以下是北美精算师历年考试要点——SOA真题Course8M（第3部分），请高顿网校的粉丝们耐心看下去哦。
　　15.(4points)YourCFOisconsideringhiringamedicalmanagementvendorthatspecializes
　　inreducingphysicalmedicineandchiropractorutilization.TheCFOwantstotest
　　whetherthevendorcanlowerHMOclaimcostsin2005.Thevendorstatesthattheycan
　　reduceutilizationforeachofthesetwoservicesby8%andreducecostsby$3.00perunit
　　in2005.Withouttheprogram,medicalunitcostisexpectedtoincreasefrom2004to
　　2005by10%andutilizationby2%.ThisprogramwillalsoincreasetheDisease
　　Managementadministrativecostsin2005by20%.
　　UsingTablesMC-4,MC-5,MC-6
　　(a)Calculatethefinancialimpactofthisprogramassumingthemedicalmanagement
　　vendor’sassumptionsarerealized.Showyourwork
　　(b)Listactionstheplanandvendorshouldtaketoensurecompliancewiththeir
　　medicalmanagementobligationswhileminimizingtheirliabilityexposure.
　　COURSE8:Fall2005-16-GOTONEXTPAGE
　　ManagedCareSegment
　　Questions15–18pertaintotheCaseStudy
 
　　16.(12points)TheBedfordGroupisexpandingintoanewmarketandneedstocontract
　　withRuralHealthplansInc(Rural),aphysicianhealthorganization,tocoverinpatient
　　andphysicianservices.Ruralisthesolehospitalproviderinthisnewmarket.Ruraldoes
　　notprovideskillednursingservices.
　　Tobecompetitive,yourMarketingManagerrequestsapremiumof$180PMPM
　　(excludingprescriptiondrugs).YourCFOrequiresapricingmarginof3%.
　　YouaregiventhedatainTablesMC-1,MC-2,MC-4,MC-7,andMC-8.
　　Fordeveloping2005expectedclaimscostsforthenewregion:
　　Assumetherewillbe120,000membermonths.
　　Hospitalutilizationfor2005willbethesameasthe2004combinedservicesfor
　　HospitalsID1,ID2andID3.
　　RuralwillbereimbursedbasedontheHospitalID2feeschedule.
　　AssumeeveryRuraladmissionisatleastatwo-daystay.
　　Physiciancostsareexpectedtorepresent45%oftotalmedicalcosts.
　　Youplantoofferproviderincentives:
　　RuralwillbeofferedanincentivesimilartoHospitalID2exceptthetarget
　　averagelengthofstayis90%oftheexpectedaveragelengthofstay.
　　Physicianswillhavea20%withholdtoberepaidthreemonthsaftertheendof
　　theyear.
　　Anyinstitutionalsurpluswillbesplitwiththephysiciansbutwillfirstbeusedto
　　offsetanywithholddeficits.
　　Forincentivepurposesyouhavetargetedutilizationtobeasfollows:
　　ServiceAdmits/1000Days/1000
　　Medical25.080
　　Surgical15.070
　　Psychiatric4.040
　　Alcohol&DrugAbuse1.510
　　Maternity15.030
　　(a)Listpotentialsourcesofdatatosupplementyourowndataandconcernsyoumay
　　havewitheachofthesesources.
　　(b)Calculatethe2005expectedhospitalinpatientPMPMclaimcostforRural.Show
　　yourwork.
　　COURSE8:Fall2005-17-GOTONEXTPAGE
　　ManagedCareSegment
 
　　16.Continued
　　(c)CalculatethehospitalincentivethatwouldbepaidtoRuralfor2005ifthey
　　achievetargetedutilization.Showyourwork.
　　(d)Calculateoutpatientfacilityclaimscostsassumingyouchargethe$180premium
　　andusingresultsfromyourpriorcalculations.Showyourwork.
　　(e)Developthephysicianwithholdandhospitalincentiveliabilitiesattheendof
　　2005assumingthatactualincurredclaimsare$9millionforphysicianservices,
　　$10millionforinstitutionalservices,andthattargetedutilizationisachieved.
　　Usetheresultsfromyourpriorcalculations.Showyourwork.
　　COURSE8:Fall2005-18-GOTONEXTPAGE
　　ManagedCareSegment
　　Questions15–18pertaintotheCaseStudy
 
　　17.(5points)Throughproviderprofilingefforts,youobservedthatHospitalID2performs
　　anunusuallyhighnumberofcaesariansection(C-Sections)deliveries.Yourdiscussions
　　withthishospitalresultedinanimplementationofanewprogramthatwilllowertheir
　　rateofC-Sectionsby10%.Theone-timecostofthisprogramis$50,000whichyouhave
　　agreedtofund.Inreturn,HospitalID2willagreetochangetheirreimbursementtoaper
　　casebasis.
　　Youaregiventhefollowing:
　　TablesMC-2,MC-3,andMC-7
　　Incurredmaternityclaimsatallhospitalswere$7,800,000for2004.
　　IncurredmaternityclaimsatHospitalID3were$800,000for2004.
　　Priortothisnewprogram,30%ofalldeliveriesatHospitalID2wereC-Sections
　　andC-Sectionscost80%morethannormaldeliveries.
　　(a)Discusstheadvantagesandconcernswhenusinginpatientclaimsdataforquality
　　improvementandutilizationmanagementpurposes.
　　(b)CalculatetheaveragecostperadmitforC-SectionsandNormalDeliveriesat
　　HospitalID2.Showyourwork.
　　(c)Calculateexpectedsavingsresultingfromimplementingthisnewprogramand
　　changingreimbursementtoHospitalID2toamaternitycaserate.Showyour
　　work.
　　COURSE8:Fall2005-19-GOTONEXTPAGE
　　ManagedCareSegment
　　Questions15–18pertaintotheCaseStudy
　　高顿网校之做人道理馈赠：该笑的时候没有快乐，该哭泣的时候没有眼泪，该相信的时候没有诺言。