Description: As actuaries in health care, we spend most of our time focused on reviewing claims, enrollment and clinical data. That information is captured while patients are in health care facilities. Yet most people spend only a small fraction of their time in these facilities. This article explores what types of data are available to actuaries the provide a more holistic view of the member so that a members physical and emotional needs, the social determinants of health can be taken into consideration along with their clinical needs. Two uses cases are presented so actuaries can see how these types of analyses can be leveraged to improve clinical, operational, and financial performance of risk bearing health entities. Understanding the customer (member) not just the patient enables actuaries to provide new insights and values to our stakeholders across a wide range of business and risk applications.

Description: ACA risk adjustment is intended to "bridge the gap" between allowed rates and actuarial rates. If risk adjustment methodology is not bridging that gap & becomes an additional input to pricing formulae, it is not serving its intended purpose.

Description: This is Part 2 of 2 on changes affecting Medigap insurers. It focuses on marketing and regulatory differences between Medigap and Medicare Advantage that affect the competitiveness of Medigap plans.

Description: When designing and pricing a healthcare product, it is not only important to know how to model frequency and severity, but it is essential to understand human behavior. Of course, the issue of anti-selection in medical insurance is well known as individuals know more about their health and prior expenditures than an insurer does. This type of behavior is certainly rational, and to be expected.