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18. (6 points) you are an actuary for the bedford group, the managed care division of wonderful life insurance company. the cfo has committed to the board that contribution to surplus will grow by 20%. you are given the following in addition to information in tables mc-1, mc-3, and mc-6: • ending 2004 surplus = $100 million. • the average premium increase is 7% from 2004 to 2005. • claim trend for 2005 is estimated to be 8% for medical and 15% for prescription drugs. • no change in provider liability from 2004 to 2005 • a one-time $3,000,000 expense charge for sarbanes-oxley and hipaa compliance in 2005 was immediately expensed. • administrative and facility costs were the same as in 2004. • no it capital expenditures were paid in 2004 nor expected for 2005. • mis & it costs in 2004 were 30% higher than expected due to non-recurring consultant fees. • salaries and other administrative costs increased on average 3.5% from 2004. • 2005 total membership did not change from 2004. • commissions and premium tax as a percent of premium is as shown in table mc-1. • corporate taxes are expected to be 37.5% of operating earnings before taxes. • no other income was recorded in 2005. (a) (5 points) calculate the expected 2005 investment income based on the above assumptions which would be needed to meet the cfo’s contribution to surplus target and comment on the reasonableness of the cfo’s commitment. show your work. (b) (1 point) describe actions that can be taken to increase surplus. course 8: fall 2005 - 20 - go to next page managed care segment 19. (4 points) whitecoat health plan (whp) pays laboratory providers at a fixed percentage of billed charges. over the last two years, costs for these services have escalated rapidly, and whp has decided to introduce a fee schedule for some provider types and services. effective january 2006, whp will contract with one clinical lab for specific lab procedures at a flat fee per procedure. you have been given the following information: 2006 rate per service 3/1/2004 – 2/28/2005 billed charges 3/1/2004 – 2/28/2005 procedures procedure 1 $20 $7,361,770 146,067 procedure 2 $17 $10,226,250 252,500 procedure 3 $30 $6,841,766 85,844 • whp currently reimburses laboratory services at 70% of billed charges. • annual trend for billed charges per service is 4%. • total billed charges are expected to increase by 15% per year. • all services for the three procedures are expected to be delivered through whp. (a) calculate whether the arrangement for 2006 will produce savings over the current reimbursement. show your work. (b) discuss other methods whp can employ to reduce ancillary costs. course 8: fall 2005 - 21 - go to next page managed care segment 20. (6 points) wrinkle-be-gone cosmetics (wbgc), a large employer group has approached your prescription benefit manager (pbm) to quote their self-funded retiree drug plan. you were given their current and proposed benefit plans. benefit percentage claims cost current plan new plan $0 - $3,000 75% 75% $3,001-$5,000 50% 0% $5,001-$7,500 50% 50% $7,501-$10,000 0% 90% $10,001 + 0% 90% • the plan is a closed formulary drug plan • administration fees are targeted to be $1.50 pmpm all claim costs indicated below are billed charges net of discounts, but before member cost sharing. annual rx costs members avg no. of scripts annual cost per member percent generic percent brand $0 - $3,000 2,220 12.5 $615 80% 20% $3,001-$5,000 925 44 $3,216 65% 35% $5,001-$7,500 370 68 $6,018 30% 70% $7,501-$10,000 111 84 $8,127 10% 90% $10,001 + 74 110 $12,375 0% 100% wbgc will remain self-insured and proposes to pay no administrative fees to the pbm, but the pbm will retain rebates as their fee. assume that all members in the group have at least one script per year. rebates are paid to the pbm for brand drugs only at a rate of $1.20 per script. (a) (1 point) describe the effects of benefit maximums and their advantages and disadvantages as part of a prescription drug plan design. (b) (3 points) calculate the difference in expected costs to wbgc under the current and proposed plan designs. show your work. (c) (2 points) calculate the projected rebates under the proposed plan design to determine if the proposal meets the targeted administrative fee. show your work. course 8: fall 2005 - 22 - stop managed care segment 21. (3 points) (a) describe the steps needed to develop a clinical pathway for an inpatient episode. (b) describe alternative formats used for information displays of clinical pathways and the advantages and disadvantages of each.  |
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