the Individual Costs of Chronic Kidney Disease
December
Chronic Kidney Disease (CKD) affects many lives and has a large impact on health systems around the world. To better understand and predict costs for insurance plan members with CKD in the United States, we built a new model of their individual costs. Our model is the first to explicitly model both the CKD stage transition process and the distribution of costs given those stages.
Getzen Model of Long-Run Medical Cost Trends Update for 2022-2030+
November
COVID has washed over healthcare like a tsunami. According to Medicare actuaries, trends have been turned upside down in 2021, but will reverse back in 2023 as medical costs rebound. It is more prudent to base projections on long run trends for a period after the storm, extrapolating from 2026 forward, leaving the intervening turbulence (years 2022 -2025) mostly unspecified.
Oral Health in U.S. Children
November 2021
In this report, we explore the impact of clustering using the Medical Expenditure Panel Study (MEPS) data for children (aged 5 to 17) to build a bridge between oral health and overall health using dental and medical expenditures. We include social determinants of health as cluster input variables using the Partitioning around Medoids (PAM) method to identify children and their families who could potentially benefit from population health management related to oral health.
“Uninsured Rate” Measurements and Health Policy Considerations
September

The Patient Protection and Affordable Care Act (ACA) was signed into law March 23, 2010. The transformative health care legislation was multi-faceted, but its primary purpose was to reduce the number of uninsured Americans. In alignment with the SOA’s Strategic Plan objective to “inform the public’s understanding of key societal issues,” this report examines the various publications reporting on the uninsured rate which stakeholders frequently access to measure policy efficacy and inform future policy considerations.
2022 Health Care Cost Model
April

The Society of Actuaries (SOA) created the SOA 2022 Health Care Cost Model (model) to enable users to estimate future U.S. health care insurance costs. This model allows a user to consider a variety of scenarios and create inputs that can forecast the impact on the health care service system. The model will be updated periodically to reflect the latest data on both the outbreak and insurance health care costs. A user guide, user training video and model documentation guide have also been developed to support the model.
An Actuarial Perspective on the Relationship of Patient Centered Medical Homes and Healthcare Costs
March

This paper helps the audience understand the actuary’s role in estimating the financial impact of primary care programs. In addition, the paper can be used by actuaries to think about key issues when estimating the financial impact of their employers’ and clients’ own primary care programs.
Determining the Role of Anthropogenic Climate Change on Human Health Outcomes: A Case Study on Heat Related Illness Attribution
February

This report is targeted to actuaries that are interested in identifying the adverse human health outcomes resulting from anthropogenic climate change. As the primary focus of actuarial research is to promote human health and minimize the preventable economic burden, this document also provides recommendations to mitigate against excess heat related illness (HRI) due to extreme heat.
Modeling Effects of Enrollee Choice
January

In health insurance marketplaces, prospective insured individuals and groups are able to choose from a range of available plans. This study uses health care encounter data to simulate the choices faced by health insurance shoppers under a variety of conditions and measures the simulated effect of increased consumer choice and consumer information on medical loss ratios and, as a consequence, insurer profitability.

