Ian Duncan

• B. Phil. PhD FSA FIA FCIA FCA CSPA MAAA
• Professor (Adjunct) at University of California, Santa Barbara

A growing topic in healthcare in the United States and other countries is the decentralization of risk from the ultimate healthcare payer (insurance companies and government in the United States; national health systems in other countries) to providers of healthcare services. Healthcare providers have traditionally taken clinical risk.1 However, pa...

Reimbursement for health care services is transferring more risk away from payers and toward health care providers in the form of Alternative Payment Models (APMs), also known as Value-Based Care (VBC) models. VBC models cover a wide variety of forms but all include guarantees by providers of services to improve quality of care and/or reduce cost....

Patients frequently have comorbidities that when combined with their primary diagnosis qualifies the patient for hospice. Consequently, patients are at risk for polypharmacy due to the number of medications prescribed to treat both the underlying conditions and the related symptoms. Polypharmacy is associated with negative consequences, including i...

Purpose: Hispanics/Latinos in the United States bear higher burden of type 2 diabetes (T2D) and associated complications compared with the general population. Health insurance coverage is also lower in this population. We examined the association of health insurance with biological and psychosocial determinants of cardiometabolic risk among U.S. Me...

Background: In the United States (U.S.), the prevalence of both diagnosed and undiagnosed type 2 diabetes (T2D) is nearly twice as high among Mexican-origin Hispanic/Latino adults compared to non-Hispanic Whites. Rates of diabetes-related complications, e.g., acute stroke and end-stage renal disease, are also higher among Hispanic/Latino adults co...

Purpose: To examine the burden and cost of diabetes among fee-for-service Medicare beneficiaries. Methods: Medicare 5% File data for type 1 diabetes (T1D) and type 2 diabetes (T2D) consisting of 1,397,933 enrollees in fee-for-service without Medicare Advantage during the period 2012–2013 were analyzed by race and ethnicity. Results: Although non-Hi...

Aims: The aim of this study is to compare some machine learning methods with traditional statistical parametric analyses using logistic regression to investigate the relationship of risk factors for diabetes and cardiovascular (cardiometabolic risk) for U.S. adults using a cross-sectional data from participants in a wellness improvement program. M...

Background: New population health community-based models of palliative care can result in more compassionate, affordable, and sustainable high-quality care. Objectives: We evaluated utilization and cost outcomes of a standardized, population health community-based palliative care program provided by nurses and social workers. Design: We conducted...

As the Medicare program struggles to control expenditures, there is increased focus on opportunities to manage patient populations more efficiently and at a lower cost. A major source of expense for the Medicare program is beneficiaries at end of life. Estimates of the percentage of Medicare costs that arise from patients in the last year of life d...

Purpose: It is well known that minority patients, and particularly African Americans undergo lower rates of cardiac procedures than the white population, even when covered by equivalent insurance. Methods: We analyzed the rates of percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI) and for intermediate corona...

Diabetes disproportionately impacts minority populations in the United States. In particular, Hispanics are almost twice as likely as non-Hispanic whites to be diagnosed with diabetes and have higher rates of end-stage renal disease (ESRD) due to diabetes. We analyzed data from the Medicare 5% sample file by race/ethnicity for type 1 (T1D) and type...

Diabetes disproportionately impacts U.S. minority populations, with Hispanics almost twice as likely as non-Hispanic whites (nHW) to be diagnosed. We analyzed data from the Medicare 5% sample file by race/ethnicity for both type 1 (T1D) and type 2 diabetes (T2D). We identified 1,397,933 enrollees in fee-for-service without Medicare Advantage covera...

Predictive models for hospital readmission rates are in high demand because of the Centers for Medicare & Medicaid Services (CMS) Hospital Readmission Reduction Program (HRRP). The LACE index is one of the most popular predictive tools among hospitals in the United States. The LACE index is a simple tool with 4 parameters: Length of stay, Acuity of...

In 2006, Massachusetts implemented a substantial reform of its health insurance market that included a new program for uninsured individuals with income between 100% of Federal Poverty (the upper limit for state Medicaid benefits) and 300% of Federal Poverty. Enrollment was compulsory for all citizens due to a mandate. Consumers who enrolled in thi...

Objective: Evaluate a large employer's wellness intervention by studying outcomes across the value chain, and testing Health Engagement's (HE) dose-response relationship to outcomes. Methods: Evaluation included 37 measures across eight outcomes domains (OD) using repeated measures, analysis of variance and logistic regression. Results: Partic...

In California, 1 in 3 hospital beds are occupied by adults with diabetes. The aim of this study was to examine whether diabetes impacts length of stay (LOS) following common elective orthopedic procedures compared to nondiabetic individuals, and also the performance of hospitals across California for these procedures. Using the Public Use Californi...

A common acute condition seen by providers in retails clinics is the evaluation and treatment of acute otitis media (AOM) in children younger than age 20. Annual direct treatment costs for AOM were US $5.3 billion in 1998 dollars. Based on the experience of a large retail pharmacy employer, the authors compared AOM episodes in covered dependents yo...

