Actuarial Notes

Exam GH-301

GH 301 – Health Analytics Management is an exam of the Society of Actuaries' Fellowship (FSA) pathway. Its syllabus covers the Nov 2026/Mar 2027/Jul 2027 sittings.

Learning Objectives

Provider Contracting and Reimbursement (20–30%) The candidate will understand how to evaluate the effectiveness of provider reimbursement methods from both a cost and quality viewpoint.

  1. Describe contracts between payers and providers
  2. Calculate provider payments under various reimbursement methods
  3. Evaluate standard contracting methods from a cost-effective and quality perspective
  4. Evaluate accountable care organizations (ACO) and their impact on quality, utilization, and cost

Readings:

  • Video: Challenges of Provider Reimbursement (Background)
  • Video: Today’s Provider Reimbursement Landscape (Background)
  • GH301-105-25: Chapter 45 of Group Insurance, Skwire, Daniel, 8th Edition, 2021 (1a)
  • Provider Payment Arrangements, Provider Risk, and Their Relationship with Cost of Healthcare, Oct 2015 (excluding Appendices) (1b, 1c, 1d)
  • Value-Based Care Framework, The Actuary, Apr 2020 (1d)
  • The Cost of Value-Based Care, The Actuary, Apr 2020 (1d)
  • GH301-100-25: Evaluating Bundled Payment Contracting (1b, 1c)
  • GH301-112-26: PY2025 ACO REACH RTA Tailwind (1d)
  • GH301-113-26: ACO REACH PY2026 Explained: What is Changing and Why it Matters (1d)
  • GH301-102-25: Episode-Based Physician Profiling: A Guide to the Perplexing (1c)
  • GH301-103-25: Physician Cost Profiling – Reliability and Risk of Misclassification (1a)
  • GH301-104-25: The Application of Tiering in Healthcare (1a)
  • Surprises in the No Surprises Act: An Interview with Greg Fann, Health Watch, Sep 2024 (1a, 1b)
  • Surprises in the No Surprises Act: An Interview with Greg Fann (Part 2), Health Watch, Nov 2024 (1a, 1b)

Disease Management (20–30%) The candidate will understand how to evaluate healthcare intervention programs.

  1. Describe, compare, and evaluate programs
  2. Estimate savings, utilization rate changes, and return on investment
  3. Apply the actuarially adjusted historical control methodology
  4. Calculate chronic and non-chronic trends in a manner that reflects patient risk

Readings:

  • Managing and Evaluating Healthcare Intervention Programs, Duncan, Ian G., 2nd Edition, 2014
    • Ch. 3: Care Management Programs and Interventions (2a)
    • Ch. 8: Understanding the Economics of Care Management Programs (2b)
    • Ch. 9: Applying the Economic Model: The Example of Opportunity Analysis (2b)
    • Ch. 11: The Use of Propensity Scoring in Program Evaluation (2b)
    • Ch. 12: An Actuarial Method for Evaluating Care Management Outcomes (excluding Appendix 12.2-12.3) (2c)
    • Ch. 13: Understanding Patient Risk and Its Impact on Chronic and Non-Chronic Member Trends (2d)
    • Ch. 16: Testing Actuarial Methods for Evaluating Disease Management Savings Outcomes (excluding Appendices) (2b)
  • GH301-106-25: End-of-Life Outcomes with or without Early Palliative Care: A Propensity Score Matched, Population-Based Cancer Cohort Study (2b)
  • Reimagining Pharmacy Financing, SOA Research Institute, Mar 2024, Sections 2 (background) & 3 (2b)

Healthcare Risk Adjustment1 (15–25%) The candidate will understand how to apply risk adjustment in actuarial work.

  1. Apply risk adjustment to underwriting, pricing, claims, and care management situations (applications include Medicare, Medicaid, and ACA products)
  2. Apply risk adjustment concepts to normalize population claims experience
  3. Apply applicable best practices in risk adjustment

Readings:

