Health Section Issue 78, May 2015, Health Watch

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I S S U E 7 8 M AY 2 0 1 51A Modern Approach toTraditional ReservingBy Peter Horman2Letter from the EditorBy Valerie Nelson3Chairperson’s CornerBy Andie Christopherson8Implementing USPSTFRecommendations onBehavioral Counseling forCardiovascular DiseaseBy Ed Cymerys and SeanDuffy12 A Practical Guide toPrivate ExchangesBy Karen Shelton and DavidPetta18 Basic Health Program:Why Do Some StatesBother and Others Don’t?By Karan Rustagi, TimCourtney and Julia Lerche22 Retiree Health Benefitsand the U.S. SupremeCourtBy Jeffrey Petertil26 Articles in the NorthAmerican ActuarialJournal of Interest toHealth ActuariesBy Ian Duncan27 Examining the EvidenceWhy Do Cause andEffect Matter for HealthActuaries?By Tia Goss Sawhney andBruce PyensonHealth WatchA Modern Approach to TraditionalReservingBy Peter HormanFor over 20 years health actuaries have had the computing power and software to applyadvanced statistical methods to set reserves and eliminate more traditional reservingapproaches. In practice most reserving actuaries, auditors and insurance examinersemploy the traditional lag triangle and forecasting methods, which have changed very littlein the last 40 years. Today’s reserving actuaries often struggle with tight timelines, increasedreporting needs, and more actuarial liabilities (3Rs, medical loss ratio (MLR) rebates, provider risk contracts, and more). In this article, I will outline four modern conveniences thatcould help keep traditional reserving methods relevant for years to come. To start, I willdefine what I mean by a traditional reserving approach.Traditional Reserving Approach: The common actuarial practice of using a claims lag triangle to estimate claims completion, assess recent trends, and impute seasonal patterns. Thegoal for each month is to estimate the ultimate incurred claims level and then net out any paidclaims to calculate the reserve. For most months the ultimate incurred per member per month(PMPM) is estimated using the completion factors. For the recent and very incompletemonths, the actuary forecasts ultimate claims PMPM using completed months, a trend estimate, and any observed seasonal pattern. In addition, it is common to have multiple reservecells—one for each business line and with multiple claims categories (inpatient, outpatientand other non-facility medical, Rx, and mental health).CONTINUED ON PAGE 4

Letter from the EditorBy Valerie NelsonI S S U E 7 8 M AY 2 0 1 5Health WatchPublished by the Health Section Councilof the Society of Actuaries.This newsletter is free to section members.Current issues are available on the SOA website(www.soa.org).To join the section, SOA members and nonmembers can locate a membership form on theHealth Section Web page at http://www.soa.org/health/2015 Section LeadershipOfficersAndie Christopherson, ChairpersonElaine Corrough, Vice-ChairpersonBrian Pauley, Secretary/TreasurerCouncil MembersTerry BauerKara ClarkDavid DillonDaniel FeuchtEric GoetschJulia LambertBill O’BrienMichelle RoarkRina VertesEditorial Board MembersValerie Nelson, Editor-in-Chiefvalerie nelson@bcbsil.comJ. Patrick Kinneyph: 585.238.4379Patrick.Kinney@excellus.comJeff Millerph: 913.707.0067jeff@jdmfsa.comSOA StaffKaren Perry, Publications Managerph: 847-706-3527 f: 847-273-8527kperry@soa.orgJoe Wurzburger, Staff Partnerjwurzburger@soa.orgLeslie Smith, Staff Specialistlsmith@soa.orgJulissa Sweeney, Graphic Designerph: 847.706.3548 f: 847.273.8548jsweeney@soa.orgThis publication is provided for informationaland educational purposes only. The Society ofActuaries makes no endorsement, representationor guarantee with regard to any content, anddisclaims any liability in connection with the useor misuse of any information provided herein.This publication should not be construed asprofessional or financial advice. Statements of factand opinions expressed herein are those of theindividual authors and are not necessarily those ofthe Society of Actuaries. 2015 Society of Actuaries. All rights reserved.2 May 2015 Health WatchIhope everyone is enjoying the spring!This issue’s cover article is on reserving—modern approaches that is! Written byPeter Horman, this piece discusses the changing world of the valuation actuary and waysto address that change.Ed Cymerys and Sean Duffy have contributed a very interesting read on the latest U.S.Preventive Services Task Force requirementsand how health plans can think and actcreatively to become compliant with theserequirements.Finally, in this installment of “Examiningthe Evidence,” Tia Goss Sawhney and BrucePyenson deliver a great read on the subject ofcause and effect.Also, an exciting special edition of HealthWatch is coming out this summer with a solefocus on a five-year retrospective since thepassage of the Affordable Care Act and howour world has changed. Please look for thispublication in your mailbox and on SOA.org.Private exchanges have been picking up alot of interest in the employer benefits community. Karen Shelton and David Petta havewritten a study note on this topic, which isbeing printed in this publication, since it willbenefit all actuaries to understand this growing platform.Basic Health Programs were discussed inthe feature article in the January publication. In this publication, Karan Rustagi, TimCourtney and Julia Lerche follow up on thistopic using the lens of the state and the considerations from that perspective.Jeffrey Petertil’s article covers the impactof a recent Supreme Court of the UnitedStates decision on the assumed duration ofemployer-sponsored retiree health benefits.This article is also being featured in PensionSection News.The North American Actuarial Journal(Volume 19, Issue 1) contains two healtharticles that would be of interest to theHealth Watch readership. Please check out:“Multi-State Actuarial Models of FunctionalDisability” by Michael Sherris et al, and“Anatomy of a Slow-Motion Health InsuranceDeath-Spiral” by Ted Frech and MichaelSmith.Valerie Nelson, FSA,MAAA, is an executivedirector and actuary atBlue Cross/Blue Shieldof Illinois. She canbe reached atvalerie nelson@bcbsil.com.