2020

COVID-19 Mitigations in the U.S.
December
This report provides highlights of a weekly survey of practices regarding the mitigation of the spread of COVID-19.
Comparing Measures of Social Determinants of Health to Assess Population Risk
November
Social Determinants of Health (SDOH) include the social and physical conditions in which people are born, live and work on a daily basis. This project advances a growing body of literature to inform the ongoing optimization of population health and payment models.
Getzen Model of Long-Run Medical Cost Trends Update for 2021–2030+
October
An update to the Getzen Model of Long-Run Medical Cost Trends for 2021–2030+.
2021 Health Care Cost Model
June
The Society of Actuaries (SOA) created the SOA 2021 Health Care Cost Model (model) to enable users to estimate future U.S. health care insurance costs. This model allows a user to consider a variety of scenarios and create inputs that can forecast the impact on the health care service system. The model will be updated periodically to reflect the latest data on both the outbreak and insurance health care costs. A user guide, user training video and model documentation guide have also been developed to support the model.
Society of Actuaries Research Brief: Impact of COVID-19, June 12, 2020
June
This Society of Actuaries Research Brief has been constructed to highlight some of the key features of the COVID-19 epidemic and contemplate the risks for the actuarial profession to consider in their work.
Direct Primary Care: Evaluating a New Model of Delivery and Financing
May
The Society of Actuaries (SOA) commissioned Milliman to develop this report to provide health care stakeholders (patients, payers, policymakers and actuaries) with a comprehensive description of Direct Primary Care (DPC) as well as an objective actuarial evaluation of certain claims made about the DPC model of care.
Projections of COVID-19 Hospitalizations and Deaths, Updated April 24, 2020
April
Since the outbreak began in January, numerous research groups throughout the world have developed models to forecast the number of deaths that could result from COVID-19. Dr. Thomas McAndrew and Dr. Nicholas Reich of the University of Massachusetts Amherst have, on a weekly basis beginning in mid-February, surveyed experts who are separately engaged in efforts to model the outbreak. This brief looks at these models.
Mental Health Trends and COVID-19
April
With the pandemic outbreak of coronavirus disease (COVID-19) through the world in the first part of 2020, many resulting outcomes have triggered the potential to see an increase in the use of mental health benefits in health care insurance systems.
COVID-19 Costs to Commercial Health Insurers
April
Due to the COVID-19 pandemic, the health care services industry is undergoing upheaval with ramifications on many different aspects, from access to services, to cost and utilization of services.
Fifty States, Fifty Stories: A Decade of Health Care Reform Under the ACA
March
The SOA released new research with actuarial insight and key learnings on the Affordable Care Act (ACA), in recognition of the tenth anniversary of this legislation.
A Summary of the Health Care Cost Institute’s 2020 Annual Cost and Utilization Report
February
The Health Care Cost Institute (HCCI) recently released their annual health care cost and utilization report on February 13, 2020, which illustrates employer group commercial health care costs and trends from 2014 – 2018. This reports summarizes the HCCI report.

2019

A Summary of the Latest Updated Medical Loss Ratio Methodology and Historical Results
December
The SOA is releasing this brief report which summarizes the most current Medical Loss Ratio (MLR) methodology highlighting some of the most recent changes in methodology and requirements.
Getzen Model of Long-Run Medical Cost Trends Update for 2020–2029+
October
A divisive confrontation over health care pricing is almost inevitable over the next few years. What will ultimately happen is a political decision, not an actuarial one—but it will have major consequences for the trend in health care costs and the divergence between public and private insurance premiums.
Economic Impact of Non-Medical Opioid Use in the United States
October
This report summarizes a study that estimates the total economic burden of the opioid crisis in the United States from 2015 through 2018 and projects future costs of the opioid epidemic for 2019.
Health Plan Strategic Implications of MACRA
August
The SOA is pleased to make available a research report providing insight and considerations for the actuarial profession in assessing the potential risk and opportunities of MACRA to both provider and payer organizations.
Commercial Health Care Cost and Utilization Trends From 2009–2015
July
Health care cost trends are a key ingredient that health care actuaries use in their practice. In collaboration with the Health Care Cost Institute (HCCI), the Society of Actuaries has put together a data extract for practicing health actuaries to be able to better understand historical trends and cost disruptors.
Cancer Genomics
May
The treatment of advanced cancer is undergoing a major paradigm shift. Traditional pillars of cancer treatment – surgery, radiation, and chemotherapy – are moving to two new efficacious approaches: tumor genomics and immunotherapy. This analysis report introduces SOA stakeholders to these brand-new areas, examines the growing clinical evidence, and sets initial projections for cost effectiveness.
A Summary of the 2020 Actuarial Value Calculator
April
The Centers for Medicare and Medicaid Services (CMS) recently released the final 2020 Actuarial Value Calculator and Actuarial Value Calculator Methodology.
HCCI Annual Health Care Cost and Utilization Report Summary Analysis
February
This is a summary analysis of the Health Care Cost Institute’s annual health care cost and utilization report from February 12, 2019.

