Health Care Reform: Pricing, Exchanges, Providers and Employers
Presenter: Mary van der Heijde, FSA, MAAA
Principal and Consulting Actuary
Presenter: Jordan Paulus, FSA, MAAA
Presenter: T.J. Gray, ASA, MAAA
Health care is undergoing major and important changes as major provisions of the Affordable Care Act (ACA) are rolled out in 2014. These changes will have major effects on individuals, employers, health plans, and health care providers. This course builds an understanding of the fundamentals before tackling the major implications of reform for each of those groups. This course is targeted to health care providers, business leaders, and other professionals who want to learn to navigate the challenges and opportunities of health care reform. The focus will be on addressing the key issues without getting lost in the details of the regulations. By the end of this course, participants will have the background knowledge to better face – and surmount – the coming challenges and opportunities of health care reform.
Time to view this video is 25 minutes.
Course Learning Objectives
Upon completion of this course the learner will be able to:
- Understand how health care reform changes the landscape of the healthcare market, including the purpose and effects of the individual and employer insurance mandates, the state and federal exchanges, and Medicaid expansion.
- Identify changes in the way health insurance products are being priced and managed starting 2014 and beyond.
- Discuss how reform to both Medicaid and private health plans affect health care providers.
- Identify and understand the changes facing both large and small employers in the post-reform landscape.
Time to complete this course is approximately 75 minutes.
Presenters: Mary van der Heijde, FSA, MAAA
Mary is a principal and consulting actuary with the health practice in the Denver office of Milliman. She joined the firm in 2001.
Mary has been heavily involved in healthcare reform, with focus both on current required changes and on pricing and strategy for entry to health exchanges. Mary works extensively on individual and small group underwriting and pricing and leads the development of Milliman’s “Small Group Medical Underwriting Guidelines” and “Individual Medical Underwriting Guidelines” products for the United States, Brazil, and Mexico. She has recently done significant work assisting insurers in the individual market, including pricing, design, medical underwriting implementation, and other market and competitive considerations. She has also worked in areas of predictive modeling, including risk adjusters, lifestyle based analytics, and other tools to enhance initial underwriting.
She has considerable experience in pricing, having worked intensively on pricing healthcare costs for the federal government’s multi-billion dollar TRICARE program. In addition, she has done extensive work in litigation support for Medicaid rate setting expert witness cases. She has also worked for the Center for Medicare and Medicaid Services (CMS) as a part of Milliman’s ACRP Audit team. She has ample experience in statistical and longitudinal data analysis. Mary also helped in development of the book “True Group Long-Term Care” and has worked in long-term care modeling and pricing. Her recent projects include plan utilization rate development for large insurers, researching and pricing changes in benefit coverage, and plan analysis.
Mary received a BS (with highest distinction) in Applied Mathematics, University of Colorado at Boulder and a Certificate in Actuarial Sciences, University of Colorado at Boulder.
Presenters: Jordan Paulus, FSA, MAAA
Jordan is an actuary with the Denver office of Milliman. He joined the firm in 2012.
Jordan has been heavily involved in healthcare reform initiatives since joining Milliman. His areas of work include pricing and filing for qualified health plans under the Affordable Care Act, HHS federal risk adjuster strategy, and product development for exchange-offered plans. Jordan has been involved with financial reporting and actuarial attestations for annual statements. He has considerable experience with reserving modeling, including IBNR, premium deficiency reserves, and federal MLR rebate reserves. Other recent work includes development of Milliman Advanced Risk Adjusters (MARA) software.
Prior to joining Milliman, Jordan worked in employee benefits consulting, primarily developing strategies for large self-insured employers in light of healthcare reform.
Jordan co-authored a study entitled Economic Impact of Integrated Medical-Behavioral Healthcare that quantifies the possible savings achieved through integrated interventions by medical and behavioral health professionals.
He also co-authored a report exploring the financial considerations in opening a healthcare exchange for the government of the United States Virgin Islands. Work included commercial and Medicaid population migration modeling, claims cost and trend projections, and modeling of premium subsidies and cost sharing subsidies under the ACA.
Jordan received a BA, in Mathematics and Economics, Wartburg College, Waverly, Iowa.
Presenters: T.J. Gray, ASA, MAAA
T.J. is an associate actuary with the Denver office of Milliman. He joined the firm in 2007.
T.J.’s area of expertise centers around helping insurers prepare for changes in the health insurance market due to healthcare reform—including product development, compliance with essential health benefits, pricing, rate filing, and exchange strategy considerations.
He assisted numerous healthcare CO-OP applicants with the preparation of proforma financial projections and applications for funding and start-up operations.
T.J. has experience in the behavioral healthcare arena, including capitation and risk analysis. He developed a model for strategic compliance with the Mental Health Parity and Addiction Equity Act of 2008. He assists in the development of the behavioral healthcare components of the Milliman Health Cost Guidelines®.
He also assists with the development of Milliman’s Medical Underwriting Guidelines, with a focus on prescription drugs. T.J. coauthored a paper entitled The Economic Measurement of Medical Errors, which quantifies the cost of medical errors to the United States economy.
T.J. received a B.S. (cum laude), in Actuarial Science, Brigham Young University.
Developing Organization: Milliman
Milliman is among the world’s largest providers of actuarial and related products and services. Founded in 1947, Milliman is an independent firm with offices in major cities around the globe. They are owned and managed by their principals—senior consultants whose selection is based on their technical, professional and business achievements.
Milliman serves the full spectrum of business, financial, government, union, education, and nonprofit organizations. In addition to their consulting actuaries, Milliman’s body of professionals includes numerous other specialists, ranging from clinicians to economists.
Despite their impressive growth over the past six decades, they still operate according to the guiding principles of their founders, Wendell Milliman and Stuart Robertson. They retain their rigorous standards of professional excellence, peer review and objectivity. They remain committed to developing innovative tools and products and providing expert solutions. And they continue to earn their clients’ trust by keeping their focus fixed on their clients’ business objectives.