Chairperson’s CornerBy Andie ChristophersonIhave been stalling for weeks in writingthis segment, having no idea what towrite about! It’s challenging to measureup to the high quality of the articles in eachedition of Health Watch, given the excellentleadership of our editor and the outstandingarticles our members continue to submit. I’mgetting tired of saying it, but it is a crazy timeto be in our profession. I both love what I’mdoing, and feel like my hair is on fire on adaily basis. There is so much to learn, keepup with, do and review. So I’m going to keepthis corner short and sweet.We have a number of outstanding eventson which council members and friends ofthe council have been working hard to plan.Knowing how people’s time is in such shortsupply, I highly recommend you take advantage of the opportunities to cram as muchthought leadership and learning in, as efficiently as possible. I know I will be!camps on Valuation, Advanced CommercialPricing, and Medicare Advantage for late inthe year, with a half day of professionalismto get that continuing education requirementbox checked.Whatever choice you make for continuingeducation, I know it’s time to get back towork for me! So without further ado, I’ll letyou dive into this edition of the newsletter,and I wish you the best of luck with whateveryour particular flavor of busy is this time ofyear.Andie Christopherson,FSA, MAAA, is chiefactuary at Land ofLincoln Health inChicago, Ill.She can be reachedat achristo@landoflincolnhealth.org.First, our 2015 Health Meeting is coming up.It’s being held June 13-15 in Atlanta. Theschedule is packed with interesting, forwardlooking topics and key note speakers. Wewill also be offering a new seminar immediately following the meeting—Best ActuarialPractices in Health Studies. There are aplethora of topics which need further analysisand explanation in our field, and this seminarshould provide the tools on how to messageand present the findings to practicing actuaries in a meaningful and succinct way.Looking into the second half of the year,we are making great strides in expandingthe health offerings at both the ValuationActuary Symposium (August 31-September1 in Boston) and the Annual Meeting &Exhibit in Austin, October 11-14. As springbecomes a busier time for a larger portionof our profession, we recognize the need fordeeper offerings to work around busy schedules. As this issue goes to press, we are in theprocess of lining up a trio of in-depth bootHealth Watch May 2015 3

