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北美SOA真题Course8M（最三部分）——2014年精算师

来源：高顿网校 2014-07-18

　　打算考今年秋季精算师的有没有？来高顿网校报名吧。我们这里题库和网校啥都有！下面是北美SOA真题Course8M（最三部分）——2014年精算师。
　　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
　　高顿网校之旷世名言：要有自信,然后全力以赴--假如具有这种观念,任何事情十之八九都能成功--威尔逊

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