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Casualty Actuarial Society
1999 Special Interest Seminar
Health and Managed Care
October 18, 1999
Managed Care –
What Is It and
What Might It Be?
“The Next Generation”
Presented by:
David V. Axene, FSA, MAAA
Milliman & Robertson, Inc.
Milliman & Robertson, Inc.
Woodrow Milliman
INTERNATIONALLY
San Diego, California
1
The Butterflying of Managed Care
Fee maximums
Cost containment
Fee discounts
Incident management
Episodic management
Health status management
Milliman & Robertson, Inc.
Woodrow Milliman
INTERNATIONALLY
2
Five Guiding Principles
Only medically necessary services, and
no more intense than necessary to
provide the improvement in health
status that is reasonable for the patient
to expect.
Provided by a healthcare provider with
the appropriate expertise level, or at a
cost level not greater than the charge
of the appropriate expertise level.
Milliman & Robertson, Inc.
Woodrow Milliman
INTERNATIONALLY
3
Five Guiding Principles
continued
Provided in a setting not more intensive
or costly than necessary, recognizing
the key non-clinical factors.
Provided at a competitive price with
other providers in the marketplace.
Provided at a reasonable administrative
cost.
Milliman & Robertson, Inc.
Woodrow Milliman
INTERNATIONALLY
4
Components Needed to Effectively
Manage Health Status
Clinical descriptions of appropriate care
Utilization review and case management templates to
monitor care concurrently and retrospectively
Patient behavior/activity modification guidelines
Duration of care guidelines describing key monitoring
points to chart patient progress
Computerized patient medical records to permit realtime monitoring (past, present and near term)
Course-of-care maps and decision trees showing
alternatives and interventions to minimize decline
Milliman & Robertson, Inc.
Woodrow Milliman
INTERNATIONALLY
5
Resource Management Models
Financial or actuarial models to optimize
structural and practice efficiency
Helps providers adapt to more efficient
structures and practices
Key components
Statistical data consistent with practice
guidelines
What, how many and how much it costs
Incentives to achieve desired outcomes
Milliman & Robertson, Inc.
Woodrow Milliman
INTERNATIONALLY
6
Real Life Examples
Outpatient surgery facility models
Consumer communication tools
Workers’ Compensation
Milliman & Robertson, Inc.
Woodrow Milliman
INTERNATIONALLY
7
Summary
Valuable education tool for both
patients and physicians
Basis for benchmarking
Foundation for future improvements
Success through simple thoroughness
Integration of actuarial science with the
practice of medicine provides a strong
foundation for all developments
Milliman & Robertson, Inc.
Woodrow Milliman
INTERNATIONALLY
8
Outpatient Surgery Facility Models
Milliman & Robertson, Inc.
Woodrow Milliman
INTERNATIONALLY
9
Consumer Communication Tools
Milliman & Robertson, Inc.
Woodrow Milliman
INTERNATIONALLY
10
Workers’ Compensation
Milliman & Robertson, Inc.
Woodrow Milliman
INTERNATIONALLY
11