A Modern Approach FROM PAGE 1Peter J. Horman, FSA,MAAA, is a former chiefactuary who recentlystarted an independentconsulting firm HormanMathematical andActuarial Solutions, inBoston, Mass. He canbe reached at peter@hma-solutions.com.While the traditional approach has many variations and is unique to each actuary, for this articleI am assuming a model with 36 months of data,where the most recent two months use the PMPMforecast and older months use completion factors.The numbering system I will use assumes the mostrecent and most incomplete month is Month 1.For example, at year-end 2014, December 2014 isMonth 1, November 2014 is Month 2, and January2012 would be Month 36.addressing the questions. First, a good rule of thumbin automation is to spend the time you saved checking the results (this is also a good way to minimizestaff fears of automating their job away). Second,robo-reserving may lead to some embarrassing professional moments; at a minimum I recommend asimple reasonableness check to all automated work.For the third question, not all projects carry thesame financial risks or professional liability, so thereality is there will likely be some trade-offs.In order to effectively address today’s health reserving challenges, this article will explore the following tools: automation, data storage, use of riskscores, and statistics. These four tools can help beattimelines, increase reporting and improve accuracy.Automation is a must in today’s world. In additionto speed, automation generates the accuracy, consistency and detail data required to advance traditionalreserving to the next level.Automation and the Eight-DayCloseMost of us have moved to the eight-day financialclose, meaning the reserve is likely due to theaccountants by the fifth business day. In response,many actuaries have applied some degree of automation. This article is not going to go into depthabout how and why to automate except to state thataside from possibly the actuarial judgment, most ofthe process can be automated.With an automated process an actuary will haveorganized data elements that can be retained andused. As research for this article I counted thenumber of components in my standard reservingworkbook—over 17,000 data points. Compoundingthe 17,000 times the number of business lines andclaims categories, I had 2.5 million reserving datapoints per month. This creates a need to structure anentire database out of just information in the reserving workbooks.A more interesting discussion is how actuariesshould behave in an automated environment. I findthere are three important questions each actuaryshould address when using an automated process:I am not suggesting storing all the data, but thefollowing are some examples of projects and dataelements that could be stored for reserving:1. How much can you rely on an automatedprocess (in other words, do you need tocheck every cell)?2. Is robo-reserving (relying 100 percent onautomated calculations) an actuarial soundpractice?3. Do the answers to questions 1 and 2 changedepending on if it is quarterly statutoryreports, year-end orange blank, or managerial reporting?These questions are open for interpretation, and arebased on each individual’s comfort level, resourceavailability, and quality of automation. However, Ihave found the following guidelines are effective in4 May 2015 Health WatchSpace Is Cheap and Data IsValuable Tracking restatements (requires reserve and paidclaims) Estimating your durational accuracy (requiresincurred estimates by month) Comparing lag factors (requires storing allreserve factors, not just actuaries’ picks) Simulating reserve volatility and fitting statisticaldistributions (see examples in later section).Having a well-structured database of reserving datawill speed up standard recast analysis and open thedoor to many new and useful reporting applications.Organized data storage is the starting point to themodern approach and enables important advanceslike the integration of risk scores or applications ofstatistics.

Member Level ReserveAllocationA reserving actuary’s biggest resource drain maybe the detailed reporting requirements requestedby senior management. Building an extra reservemodel for each reporting cell creates work and lowers credibility of that model. Most actuaries haveprospective risk scores readily available. These area great tool to allocate the reserve to the individualmember level. With a member level allocationof reserve, reporting can be efficiently and easilyperformed at any level. Some examples where thismethod has assisted me include:1. Reporting to detailed lines of business—forexample, at the employer account level2. Developing provider-level allocations forprovider bonus accruals3. Affordable Care Act (ACA) 3Rs—reinsurance and allocating claims to exchange vs.non-exchange products.A benefit of the member-level allocation that shouldnot be lost is the ability to calculate all the accrualsand directly tie them to the incurred but not reported(IBNR) for the auditors.The goal is to allocate the reserve for months with zero,one or two months of run-out to each member (oldermonths can use the lag factors or a uniform PMPM).The method can be straightforward to complex—I willintroduce the simplest form, and then outline someideas for developing more complex allocations.The simple method assumes all members have a fullmonth of eligibility and a valid risk score. Using thesimple assumptions in this formula ensures analgebraic equivalence between the total monthlyreserve in any reserve cell and the sum of the member-level reserve allocation across that reserve cell.month kReserve month k monthi ReserveRiskScorememberi Mj 1RiskScorememberjWhereReserve month kmemberi The member reserve allocationfor month k for member iReserve month k Total dollar portion of the IBNRreserve due to month kRiskScore Prospective risk score (I will leave itto the actuary on appropriate risk score selection).The calculation assumes there are M members andmember i is one of those members.Conceptually the simple method is a great way tounderstand the risk score allocation, but many mayfind it is too simple to effectively work in practice.Members have different plan designs; some providers have lower costs; and not all members have anavailable risk score—hence the need for more complex methods. I will not outline the formulas hereexcept to say that while they add complication theyare fairly straightforward to address. Some items toconsider include:1. Addressing partial risk scores—It is key thatactuaries understand the risk scores theyare using. Modern risk score models adjustfor members with fewer than 12 months ofexperience; however, some older versionsdo not. In addition, new members may nothave a risk score so you may need to build analgorithm to default to a demographic factor.2. Experience cells—Allocating the reserve toa provider or employer group may requireadding an experience adjustment factor. Apossible approach might be taking the mostrecent 12 months of experience and adjustingfor credibility (a good start is the credibilityformula used in large group underwriting).3. Plan design—Adding a benefit factor isfairly easy in the reserve allocation, but eventhis can get complex if you try to adjust forspecific benefit seasonality. Don’t let perfection be the enemy of the good.The list of refinements is never-ending, but themost important item to remember using complexmethods is that you may lose the algebraic equivalence the simple method relied upon; complexmethods require a conservation of reserve factor. Aformula to conserve the total reserve is below:Conservation Factor month k Reserve month k Reserve month kmemberiMj 1CONTINUED ON PAGE 6Health Watch May 2015 5