  • Healthcare Risk Adjustment and Predictive Modeling, Duncan, Ian G., 2nd Edition, 2018 (3a, 3b)
    • Ch. 13: Medicaid Risk Adjustment
  • Risk Adjustment in State Medicaid Programs, Health Watch, Jan 2008 (3a, 3b)
  • Healthcare Risk Adjustment and Predictive Modeling, Duncan, Ian G., 2nd Edition, 2018
    • Ch. 14: Risk Adjustment in Medicare (excluding Appendix 14.1 & 14.2) (3a, 3b)
    • Ch. 21: Risk Adjustment on the ACA Exchanges (3a)
  • Creating Stability in Unstable Times – A Look at Risk Adjustment and Market Stabilization, The Actuary, Dec 2017 (3a, 3b)
  • Changing with the Times: The Past and the Future of ACA Risk Adjustment, Health Watch, Jun 2020 (3a)
  • GH301-107-25: HHS-Operated Risk Adjustment Technical Paper on Possible Model Changes, Oct 2021 (Ch. 1, 5 & Appendix A) (3a)
  • Restoring the Indifference Ideal: If It’s Not Adjusting for “Risk,” It’s Not “Risk Adjustment”, Health Watch, Jun 2022 (3a)
  • ASOP 23: Data Quality (excluding Appendices) (3c)
  • ASOP 41: Actuarial Communications (excluding Appendices) (3c)
  • ASOP 45: The Use of Health Status Based Risk Adjustment Methodologies (excluding Appendices) (3c)
  • 1 Risk Adjustment in this course refers to adjusting revenue or capitation rates as applicable to the US health insurance market. This is distinct from the IFRS concept of risk adjustment.

Medical Data (10–20%) The candidate will understand how to describe medical coding, sources of data, and data quality.

  1. Identify various medical terms, diseases, and treatment options relevant to health actuarial work
  2. Identify and explain the use of coding sets used in health practice (CPT, ICD-10, DRG, Revenue Codes)
  3. Describe how coding sets change over time and evaluate the potential impact on actuarial analysis
  4. Evaluate impacts of changes in coding structures on provider reimbursement
  5. Describe and interpret clinical policy bulletins
  6. Distinguish between public and private data
  7. Evaluate types of study methods and identify the method used for a given study
  8. Research a question using multiple data sources

Readings:

  • eLearning Module: FSA: Terminology and Analytical Use of Data for Healthcare Actuaries (4a-4h)

Social Determinants of Health (5–15%) The candidate will understand how to explain the social determinants of health (SDOH) and their impact on health care costs and policy.

  1. Explain the social determinants of health and how they impact the cost of healthcare
  2. Describe program design and economic techniques used to measure program performance
  3. Describe the current use of SDOH in traditional actuarial practices
  4. Evaluate applications of SDOH derived statistics in actuarial models

Readings:

  • GH301-108-25: Social Determinants of Health in the Work of Health Actuaries (5a-5d)
  • GH301-109-25: Health in Housing: Exploring the Intersection Between Housing & Health Care (excluding Appendices) (5b)
  • GH301-110-25: UMass Risk Adjustment Project for MassHealth Payment and Care Delivery Reform: Describing the 2017 Payment Model, pp. 3-9 & Table 2 (5d)
  • GH301-111-25: MassHealth Social Determinants of Health Risk Adjustment Model: Version 4.0, pp. 1-9 (5d)
  • How Does Where You Live Impact Your Health?, SOA Research Institute, Mar 2022, Sections 3 & 5 (5d)
  • Social, Physical and Cultural Determinants of Health: Their Incorporation into Actuarial Data and Workstreams, SOA Research Institute, Apr 2023, Sections 3-6 (5b, 5c)

Predictive Analytics (0–10%) The candidate will understand how to apply the framework of predictive analytics to healthcare data and business applications.

  1. Describe common applications of predictive analytics in health care
  2. Differentiate between types of risk score models
  3. Describe common healthcare data sources for predictive modelling
  4. Identify challenges specific to the use of healthcare claims in model development
  5. Describe ethical considerations for actuaries in developing predictive models

Readings:

  • eLearning Module: FSA: Predictive Modeling for Healthcare Actuaries (6a-6e)

