Description: Healthcare risk adjustment methodologies have become increasingly complex, largely due to the belief that complexity enhances accuracy. However, a disconnect exists between how healthcare risk is assessed and how payments are adjusted. This article explores the stark difference between measuring the accuracy of a risk assessment model at a member level, and that of a risk adjustment mechanism at the health plan level. I show that a highly simplified approach that does not use diagnosis codes can have similar accuracy on risk adjusted payments to models that do. These findings suggest that accuracy is not a barrier to developing simpler risk adjustment methodologies, which can improve payment accuracy and reduce the financial incentive for coding diagnoses.

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: Inspired by other financial savings products available to Canadians, this article describes a potential solution for financing future health expenses with the creation of a Registered Health Savings Account (RHSA). This solution has been thought on the basis of four premises : 1- Individual Accountability for Health Expenses; 2- Early Savings Leads to More Accumulation; 3-PreferredTax Treatment for Personal Health Savings; 4- Complementing current public and private health systems; Main elements of the RHSA are described (Contributions, Accumulation, Utilization of account, Management by financial institutions).RHSA'S expected balances and some other results under three scenarios (a person in good health, one in poor health, and one with unexpected death at age 45) are summarized in a table. Health expenses deducted yearly from RHSA's balance were estimated using total, per capita, provincial government health expenditures by age-band for Canada, in 2020, from the Canadian Institute of Heath Information’s (CIHI), which account for 71.8% of total expenditures, that is public + private. Thus 28.2% of total expenditures were used for private health expenditures, then forecasted to 2024 and projected using a 4% annual trend. Some objections to the solution explored were anticipated as well as some refutations to these objections.