13. (5 points) You are a product development actuary working for a multi- line insurance
company. The company is developing an individual medical insurance product.
(a) Outline the types of premium rate and renewal guarantees that may be used and
characteristics of each.
(b) Describe factors that influence the level of lapsation rates for these types of
policies.
(c) Explain the differences between underwriting life insurance and underwriting for
major medical insurance.
(d) Describe sources of information the underwriter might utilize.
14. (3 points) You are an actuary for JKL Life which has recently decided to enter the group
medical line of business. You have been asked to lead a project to design the needed
management information system.
(a) Review the challenges of producing management information reports.
(b) Describe information/reports that would be useful to analyze claims and expenses.
COURSE 8: Fall 2002 -12- GO ON TO NEXT PAGE
Managed Care Segment
Afternoon Session
Questions 15 – 17 pertain to the Case Study
15. (6 points) You are an actuary for the Bedford Group. In a meeting with the VP of
Provider Contracts, you are told that IPA1 and IPA3 are considering consolidating
operations and would like to meet next week to formulate a new contract.
Your CEO is concerned that this consolidation would impact physician contracts. She
wants to hold physician costs for all IPA’s prior to any risk-share arrangements to 125%
of 2000 Medicare RBRVS.
Using Tables MC-5 and MC-7:
(a) Review the advantages and disadvantages of different contracting arrangements
between physician entities and managed care companies.
(b) Describe the legal structure of an IPA and explain why IPA1 and IPA3 may or
may not want to consolidate.
(c) Calculate the overall percentage of 2000 Medicare RBRVS paid in 2001.
Show your work.
(d) Calculate the percentage of 2000 Medicare RBRVS that must be negotiated with
the consolidated IPA in order to meet the CEO’s requirements. Show your work.
COURSE 8: Fall 2002 -13- GO ON TO NEXT PAGE
Managed Care Segment
Afternoon Session
Questions 15 – 17 pertain to the Case Study
16. (4 points) You are an actuary for the Bedford Group. Hospital ID 1 has been
successful with its Maternity case rate and would like to consider moving to a
case rate or capitation reimbursement for its Medical and Surgical services.
Using Tables MC-2 and MC-7:
(a) Explain differences between case rate, capitation and per diem reimbursement
arrangements and provide reasons why Hospital ID 1 may want to consider
changing.
(b) Calculate a combined case rate for all Medical and Surgical inpatient services for
Hospital ID 1 using 2001 experience. Show your work.
(c) Describe the financial issues that Hospital ID 1 should consider prior to revising
its current contract.
COURSE 8: Fall 2002 -14- GO ON TO NEXT PAGE
Managed Care Segment
Afternoon Session
Questions 15 – 17 pertain to the Case Study
17. (12 points) You are the Chief Actuary for the Bedford Group and have been approached
by a vendor offering demand management programs. You have determined that these
programs can save 5% per year on Hospital ID 1 inpatient medical and surgical claims at
a cost of $150,000 per year in administrative expenses.
In recent years Hospital ID 1 has been approaching full capacity of its inpatient
beds. They are considering implementing a clinical pathways program. The
hospital estimates that by implementing the program, it can reduce its medical and
surgical inpatient days by 10%. Implementation cost for the program is estimated
to be $250,000. Hospital ID 1 has approached you to share in half the
implementation cost and to increase their reimbursement by 5% to recognize the
improvement in care.
In addition to inpatient claims, the Bedford Group paid $57,960,000 in outpatient
claims to Hospital ID 1 in 2001. Assume no other contract provisions change and
membership and utilization remain at 2001 levels.
Using Tables MC-2, MC-3, MC-7, and MC-8:
(a) (2 points) Compare and contrast disease management and demand manageme nt.
(b) (2 points) Describe clinical pathways and their possible uses.
(c) (6 points) Calculate the expected impact on 2001 revenue to Hospital ID 1 from
the Bedford Group for the following programs:
(i) clinical pathways
(ii) demand management
(d) (2 points) Due to limited resources, only one of the two programs may be
implemented. Recommend which program you would choose. Support your
recommendation and show any related work.
COURSE 8: Fall 2002 -15- GO ON TO NEXT PAGE
Managed Care Segment
Afternoon Session

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