Predictive models of health care costs have become mainstream in much health care actuarial work. The Affordable Care Act requires the use of predictive modeling-based risk-adjuster models to transfer revenue between different health exchange participants. Although the predictive accuracy of these models has been investigated in a number of studies...

In California, 1 in 3 hospital beds are occupied by adults with diabetes. The aim of this study was to examine whether diabetes impacts length of stay (LOS) following common elective orthopedic procedures compared to nondiabetic individuals, and also the performance of hospitals across California for these procedures. Using the Public Use Californi...

Abstract The purpose of this retrospective, longitudinal study was to assess longitudinal associations between modifiable health risks and workplace absenteeism and presenteeism and to estimate lost productivity costs. Across the 4-year study period (2007-2010), 17,089 unique employees from a large US computer manufacturer with a highly technical w...

This article was downloaded by: [University of California Santa Barbara] On: 26 February 2015, At: 14:47 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK North American Actuarial Journal Publication details, including instructions...

The Walgreens Connected Care Multiple Sclerosis (CCMS) treatment management program provides enhanced levels of monitoring, oversight, and care for patients taking MS disease-modifying agents. This study compared rates of adherence to MS medications for patients participating in the CCMS program for at least 6 months with those for patients partici...

Objective: To determine if patients using human immunodeficiency virus (HIV)-specialized pharmacies have greater adherence to drugs used to treat comorbid conditions and HIV compared with patients who use traditional pharmacies. Design: Retrospective cohort study, with patients' propensity matched based on pharmacy use: HIV-specialized versus tr...

Abstract Despite levels of health spending that are higher per capita and as share of gross domestic product than any country worldwide, the US health care system is fragmented, technology and administration heavy, and primary care deficient. Studies of regional variations in US health care show similar "disconnects" between higher spending and bet...

The effect of a collaborative pharmacist-hospital care transition program on the likelihood of 30-day readmission was evaluated. This retrospective cohort study was conducted in two acute care hospitals within the same hospital system in the southeastern United States. One hospital initiated a care transition program in January 2011; the other hosp...

Abstract The objective of this study was to examine the efficacy of a worksite weight management program on the reduction of weight and lipid levels in employees and their dependents. This retrospective study examined the impact of a one-on-one worksite weight management program. Patients with a body mass index (BMI)>30, or a BMI>25 and 2 or more r...

A major employer implemented a change to its employee health benefits program to allow beneficiaries with diabetes or high cholesterol to obtain preselected generic antidiabetic or generic antihyperlipidemic medications with a zero dollar copayment. To receive this benefit, plan beneficiaries were required to participate in a contracted vendor's ca...

Health care systems in many countries are using the "Triple Aim"-to improve patients' experience of care, to advance population health, and to lower per capita costs-as a focus for improving quality. Population strategies for addressing the Triple Aim are becoming increasingly prevalent in developed countries, but ultimately success will also requi...

Abstract Individuals with type II diabetes have an increased risk of cancer diagnosis (relative risk [RR]=1.12-2.50) and mortality (RR=1.4) compared to normoglycemic individuals. Biologic mechanisms, including mitogenic effects of insulin, hyperglycemia, and increased oxidative stress, as well as behavioral factors (eg, difficulty managing the como...

In an attempt to contain Medicaid pharmacy costs, nearly all states impose dispensing limits on medication days' supply. Although longer days' supply appears to increase the potential for medication wastage, previous studies suggest that it may also decrease pharmacy expenditures by reducing dispensing fees and drug ingredient costs. This study was...

Although annual influenza vaccination could decrease the significant economic and humanistic burden of influenza in the United States, immunization rates are below recommended levels, and concerns remain whether immunization programs can be cost beneficial. The research objective was to compare cost benefit of various immunization strategies from e...

Adherence, medication wastage, and reduction in hospital admissions were investigated in a retrospective test-control study design for patients enrolled in the oral chemotherapy cycle management program (CMP), a program that offers clinical support, dose monitoring, and early identification of side effects for patients on select oral chemotherapy....

To evaluate the impact of a community-based pharmacist-led face-to-face counseling program on medication adherence for patients who were new to therapy (NTT) for statin medications. This retrospective cohort study evaluated a program that was implemented in 76 national community pharmacies located in the midwest USA. It consisted of two face-to-fac...

Pharmacy benefit management (PBM) companies promote mail order programs that typically dispense 90-day quantities of maintenance medications, marketing this feature as a key cost containment strategy to address plan sponsors' rising prescription drug expenditures. In recent years, community pharmacies have introduced 90-day programs that provide si...

To assess medication adherence rates of patients utilizing an online prescription management account compared with nonusers. A retrospective analysis was conducted using de-identified pharmacy claims data from a pharmacy benefit manager covering the period from April 1, 2009, to March 31, 2011. Patients who were continuously eligible throughout the...