2018

Evaluating Payment Models for High-Cost Curative Therapies
October
The SOA is pleased to make available a research report that evaluates alternative payment models that potentially could be instituted by health care payers and manufacturers to pay for high-cost curative disease therapies and prescription drugs.
Hospice Care Research: An Analysis of End-of-Life Costs for Terminally Ill Medicare Fee-for-Service (FFS) Cancer Patients
October
The SOA is pleased to make available a research report analyzing the cost of care for deceased cancer patients over the last six months of life. The analysis focuses on the cost differential of hospice care versus not entering hospice for such patients.
Modeling Long Term Healthcare Cost Trends – Update for 2019
October
The Society of Actuaries' Pension Section and Health Section Research teams originally commissioned Professor Thomas E. Getzen of Temple University to construct a resource model for the projection of long term healthcare cost trends. The Society of Actuaries continues to make annual updates to the model to ensure its usefulness and relevancy.
Predicting High-Cost Members in the HCCI Database
September
Using the Health Care Cost Institute (HCCI) database, which contains claim information on approximately 47 million members annually over a seven-year time period, we examined which characteristics best predict and describe high-cost members.
Patient Attribution
September
This paper describes the key elements of attribution methodology, identifies the challenges and opportunities associated with each and discusses key considerations related to risk and risk transfer from payers to providers.
Analysis of Individual Disability Income Tables
August
The Society of Actuaries Health Section Research Committee is pleased to make available the first of two reports analyzing industry Individual Disability Income (IDI) claim incidence and termination experience trends relative to the 2013 IDI Valuation Table base incidence and termination rates. The first report covers claim incidence trends.
Examining Predictive Modeling-Based Approaches to Characterizing Health Care Fraud
March
The Health Section Research Committee is pleased to make available a research report providing a systematic evaluation of the modeling methodologies and data samples used to characterize health care fraud.
Model of Long-Term Health Care Cost Trends in Canada
March
The Canadian Institute of Actuaries (CIA) and the Society of Actuaries (SOA) are pleased to make available a resource model that provides long-run (to 2050 and beyond) forecasts of health care spending in Canada.
Provider Networks – Actuarial Perspective on Performance In and Out of Exchanges
March
The Health Section Research Committee and the Health Section are pleased to make available a research report describing aspects of provider network performance in health care settings with particular focus on experiences with Exchanges.
Actuarial Review of Insurer Insolvencies, Future Preventions
January
Sponsored by the Canadian Institute of Actuaries (CIA), Casualty Actuarial Society (CAS), and Society of Actuaries (SOA), this study looks at causes of insolvency and decisions made by management, regulators, and policyholders over the life cycle of the insolvency. This study is intended to educate insurance professionals on historical insurer impairments and insolvencies and possible future prevention indicators.
Insurance Risk and Its Impact on Provider Shared Risk Payment Models
January
The Society of Actuaries Health Section is pleased to make available a report examining the risk associated with the unpredictable variation in utilization and cost of services.

2017

Medicaid Managed Care Organizations: Considerations in Calculating Margin in Rate Setting
March
The Society of Actuaries Health Section Research Committee is pleased to make available a research report that describes the components of margin for calculating capitation rates in a Medicaid context along with a description of practical issues that may be encountered by MCO’s. The report includes observations from interviews with MCO executives as well as financial results analysis of MCOs nationwide.
Opioid Overdose Deaths in the United States
February
The Society of Actuaries is pleased to make available an article describing the demographics and geography of the increasing number of opioid deaths in the United States. The article summarizes data available from the Centers for Disease Control.
A Case Study of Risk Adjustment for Texas Medicaid
February
The Society of Actuaries Health Section is pleased to make available a research report that examines the impact on risk scores in risk adjustment models when there are timing differences for model updates of pharmacy data and risk factor mappings. The analysis was done through a case study of Texas Medicaid using the CDPS (Chronic Disability and Payment System) risk adjustment model.