高顿网校小编为您精心编制的2014年秋季*7整理好的精算师北美地区2001年11月November2001Course8I（最后一课）。
　　14. Continued
　　(i) Calculate the manual premium rates by tier for Bailey Industries using HMO
　　rate relativities in the table above and the total premium you calculated in
　　(a) (ii) above. Show your work.
　　(ii) Bailey Industries requires that the HMO premium rates be recalculated
　　using the POS rating relativities. Develop revised rates to meet this
　　requirement. Explain why offering HMO premium rates that mirror the
　　POS rating slope may or may not be in Bailey Industries’ best interest.
　　Show your work.
　　(iii) Describe the documentation you would include in your files to demonstrate
　　that Actuarial Standards of Practice concerning HMOs or other managed
　　care health plans were followed in your work.
　　(c) (3 points) Outline a report for Bailey Industries explaining the potential impact of
　　adverse selection resulting from the following types of market reform:
　　(i) Insurer Rules of Issue,
　　(ii) Government mandated benefits and laws,
　　(iii) Rating methodologies, and
　　(iv) Marketing practices.
　　COURSE 8: November 2001 -12- GO ON TO NEXT PAGE
　　Managed Care
　　Afternoon Session
　　Questions 14 through 16 pertain to the Case Study
 
　　15. (14 points) You are an actuary for The Bedford Group. A meeting has been called to
　　address spiraling costs in two areas: behavioral health/chemical dependency and
　　radiology services.
　　Radiological Services
　　Your CEO also has concerns regarding the increase in radiology costs even though
　　utilization has decreased. The VP of Provider Contracts is predicting a 25% increase in
　　2001 in physician radiology average charges. None of the benefit plans sold require any
　　member cost sharing for physician radiology benefits.
　　Behavioral Health and Chemical Dependency (BH/CD)
　　Your CEO is considering carving-out all BH/CD services due to increasing costs and
　　increased regulatory pressures. Total claims for BH/CD services in 2000 were $24
　　million for both HMO and POS products.
　　Lighthouse Behavioral Services (LBS), a managed behavioral health company, has
　　approached The Bedford Group to provide the full continuum of care for BH/CD
　　services. LBS will provide all BH/CD services on a capitated basis. After reviewing The
　　Bedford Group’s 2000 BH/CD claims, LBS believes they can affect BH/CD claim costs
　　under the following assumptions:
　　? LBS uses The Bedford Group provider contracts
　　? Utilization of services in Hospital ID1 will not change
　　? Utilization of services at Hospital ID2 and ID3 will be reduced by 50%
　　? 80% of the reduced Hospital ID3 services will then be moved to Hospital ID2
　　? Outpatient utilization will increase by 15%
　　? Hospital ID1 and ID3 costs/admission will not change
　　? Hospital ID2 costs/admission will increase by 50%
　　? Outpatient charges/services will go down by 25%
　　? LBS will add an administrative charge of $1.10 PMPM
　　(a) (2 points) Discuss differences between BH/CD and radiology services in how
　　access to care is obtained and utilization is controlled in a managed care
　　environment.
　　(b) (2 points) Describe mechanisms The Bedford Group can use to reduce provider
　　reimbursement costs for BH/CD and for radiology services.
　　COURSE 8: November 2001 -13- GO ON TO NEXT PAGE
　　Managed Care
　　Afternoon Session
 
　　15. Continued
　　(c) (2 points) Outline issues you would consider in determining whether carve-out is
　　preferable to carve-in strategies for both BH/CD and for radiology services.
　　(d) (1 point) Calculate the capitation rate for physician radiology services for the year
　　2001 using the case study data and assuming the VP of Provider Contracts’
　　prediction is correct. Show your work.
　　(e) (7 points) Calculate the capitation LBS would have charged in 2000 based on
　　The Bedford Group’s actual utilization experience. Determine the financial
　　impact to The Bedford Group in 2000 if LBS’ assumptions had been true. Show
　　your work.
　　COURSE 8: November 2001 -14- GO ON TO NEXT PAGE
　　Managed Care
　　Afternoon Session
　　Questions 14 through 16 pertain to the Case Study
 
　　16. (4 points) As the Actuary for The Bedford Group, you have been discussing the hospital
　　inpatient utilization with the Medical Director. The table below shows the unmanaged
　　and optimal utilization levels reflecting The Bedford Group’s demographic mix and
　　geographic location.
　　Assume the table below applies for both 2000 and 2001.
　　Admits /1,000 Days /1,000
　　Unmanaged 75 345
　　Optimally Managed 55 180
　　(a) Calculate the actual 2000 and budgeted 2001 degree of healthcare management
　　for The Bedford Group using data from Table MC-4. Outline factors to consider
　　when *uating the hospital utilization and cost data. Show your work.
　　(b) Outline a report to the Medical Director that describes medical management
　　approaches that may be used to meet budgeted utilization for 2001.
　　COURSE 8: November 2001 -15- GO ON TO NEXT PAGE
　　Managed Care
　　Afternoon Session
 
　　17. (4 points) You are a consulting actuary for an HMO *uating a prescription drug
　　benefit program for its health plans. You will be making a presentation to the Board and
　　will need to include the following:
　　(a) Describe the three general categories of prescription drugs as distinguished by
　　manufacturers’ patents.
　　(b) Outline plan features used to control prescription drug average charges and utilization.
　　(c) Describe functions performed by a Pharmacy Benefit Manager (PBM) and how a PBM can
　　manage drug costs.
　　COURSE 8: November 2001 -16- STOP
　　Managed Care Segment
　　Afternoon Session
 
　　18. (7 points) You are the financial actuary for PDQ HMO and have been asked by your
　　CFO to develop an operating statement forecast for 2002. PDQ sells exclusively
　　commercial group business. PDQ is considering the financial impact of several changes
　　which are targeted to occur on July 1, 2002.
　　(a) Describe the components of an operating statement. Discuss assumptions needed
　　for forecasting an operating statement for PDQ.
　　(b) The claim administration system will become more automated to increase
　　efficiency. Describe the impact of this change on your forecast assumptions.
　　(c) PDQ has a staff model HMO subsidiary, DOX. Market pressures may force DOX
　　to move to an IPA model. Describe how this change might impact your forecast
　　assumptions for DOX.
　　(d) Your Medical Director will implement stricter utilization management controls
　　and initiate a Disease Management (DM) program. To accomplish this, she will
　　be contracting with an outside vendor for disease management services. Describe
　　the impact of these initiatives on your forecast assumptions. Discuss how your
　　assumptions would differ if the DM program were developed in-house.
　　(e) The jurisdiction in which PDQ is domiciled is implementing a premium tax, a
　　high risk pool charge, and mandated benefits covering services previously
　　excluded from your policies. Describe how these reforms will impact your
　　forecast assumptions.
　　吃别人所不能吃的苦，忍别人所不能忍的气，做别人所不能做的事，就能享受别人所不能享受的一切。——高顿网校金玉良言

 

 
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