Source Material

Source Material

  • Video: Challenges of Provider Reimbursement
    • Background
  • Video: Today’s Provider Reimbursement Landscape
    • Background
  • GH301-105-25: Chapter 45 of Group Insurance, Skwire, Daniel, 8th Edition, 2021
    • Outcomes 1a
  • Provider Payment Arrangements, Provider Risk, and Their Relationship with Cost of Healthcare, Oct 2015 (excluding Appendices)
    • Outcomes 1b, 1c, 1d
  • Value-Based Care Framework, The Actuary, Apr 2020
    • Outcomes 1d
  • The Cost of Value-Based Care, The Actuary, Apr 2020
    • Outcomes 1d
  • GH301-100-25: Evaluating Bundled Payment Contracting
    • Outcomes 1b, 1c
  • GH301-112-26: PY2025 ACO REACH RTA Tailwind
    • Outcomes 1d
  • GH301-113-26: ACO REACH PY2026 Explained: What is Changing and Why it Matters
    • Outcomes 1d
  • GH301-102-25: Episode-Based Physician Profiling: A Guide to the Perplexing
    • Outcomes 1c
  • GH301-103-25: Physician Cost Profiling – Reliability and Risk of Misclassification
    • Outcomes 1a
  • GH301-104-25: The Application of Tiering in Healthcare
    • Outcomes 1a
  • Surprises in the No Surprises Act: An Interview with Greg Fann, Health Watch, Sep 2024
    • Outcomes 1a, 1b
  • Managing and Evaluating Healthcare Intervention Programs, Duncan, Ian G., 2nd Edition, 2014
    • Ch. 3: Care Management Programs and Interventions (2a)
    • Ch. 8: Understanding the Economics of Care Management Programs (2b)
    • Ch. 9: Applying the Economic Model: The Example of Opportunity Analysis (2b)
    • Ch. 11: The Use of Propensity Scoring in Program Evaluation (2b)
    • Ch. 12: An Actuarial Method for Evaluating Care Management Outcomes (excluding Appendix 12.2-12.3) (2c)
    • Ch. 13: Understanding Patient Risk and Its Impact on Chronic and Non-Chronic Member Trends (2d)
    • Ch. 16: Testing Actuarial Methods for Evaluating Disease Management Savings Outcomes (excluding Appendices) (2b)
  • GH301-106-25: End-of-Life Outcomes with or without Early Palliative Care: A Propensity Score Matched, Population-Based Cancer Cohort Study
    • Outcomes 2b
  • Reimagining Pharmacy Financing, SOA Research Institute, Mar 2024, Sections 2 (background) & 3
    • Outcomes 2b
  • Healthcare Risk Adjustment and Predictive Modeling, Duncan, Ian G., 2nd Edition, 2018
    • Ch. 13: Medicaid Risk Adjustment (3a, 3b)
    • Ch. 14: Risk Adjustment in Medicare (excluding Appendix 14.1 & 14.2) (3a, 3b)
    • Ch. 21: Risk Adjustment on the ACA Exchanges (3a)
  • Risk Adjustment in State Medicaid Programs, Health Watch, Jan 2008
    • Outcomes 3a, 3b
  • Creating Stability in Unstable Times – A Look at Risk Adjustment and Market Stabilization, The Actuary, Dec 2017
    • Outcomes 3a, 3b
  • Changing with the Times: The Past and the Future of ACA Risk Adjustment, Health Watch, Jun 2020
    • Outcomes 3a
  • GH301-107-25: HHS-Operated Risk Adjustment Technical Paper on Possible Model Changes, Oct 2021 (Ch. 1, 5 & Appendix A)
    • Outcomes 3a
  • Restoring the Indifference Ideal: If It’s Not Adjusting for “Risk,” It’s Not “Risk Adjustment”, Health Watch, Jun 2022
    • Outcomes 3a
  • ASOP 23: Data Quality (excluding Appendices)
    • Outcomes 3c
  • ASOP 41: Actuarial Communications (excluding Appendices)
    • Outcomes 3c
  • ASOP 45: The Use of Health Status Based Risk Adjustment Methodologies (excluding Appendices)
    • Outcomes 3c
  • 1 Risk Adjustment in this course refers to adjusting revenue or capitation rates as applicable to the US health insurance market. This is distinct from the IFRS concept of risk adjustment.
  • eLearning Module: FSA: Terminology and Analytical Use of Data for Healthcare Actuaries
    • Outcomes 4a-4h
  • GH301-108-25: Social Determinants of Health in the Work of Health Actuaries
    • Outcomes 5a-5d
  • GH301-109-25: Health in Housing: Exploring the Intersection Between Housing & Health Care (excluding Appendices)
    • Outcomes 5b
  • GH301-110-25: UMass Risk Adjustment Project for MassHealth Payment and Care Delivery Reform: Describing the 2017 Payment Model, pp. 3-9 & Table 2
    • Outcomes 5d
  • GH301-111-25: MassHealth Social Determinants of Health Risk Adjustment Model: Version 4.0, pp. 1-9
    • Outcomes 5d
  • How Does Where You Live Impact Your Health?, SOA Research Institute, Mar 2022, Sections 3 & 5
    • Outcomes 5d
  • Social, Physical and Cultural Determinants of Health: Their Incorporation into Actuarial Data and Workstreams, SOA Research Institute, Apr 2023, Sections 3-6
    • Outcomes 5b, 5c
  • eLearning Module: FSA: Predictive Modeling for Healthcare Actuaries
    • Outcomes 6a-6e