A Modern Approach FROM PAGE 5With the work automated and the financial reporting benefits of the member-level reserve obtained,we can shift focus to understanding and improvingthe accuracy of the reserve. The next section discusses how, with a good database and application ofprobability and statistics, you can start that process.Apply Probability andStatisticsWith the time saved from automation and the datamaintained in the reserving process, you can startto incorporate more complex statistical processes(many of which can be performed in Excel). Whilethe applications are limitless, I will outline a fewthat I have found work well in practice—simulatingreserve volatility, monitoring provider payment patterns, and applications of more advanced statistics.Monte Carlo Simulation of Reserve Volatility: Fromthe data storage we have a host of information at ourfingertips. One great example of how to leverage thatdata is to use a Monte Carlo simulation to address andjustify “good & sufficient” margin. The following isan example of a Monte Carlo simulation using historic reserving data that can be performed in Excel.Formula: To start, reserve volatility needs to bedefined. Here, I define it as the distribution of thedifference between the reserve incurred estimateand the ultimate incurred estimate. A simplified version of the formula:36Reserve Volatility Members n 1 ϵnWhereϵn Reserve Inc PMPMn - Ultimate Inc PMPMnIn this simulation Reserve Inc PMPMn is fixed, butUltimate Inc PMPMn is an unknown random variablemaking ϵ n a random variable as well. Members is asimplifying assumption that all months have the samemembership. In this case, n represents the month ofthe claims estimate (as stated earlier, n 1 is the mostrecent month, n 2 is the second month, etc.).The next step is to develop a probability distribution around each ϵ n; for this example we can usethe database we have built in the prior section toidentify historic values. See Table A for an example:In the table below, there are 10 observations from10 reserve estimates, comparing the initial incurredPMPM estimate versus the ultimate incurredPMPM estimate. Example, Observation 1 was fromthe January 2014 financial close (performed earlyFebruary 2014), and the estimate of the error forJanuary 2014 is 3 PMPM, which is the differencebetween the ultimate incurred PMPM at May 2015and the initial incurred PMPM. In practice, the actuary would want to simulate over more observations.Table A: Example of Month 1 Error DistributionReserving6 May 2015 Health WatchMonth 1 EstimateUltimate EstimateObs #Close MonthInitial TimeIncurredPMPMUlt TimeIncurredPMPMObs 1Jan-2014Jan-2014 353May-2015 356 3Obs 2Feb-2014Feb-2014 354May-2015 364 10Obs 3Mar-2014Mar-2014 355May-2015 353- 2ϵnObs 4Apr-2014Apr-2014 356May-2015 358 2Obs 5May-2014May-2014 357May-2015 353- 4Obs 6Jun-2014Jun-2014 358May-2015 357- 1Obs 7Jul-2014Jul-2014 359May-2015 364 5Obs 8Aug-2014Aug-2014 360May-2015 358- 2Obs 9Sep-2014Sep-2014 361May-2015 357- 4Obs 10Oct-2014Oct-2014 362May-2015 356- 6

