北美精算师November2003Course8M（第二部分）——SOA精算师考试，无论你来自何方，北美精算师的基础到什么阶段，考试请尽全力去考。
　　16. (4 points) You are a consulting actuary for Hospital ID1. The Bedford Group is
　　proposing t
　　to capitate Hospital ID1 for inpatient hospital services incurred by its
　　members. You have been asked by Hospital ID1 to develop capitation targets for
　　negotiations with the Bedford Group.
　　In addition to information provided in Tables MC-2 and MC-7, you have made the
　　following assumptions:
　　?  administrative expenses: 8% of capitation
　　?  risk charges: 6% of capitation
　　?  the 2002 hospital experience is credible
　　(a) Using an actuarial cost model based on your current provider contract with
　　Bedford Group, calculate the base pmpm cost. Show your work.
　　(b) List key assumptions that should be considered when determining the utilization,
　　average cost and pmpm targets in an actuarial cost model.
　　(c) Describe additional considerations that Hospital ID1 should consider when
　　*uating a capitation proposal.
　　COURSE 8: Fall 2003 - 13 - GO TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
　　Questions 15 - 18 pertain to the Case Study
 
　　17. (12 points) You are an actuary for the Bedford Group. In a meeting with the VP of
　　Provider Contracting, you are told that a large physician specialty group that provides
　　15% of all specialty services has left IPA1 and joined IPA2.
　　Assume that:
　　?  Physician risk share arrangements for 2002 and 2003 do not change.
　　?  For PCP’s in IPA1, the 2002 actual claim cost equals the t arget claim cost.
　　Using Tables MC-5, MC-7, and MC-8, and based on 2002 experience:
　　(a) Adjust the 2003 risk share arrangements for IPA1 and IPA2 to reflect the
　　provider change. Show your work.
　　(b) Calculate the expected 2003 payments to IPA1 and IPA2 based on the
　　specialty group shift to IPA2, including any risk share adjustments and
　　ignoring trend. Show your work.
　　(c) Excluding any risk share arrangements, calculate the new percent of
　　Medicare reimbursement to IPA2 to maintain pmpm cost
　　s for the Bedford
　　Group at the 2002 level. Show your work.
　　(d) In case IPA2 does not accept a change to their Medicare reimbursement
　　level, you would consider offering a specialty capitation arrangement.
　　Discuss the advantages and disadvantages of a specialty capitation
　　arrangement.
　　COURSE 8: Fall 2003 - 14 - GO TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
　　Questions 15 - 18 pertain to the case study
 
　　18. (6 points) You are the pricing actuary for the Bedford Group and have been asked by the
　　Marketing Director to develop new pharmacy premiums. She is interested in having a
　　more competitively priced product. Yo ur CFO has indicated that your profit goal is 2.5%
　　of premium.
　　Assume the HMO and POS plans have identical plan formularies with the following
　　copays:
　　?  Generic $10
　　?  Formulary Brand $20
　　?  Non-Formulary $40
　　Using 2003 budgeted experience from Table MC-4, information provided on Table MC-7,
　　and assuming AWP = $80, then:
　　(a) Calculate the premium if Bedford:
　　(i) retains all rebates.
　　(ii) uses all rebates to reduce premiums.
　　(b) Describe the purposes of rebates, issues surrounding rebates, and actions which
　　can be taken to increase rebates.
　　COURSE 8: Fall 2003 - 15 - GO TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
　　高顿网校之做人原则：平凡朴实的梦想，我们用那*10的坚持信念去支撑那梦想。