This chapter presents an overview of the US health insurance market, reviews health insurance research literature, and examines premiums, medical expenses, medical service utilization, and data envelopment analysis (DEA) efficiency measures of health insurers from different perspectives. Results...

The recent final rule on Medicaid managed care establishes the minimum medical loss ratio (MLR) requirement for Medicaid managed care and contains several provisions to strengthen delivery and payment reforms and improve efficiency and quality of care. Accordingly, this research examines the...

Medicare faces significant financial challenges because of rising health care costs. In response, Medicare reform efforts have been testing various payment and service delivery models, including accountable care organizations (ACOs), aiming to reduce expenditures while preserving or enhancing...

This article presents a conceptual framework for operationalizing strategic enterprise risk management (ERM) in a general firm. We employ a risk-constrained optimization approach to study the capital allocation decisions under ERM. Given the decision maker's risk appetite, the problem of...

Within the context of Medicare’s enunciated triple aims of better health, better care, and lower costs, we examine the effectiveness of medical loss ratio (MLR) on health outcomes of Medicare Advantage insurers. We simultaneously examine the effect of an efficiency measure for the insurer...

Direct selling (DS) is simultaneously a business model, a channel of distribution, and an activity engaged in by its distributors. In this paper, we provide a framework for analyzing and discuss academic research on the DS distribution model.We focus in particular on research that develops...

If one is interested in managing fraud, one must measure the fraud rate to be able to assess the degree of the problem and the effectiveness of the fraud management technique. This paper offers a robust new method for estimating fraud rate, PRIDIT-FRE (PRIDIT-based Fraud Rate Estimation),...