With the formula and distribution in hand the simulation steps are easy:1. Generate a random number and use it to selectan observation and its prediction error. In TableA, assume the random number is 7 then theϵ1 5 (for Excel users try int(Rand( )*10) 1to generate a random integer).2. Replicate the experiment for each run-outmonth.3. Sum across all months and multiply by membership; this is the first simulation.4. Repeat Steps 1 to 3 about 100 times.5. Evaluate the distribution of reserve errors.The simplest way is to sort high to low, thenwith 100 observations you can easily viewpercentile ranges.6. The last step is to use the historical reserverecast numbers to validate that the simulateddistribution is reasonable.This simulation is a nice way to quantify thereserve volatility; however, in my experience,reserve restatements often are caused by non-random claims processing issues. The next applicationdescribes using statistics to monitor claims processing issues.Statistical Monitoring: Often the random reservevolatility is manageable, but reserve volatility fromoperational risk, such as claims processing or provider reporting errors, may not be. Statistics can bea great tool to monitor many small items to identifyprocessing issues—one such example is a statisticalmonitoring report of each hospital’s monthly paidclaims. In the right hand column above is a graphical example of a hospital’s paid claims reported tothe insurer over nine months.Using the historic period, the actuary can developa statistical distribution and range around the standard monthly volatility. From the example it is easyto see that General Hospital had low outlier Augustand September claims reported. If these errorswere not caught early, the traditional reservingactuary would likely set the reserve too low. Whilethis example is graphical, it is possible to buildalgorithms to identify and triage statistical outliersacross all providers.Stochastic Reserving Techniques: The entire premise of this article is that actuaries do not need stochastic reserving techniques to set the reserve. Thatsaid, there are some benefits to using black boxstatistical software for fitting stochastic functions toclaims and then using them to estimate the reserve.Here are a few: Compare man vs. machine—Compare accuracy of statistical reserves versus the actuaries’reserve picks. Develop regression formulas to estimate utilization counts from the reserve PMPM pick. Another solution for dealing with very smalllines of business.Statistics and statistical processes do have a bigrole to play in the traditional reserving process.However, it is unlikely they will replace the actuaryanytime soon.ConclusionIs there a better reserving approach? I am not sure,and traditional actuaries may constantly need tolook over their shoulders. In order for the traditionalreserving approach to meet today’s demands, theactuary will need to take advantage of automationand data storage capacity. Then to meet sophisticated and detailed analysis, actuaries will also needto embrace statistics and risk scores to supplementthe reserving process. With or without these adjustments, the traditional reserving approach is likelyto be around for years to come. However, thesemodernizations may improve accuracy, add functionality, and protect your weekend.Health Watch May 2015 7

Implementing USPSTF Recommendationson Behavioral Counseling forCardiovascular DiseaseBy Ed Cymerys and Sean DuffyIn 2009, the Centers for Disease Control and Prevention (CDC) labeled chronic disease the “publichealth challenge of the 21st century.” Their report detailed the corrosive effects—for both individualsand society—of a series of creeping epidemics: obesity, diabetes, heart disease, and other conditionscaused primarily by lifestyle or behavior. Three of four Americans will die prematurely of a disease thatcould have been prevented by changing unhealthy habits.These trends aren’t new, especially when it comes to obesity; 78.6 million Americans are now consideredobese (body mass index 30), with 60 percent of all Americans falling into either overweight or obesecategories based on BMI.Edward C. Cymerys, FSA,MAAA, is an independent consultant in SanFrancisco and also servesas corporate strategyadvisor and chief actuaryfor Collective Health, Inc.He can be reached atedwardcymerys@gmail.com.Sean Duffy is the cofounder and CEO ofOmada Health (omadahealth.com), a SanFrancisco-based providerof innovative, scalableand cost-effective onlinebehavior change programs that address thegrowing epidemic ofchronic disease. He canbe reached at sean@omadahealth.com.8 May 2015 Health WatchSource: Gallup-Healthways 2014 Well-Being Index. U.S. Obesity Rate Inches Up to 27.7% in 2014. AccessedFebruary 2015. ches-2014.aspx?utm source CATEGORYWELLBEING&utm medium topic&utm campaign tiles. Jan. 26, 2015. Copyright 2015 Gallup, Inc. All rightsreserved. The content is used with permission; however, Gallup retains all rights of republication.After a stunning 37 percent increase from 1998 to 2006, obesity rates have continued to rise. While middleaged adults currently have the highest rates of obesity, rates among teenagers and children are equallyalarming, especially in some regions of the country. Obesity-related conditions like Type 2 diabetes, heartdisease and stroke represent some of the most pervasive and deadly diseases in the United States.Health plan actuaries understand obesity both as the health crisis it is, but also as a key cost driver for theirplan beneficiaries. CDC estimates that direct medical costs for obese individuals are 1,723 per year higherthan for those of normal weight.1 That’s without considering additional health care costs based on conditions connected to obesity—conditions that now affect 34 percent of Americans. Individuals with otherobesity-related metabolic syndromes can cost plans an additional 4,000 or more per year when comparedto those in normal weight ranges.

