It’s an exciting time to be involved in healthcare! To launch a robust discussion for the remainder of the meeting, two health economists provide a peek into their crystal balls, examining recent developments and giving us their predictions on the future of healthcare financing in the US.

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Medicare currently represents about 20% of national health expenditures, and Medicaid an additional 17%. Accordingly, their current financial condition and their evolving financing arrangements are critical to the fiscal health of the US. Two representatives from the CMS Office of the Actuary explain the role their office plays in healthcare finance and delivery reform, and share their experiences with the design and evaluation of value-based models such as the Medicare ACOs, Medicaid demonstrations, and other innovation models.

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How should we apply ethics and professionalism in our daily work activities? Presenters outline real-world scenarios that may not have a clear answer as to the right course of action relative to professional and ethical standards for health actuaries. We'll utilize real-time polling technology to allow audience interaction on key questions throughout the presentation, and provide 1.8 of the 3.0 credits required annually for professionalism.

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According to the CDC, more than 115 Americans die after overdosing on opioids every day. This makes this epidemic a serious national crisis that affects public health as well as social and economic welfare. There are many ways a person may become susceptible to opioid use and to understand some of these will save lives. Admiral Winnefeld speaks about his personal experiences on the topic and why he created the advocacy group Stop the Addiction Fatality Epidemic (SAFE) to eradicate opioid addiction through research, awareness campaigns and expand treatment resources.

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The opioid epidemic impacts several different aspects of insurance—health care, disability and life insurance. So, how is the insurance industry lending its expertise to curbing this nationwide problem?

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Presenters provide examples of the evolving use of data analytics in health benefit design and operation. They also discuss possible mis-use and mis-interpretation, and share thoughts on how to avoid these pitfalls.

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The Health Care Cost Institute (HCCI) started in 2011 with the goal of helping people to better understand costs and utilization of health care for Americans covered by private insurance. In order to accomplish this goal, HCCI has internal researchers to work on annual studies of the data and has made the data available to academic researchers for other projects. Several studies have been published and more are in the pipeline. In addition, a public health cost transparency tool is administered by HCCI (www.gurroo.com). The Executive Director of HCCI provides an overview of the Institute and the lead researcher for the annual cost trend report discusses their latest release.

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Narrow network strategies are becoming more common. However, health plan members must be careful to avoid Out of Network (OON) providers where costs can be two to five times in network costs. To keep costs low many plans are seeking ways to lessen the financial impact on employers and members. There are many techniques to manage OON costs, but often with significant problems for the plan costs and member cost sharing.

In this session, we view the issues as seen through payer and provider financial, clinical, network and operational lenses. This includes topics including but not limited to:

• Controlling OON services to ERAP (emergency, radiology, anesthesiology, pathology) providers;
• Limitations on place of service;
• Contract leveraging and reference pricing;
• Tertiary care and reinsurer management;
• Fraud, waste and abuse;
• Mini med and alternative healthcare insurance; and
• Marketplace purchasing options.

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How are PBMs, payers, and providers evolving to handle the prescription drug pricing trends and differences between list price and net pricing of drugs? Speakers at this session discuss specialty drug cost containment and the shifting role of providers as they share more financial risk within payer contracts. The strategies include formulary management, trend reporting, and value-based contracting principles for success.

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