The American health care system is concerned about the rise of chronic diseases and related resource challenges. Management of chronic disease traditionally has been provided by physicians and nurses. The growth of the care management industry, in which nurses provide remote telephonic monitoring and coaching, testifies to the increasing need for c...

As all countries struggle with rising medical costs and increased demand for services, there is enormous need and opportunity for mining claims and encounter data to predict risk. This chapter discusses the important topic, to health systems and other payers, of the identification and modeling of health risk. We begin with a definition of health ri...

To examine relative medication adherence of patients filling 90-day supplies of maintenance medications using retail and mail order channels. It was hypothesized that adherence rates would not differ across the 2 channels. A cross-sectional retrospective analysis was conducted using de-identified pharmacy claims data from a large pharmacy benefit m...

The purpose of this study was to evaluate the effectiveness of diabetes self-management education or training provided by diabetes educators in reducing complications and improving quality of life. Commercial and Medicare payer-derived claims data were used to assess the relationship between DSME/T and cost. Unlike the prior study that examined dia...

Older adults and persons with chronic conditions are at increased risk for pneumococcal disease. Severe pneumococcal disease represents a substantial humanistic and economic burden to society. Although pneumococcal vaccination (PPSV) can decrease risk for serious consequences, vaccination rates are suboptimal. As more people seek annual influenza v...

The oral chemotherapy cycle management program (CMP) provides clinical management support to patients receiving certain oral chemotherapies. The CMP includes a dose-monitoring (ie, split-fill) plan for early identification and management of adverse effects. If serious adverse effects are identified mid cycle, the remainder of the monthly supply is...

Examine the effect of a prenatal program on birth outcomes, specifically birth weight, in a managed Medicaid pregnant population, and identify the potential barriers to obtaining the risk screening information required for successful interventions. Retrospective propensity-adjusted cohort comparison. Retrospective propensity-adjusted comparison of...

Purpose: The oral chemotherapy cycle management program (CMP) provides clinical management support to patients receiving certain oral chemotherapies. The CMP includes a dose-monitoring (ie, split-fill) plan for early identification and management of adverse effects. If serious adverse effects are identified mid cycle, the remainder of the monthly s...

S everal oral chemotherapies and biologic therapies have been introduced in the last decade for use alone, in conjunction with intravenous therapy, or with other oral chemotherapies. The National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium, 1 one of the approved compendiums used as the basis for coverage and reimbursement pol...

The purpose of this study was to evaluate the impact of diabetes self-management education/training (DSME/T) on financial outcomes (cost of patient care). Commercial and Medicare claims payer-derived datasets were used to assess whether patients who participate in diabetes education are more likely to follow recommendations for care than similar pa...

One objective of a disease management (DM) program is the reduction of members' claims costs. A considerable amount of effort has been dedicated to standardizing the outcomes of DM measurement. An area that has not received as much attention is that of random fluctuations in measured outcomes and the related issue of the validity of outcomes subjec...

A common method of performing commercial and government (ie, Medicare, Medicaid) disease management (DM) program savings evaluations--and the basis of DMAA's Guidelines--is the adjusted historical control method. This method uses a trend adjustment to adjust for the effects of utilization and unit cost changes over time. An appropriate trend adjust...

Disease management (DM) is increasingly encountered in health plans and employer groups as a health care intervention targeted to individuals with chronic diseases (“Chronics”). To justify the investment by payers in DM, it is important to demonstrate beneficial clinical and financial outcomes. In the absence of randomized control studies, financia...

Disease management (DM) is increasingly encountered in health plans and employer groups as a health care intervention targeted to individuals with chronic diseases (''Chronics''). To justify the investment by payers in DM, it is important to demonstrate beneficial clinical and financial outcomes. In the absence of randomized control studies, financ...

Disease management (DM) is rapidly becoming an important force in the late 20th and early 21st century as a strategy for managing the chronic illness of large populations. Given the increasing visibility of DM programs, the clinical, economic and financial impact of this support are vital to DM program accountability and its acceptance as a solutio...

To describe the development and validation of a predictive model designed to identify and target HMO members who are likely to incur high costs. Split-sample multivariate regression analysis. We studied enrollees in a 350000-member HMO with > or = 1 claim in 1998 and 1999. The prediction model uses a combination of clinical and behavioral vaiables...

Financial officers have stepped in to control the alarming growth of health benefit costs. But a surprising number of companies lack an organized approach based on solid data. The author reveals an effective ten-point strategy for curbing company health plan costs—using data you may already have in house.

Disease Management (DM) programs are becoming common among health insurers. Some are convinced that these programs are of significant value in controlling health-care utilization, while others are not so sure. Actuaries are at risk of losing responsibility for the construction and evaluation of such programs to economists and biostatisticians. This...

C hief financial officers are showing increasing interest in care management inter-vention programs, because of the programs' rising importance and costs and the skepticism about their results. In turn, CFOs are turning more to their traditional source of objective financial information: actuaries. In 2003, the Society of Actuaries Health Section b...