Health care policy experts agree that the key to reversing trendson obesity, obesity-related conditions, and other chronic diseasesis behavior and lifestyle change. Policies incentivizing these typesof treatment options are finally beginning to catch up to the need.In the process, these policy shifts are creating opportunities forhealth plan actuaries to deliver solutions that improve both thehealth of their beneficiaries and the financial health of their plans.Last year, the U.S. Preventive Services Task Force (USPSTF)—anindependent body of primary care physicians, scientists, and othermedical professionals empowered by the Affordable Care Act tobetter integrate preventive care into commercial health plans—took a critical step in addressing the obesity epidemic in America.In August 2014, the USPSTF issued a final recommendation thatdoctors should provide or refer overweight or obese individualswith any other cardiovascular disease risk factors for “intensivebehavioral counseling” to promote healthy diet and physical activity. The USPSTF assigned this recommendation a “B” rating—meaning that for any commercial health plan (CHP) year beginning August 2015 or later, behavioral counseling must be coveredas a preventive benefit. CHPs with plan years beginning on Jan. 1will need to comply with the recommendation by January 2016.This requirement represents a challenge for many plans, but anopportunity for others. Actuaries will play a key role institutingthis new preventive benefit—and can do so in a way that bothprovides effective interventions for beneficiaries and remainscost-effective for their plans. This will include evaluating whichprograms should be implemented, along with estimating the costand benefits of these programs over time.Source: Boudreau, D.M., D.C. Malone, M.A. Raebel, et al. Heath Care Utilization andCosts by Metabolic Syndrome Risk Factors. Metabolic Syndrome and Related Disorders2009; 7(4):305-14.Source: Analysis of NHANES Data, 2005-2012. Prediabetes prevalence based on FPG or A1c.In its final recommendation on the topic, the USPSTF relied heavily on evidence from a landmarktrial first published in the early 2000s—the Diabetes Prevention Program (DPP). The study testedhow intensive exercise and dietary counseling could delay the onset of Type 2 diabetes among thosealready designated “prediabetic.” The study included more than 3,000 participants, divided into threesegments —those receiving lifestyle interventions, those receiving medication and nothing else, andthose receiving a placebo. The study ultimately concluded that lifestyle interventions were the mosteffective treatment—lowering the incidence of Type 2 diabetes by 58 percent when compared to theplacebo group (and besting the medicated segment). In follow-up analyses of DPP data, participantsin the lifestyle intervention trial also saw an improvement in high blood pressure, triglycerides, HDL cholesterol, and other risk factors for heart disease. In 2010, based on the results of the study, Congress authorizedthe CDC to create a National Diabetes Prevention Program, and establish standards that meet the DPP criteria.In its August recommendation, the USPSTF specifically cited the DPP as a potential solution for thoseindividuals needing intensive behavioral counseling.CONTINUED ON PAGE 10Health Watch May 2015 9

Implementing USPSTF Recommendations FROM PAGE 9However, to date, the DPP has only been offered in face-to-face settings—limiting its scope and reachfor large population segments, and making it costly for health plans to initiate their own programs. Whilesome health plans have developed their own versions of the DPP, these programs have been both costlyand largely ineffective in reaching the needed populations. But just as the USPSTF has made these typesof interventions mandatory preventive care benefits, the federal government has offered commercial plansan innovative way to comply.In January 2015 the CDC broadened the DPP criteria, recognizing online and digital programs for thefirst time. These programs still must meet the clinical standards of the DPP—a rigorous set of criteria thatrequires licensed DPP programs to meet or exceed the standards achieved by the in-person DPP. But theCDC has recognized the power of the digital health industry in addressing one of the nation’s most pressing health programs, and a new branch of medicine—digital therapeutics—may hold the key to deliveringlifesaving interventions to those who need

mate, and any observed seasonal pattern. In addition, it is common to have multiple reserve cells—one for each business line and with multiple claims categories (inpatient, outpatien

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