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 evaluating 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 evaluating 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.
**END OF EXAMINATION**

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